Chapter Three39

Hidden Hunger in theDeveloped World

Hans Konrad Biesalski
Department of Biological Chemistry and Nutrition,
University of Hohenheim, Stuttgart, Germany

“The food you eat can be either the safest and most powerful formof medicine or the slowest form of poison.”Ann Wigmore, Lithuanian holistic health practitioner, nutritionist and health educator.

40

Key messages
Solutions are available: Many countries have
implemented mandatory or voluntary
fortification of folic acid, vitamin D or iodine.
The experience of many countries indicatesthat the fortification of staple or processed
foods may be an efficient way to provide anadequate intake of micronutrients.

The term “hidden hunger” has gained significant currency
among nutrition scientists and policy-makers in recent
years. In its broadest sense, it denotes a chronic lack of
micronutrients – vitamins and minerals – whose effects may
not be immediately apparent and whose consequences may
be long-term and profound.
While much groundbreaking research into the subject ofhidden hunger has been conducted in the last two decades,
many questions remain regarding the extent andimplications of this phenomenon and the best means oftackling it. From today’s perspective, however, it is clearthat hidden hunger is a growing threat to public health,both in the developing and the developed worlds.
The following chapter provides a short introduction andexamples to this topic, which is complex, ramified, and thesubject of considerable scientific attention and controversy
as this book goes to press.

A child with rickets in India in 2006. This non-communicable disease isassociated with vitamin D deficiency and results in irreversible
malformation of the skeleton
Source: Dr Tobias Vogt

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

41

A 1960 photo of a Kings checkout worker is among the items at the New Jersey Supermarket Archives at Rutgers University. Allen Bildner,
whose parents founded Kings in the 1930s, donated memorabilia from the chain’s early days.
Source: Special Collections and University Archives, Rutgers University Libraries

Hidden hunger in the developed world
Hidden hunger, also known as chronic micronutrient
malnutrition, is experienced by more than one in three ofthe world’s total population. This term refers to a chroniclack of vitamins and minerals, which is not immediately
apparent and which can exist for a long time before clinicalsigns of malnutrition become obvious.

intake surveys in Western countries such as the USA,
Canada, Germany, France, Great Britain and many others
indicates that a sufficient intake is not being achieved in thecase of some micronutrients, according to recommendations
using RDAs as reference. This is especially the case for folicacid, vitamin D, vitamin E, iron and iodine.

It is a popular perception that most people who live in thedeveloped countries of the world enjoy a nutritionallysound diet and are not prey to hidden hunger. The reality is,however, different. Micronutrient inadequacies are to befound in the developed world as well as in the developingworld, and their current rate of growth in the developed
world gives cause for concern. Growing evidence fromAccording to the United Nations Food and Agriculture
Organization (FAO), micronutrient inadequacies may, in thelong term, lead to a wide number of health problems,
including impaired cognitive development, lower resistance todisease, and increased risks during childbirth for both mothers
and children. A particular issue in the developed world is theinadequate folic acid intake and vitamin D status.

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

42

Food bank in Hérault, France: The growth of food banks in the developed world is a sign that nutrition insecurity is by no means confined to thedeveloping world.
Source: Anne-Catherine Frey

Global map presenting hidden hunger index based on the prevalence estimates (HHI-PD) in 149 countries and prevalence of low urinary
iodine concentration in 90 countries with 2007 Human Development Index <0.9.
The hidden hunger index HHI-PD was estimated based on national estimates of the prevalence of stunting, anemia due to iron deficiency, andlow serum retinol concentration.
Source: doi:10.1371/journal.pone.0067860.g002

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

43

Key definitions
Macronutrient deficiency

Dimensions of hidden hunger

This type of malnutrition, known as Protein Energy
Malnutrition (PEM), involves a lack of protein and foodcontaining enough calories. This term is applied when hunger
is defined in terms of an insufficient intake of calories.

The human body extracts 51 different essential compounds
from food which it cannot produce itself throughmetabolism. Among these, as far as we currently know, areamino acids, as well as so-called micronutrients (vitamins,
trace elements and minerals), which exert a direct influenceon physical and mental development and the immune
system, and are vital to the body’s metabolic processes. To
date, it is only known what effects the lack of a certain few
micronutrients have on the body in the form of clinicalsymptoms, such as scurvy (due to a lack of vitamin C),
rickets (caused by a vitamin D deficiency), beriberi(triggered by too little vitamin B) and pellagra (resulting
from niacin deficiency). This naturally does not exclude thepossibility that the micronutrients which have hitherto been
the object of less analysis also have an impact on our
susceptibility to certain illnesses or the onset of such
ailments later in life.

Micronutrient deficiency
Unlike PEM, persons suffering from this type of deficiency
may display no outward signs or symptoms. As long as no
significant clinical symptoms appear, no consideration is
given to the possibility of a micronutrient deficiency. Thisbegs the question of whether a shortfall of the recommended
dietary allowances (RDA) is pathologically significant and,if so, how a diagnosis can be made.
Common micronutrient deficiencies
The most common micronutrient deficiencies among
women and children are lack of iodine, which is essential
for bodily and mental development; iron, a lack of whichcauses anemia and hampers the cognitive development ofchildren; and vitamin A, which is needed for healthyeyesight and a healthy immune system.
It is often overlooked that behind each of the deficiencies
attributed by UNICEF to an unbalanced diet there exist
further deficiencies that are not yet visible, yet which exert anegative impact on a child’s development. Likewise, a lackof other micronutrients than the above-mentioned three canhamper development long before symptoms are apparent.
The fact that both the FAO and the WHO define hunger inpurely quantitative terms – i.e., the result of too few calories– misses the mark. Even if the subjective aspect of hunger,
the empty feeling in one’s stomach, is addressed by thisdefinition, there is another aspect of hunger which is left
out: the body’s craving for essential nutritional components.
This is what is meant by ‘hidden hunger’.

The consequences of a micronutrient deficiency
Both sides of the coin – the causes and adverse effects of theabove-mentioned micronutrient deficiencies – are nothing
new and have been researched at length. It is therefore quite
astounding that they are not considered when assessing thefood situation in the world. Moreover, the ‘hidden’ deficits
of micronutrient deficiencies are known, and recommendations
are given to avoid a deficiency, for instance by means ofsupplements or food fortification. However, it is often
overlooked that the underlying cause of such deficiencies isa diet which does not meet the nutritional needs of mostpeople, not to mention children and pregnant women. It isalso not enough to push for a diet which contains all
micronutrients, except in cases of acute, life-saving
intervention. Hidden hunger must first and foremost be
uncovered and then avoided by all means. The negative, infact devastating, effects of hidden hunger, cannot bereversed once the damage is done.
Source: Hans Konrad Biesalski, Hidden Hunger, Springer-Verlag, Berlin
Heidelberg 2013

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

The return of rickets
Leading doctors [in the UK] are calling for vitamin D
supplements to be made more widely available tochildren to beat the returning scourge of rickets.
Cases of rickets have gone up four-fold in the past 15
years because many pregnant women and young
children are not getting enough of the sunshine vitamin.
Says Professor Mitch Blair of the Royal College of
Pediatrics and Child Health (RCPCH): “We know
vitamin D deficiency is a growing problem, andlocalized research reveals startlingly high levels ofvitamin deficiency among certain groups includingchildren. People can only get a fraction – just 10
percent – of their recommended daily amount ofvitamin D through food, and very little from sunlight.
So getting out in the sun more or eating more oily fish
isn’t going to solve the problem.”
Lack of vitamin D is related to a plethora of serious
illnesses in children and adults that could be
prevented through relatively simple steps such as
taking supplements.
Diabetes, asthma, multiple sclerosis, tuberculosis, andlife-threatening heart disease have been linked to lowlevels of vitamin D in early life. The RCPCH
estimates at least half of the UK’s white population,
up to 90 percent of the multi-ethnic population and aquarter of children have vitamin D deficiency.
Many people thought rickets had virtually been
eliminated after the war, but there has been a recent
rise in numbers of children with the disease. Cases
went up from 183 in 1995/96 to 762 last year.
Source: Abridged from Return of rickets: Cases up four-fold in thelast 15 years as pregnant women and children fail to get enoughVitamin D. Jenny Hope, Mail Online, December 14 2012.

An increase in poverty and poor nutritionin the developed world
An increase in poverty in industrialized countries, withchildren primarily affected, is an issue that is often
overlooked. Being poor means having a poor diet and little
dietary diversity in many cases, which means that children
who live in the land of plenty may also suffer frommalnutrition. Sadly, this fact seems to interest only a very
few people.
In a recent article in the Financial Times magazine, Where
austerity really hits home, Gillian Tett raises the issue ofhunger in the United Kingdom, with an example from a
deprived area of Liverpool:“There’s a lot of little kids going hungry round here,”
explained one friend, who works in a local community
center. Indeed, just the other day she had spoken to a family
where the child had been chewing wallpaper at night. “Hedidn’t want to tell his mum because he knew she didn’t havethe money for supper,” she explained. “We hear more andmore stories like this.”Gillian Tett’s anecdotal evidence of poverty and hunger as a
growing problem is backed by figures from the Trussell
Trust, providers of a network of food banks around the UK,
who state:“In 2011–12 food banks fed 128,687 people nationwide, in
2012–13 we anticipate this number will rise to over 290,000.
Rising costs of food and fuel combined with static income,high unemployment and changes to benefits are causing
more and more people to come to food banks for help.”
The UK is not alone. In Germany, Nanette StröbeleBenschop and Peter Tinnemann in their paper HealthInequalities in Berlin, Germany – analysis of local efforts to
support socio-economically disadvantaged people cite aproject supported by the Berliner Tafel e.V. to distribute
fresh produce on a weekly basis to the mostsocioeconomically disadvantaged people, which found thatthe daily number of people served increased by 9% fromMay 2006 to May 2010.
Source: The Financial Times, March 8, 2013; http://www.ft.com/
cms/s/2/7de158e8-86bd-11e2-b907-00144feabdc0.html#axzz2Z7CZFGe8

44

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

45Child poverty and malnutritionin the US
Child poverty in the US has reached record levels, withalmost 17 million children now affected. A growing
number are also going hungry on a daily basis.
Currently, 47 million Americans are thought to depend
on food banks. One in five children receives food aid.
For some families, cheap and easy to prepare food canmean unhealthy choices like pizza – increasing the
likelihood of obesity and health problems later in life.
In many areas schools take part in a “backpack”
program, set up to deliver food parcels to the mostvulnerable on a Friday – so that they have enough to
eat over the weekend. In eastern Iowa and western
Illinois, the River Bend Foodbank now helps 1,500
children in 30 schools through one such scheme. It
has seen the numbers needing help rise sharply.
“It’s changed dramatically since the recession. We’reup about 30% to 40% in terms of the number ofpeople coming forward,” says Caren Laughlin, who
has worked with food banks for 30 years. “That’s not
only because so many people have lost their jobs, it’salso because the jobs that are replacing them are low
paying. You cannot feed a family.”The problems are reflected across America, says thenationwide charity Feeding America, which operates
200 food banks and feeds 37 million people eachyear, including 14 million children.
It says that, in total, nearly 17 million US children
live in homes where getting enough healthy food is
not something they can count on.
Source: Abridged from The children going hungry in America,
Duncan Walker, BBC News, March 6, 2013

The history of the balanced diet
The pioneering biochemists of the first half of the 20th
century revolutionized our understanding of the role thatnutrients play in our health. Founders of the new science ofnutrition such as Casimir Funk and Tadeusz Reichstein
identified and isolated individual vitamins for the first time,and began to map out their complex functioning in themetabolism. A growing appreciation of the essential
health-giving properties of these micronutrients led to theconcept of the ‘balanced diet’ which provided adequatelevels of proteins, fats and carbohydrates as well as
sufficient amounts of vitamins and minerals. Public healthpolicy – intensified by wartime food rationing andunderpinned by educational propaganda – promoted theconcept of the balanced diet. Despite the privations of war,
the population of the United Kingdom, for instance, ate ahealthier diet than at any time in history during World War II
and the years immediately following. This generation has
shown remarkable health and longevity, which are to agreat extent traceable to good dietary habits over a long
period of time.

The decline of the balanced diet
There is a polarization in dietary lifestyles in the developed
world. While the more affluent and educated have theresources to support a healthier lifestyle and diet, those whoare economically poor, who live in ‘food deserts’ and who
do not possess a good knowledge of nutrition often do nothave access to or cannot afford a healthy, balanced diet or
do not have the means to make the right choices. Ironically,
the polarization of diets in the developed world has beenaccompanied by a massive rise in the popularity of cultrestaurants and TV chefs.

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

Sir Jack Cecil Drummond: A pioneerof nutrition science
Sir Jack Cecil Drummond was a Professor of
Biochemistry who isolated pure vitamin A in the
1930s, but perhaps his greatest achievements were intranslating original science into practical dietary
programs. His obituary in the British Journal of
Nutrition in 1954 praised these efforts:“Perhaps Drummond’s name is most closely
associated with the provision of special foods formothers and children. From the outset he pressed theclaims of nutritionally vulnerable groups. The successof his efforts in this direction is seen in the schemesthat were gradually evolved for the cheap supply andpriority rationing of liquid milk, in the earlyexperiments with blackcurrant syrup and rosehip
syrup as sources of vitamins for expectant mothers
and young children, in the subsequent provision ofconcentrated orange juice and cod-liver oil to these
two groups, and in the generous allocation ofrationed foods for school meals and the provision ofnational milk cocoa for adolescents.”
Drummond developed a system of national rationing
to ensure that everyone, whether rich or poor, had an
adequate nutritional intake. As James Fergusson
writes in his 2007 publication The Vitamin Murders:“The health of the British nation, schoolchildren
included, was not just maintained during the Second
World War but improved...[T]he incidence of almost
every diet-related illness was lower than it had everbeen. Drummond was a genuine home-front hero.”
As Tom Jaine writes in his introduction to the 1991
edition of Drummond’s The Englishman’s Food: Five
Centuries of English Diet:
Drummond was working during the heroic period ofnutritional science when the constituents of foodnecessary to maintain, and then improve, the qualityof life were finally defined. This... was the era when
deficiency diseases received their full investigation.
For centuries rickets, scurvy, pellagra, beri-beri, night
blindness and hunger-oedema had been the scourge ofvarious societies...but it needed the new nutrition to
fully explain the treatment and to rapidly extend thebenefits of cure to as many populations as possible.”
Source: Abridged from Sir Jack Cecil Drummond DSc, FRIC, FRS: A
hero of nutrition science and advocacy by Jonathan Steffen, Sight andLife 2/2012‘Food deserts’ and the problem of limitedaccess to balanced nutrition
The more varied one’s diet is, the healthier it is. Normal
body weight and growth can only be achieved if children
take their food from several different sources.
Dietary diversity depends upon certain factors, for instancethat different foods are available and also affordable. It is
this lack of diversity that is responsible for malnutrition andall of its harmful consequences.
There are districts in both urban environments and rural
settings, where shops do not stock the range of fresh andnutritious foods necessary for a balanced diet. These areas
are usually characterized by convenience stores that stock
only processed foods and by fast-food restaurants.
Residents who are unable, for whatever reason, to travel
further afield in search of a better diet therefore findthemselves in a situation where there is food to buy but thenutritional value of that food is inadequate.
In 2010 the United States Department of Agriculture
defined what’s considered a ‘food desert’ as follows: “Toqualify as a ‘low-access community,’ at least 500 people
and/or at least 33 percent of the census tract’s populationmust reside more than one mile from a supermarket or large
grocery store (for rural census tracts, the distance is morethan 10 miles).”

Food deserts in the US and other barriers
to a balanced diet
The United States Department of Agriculture (USDA) has
replaced their original Food Desert Locator with the moredetailed Food Access Research Atlas. This sophisticatedmapping tool allows users to investigate multiple indicatorsof food store access, and highlights the areas of the US
which can be classified as ‘food deserts’
It should be pointed out that, in all cultural andgeographical settings, the question of access to food has
many dimensions, and that a variety of factors may
combine to prevent an individual, or a group of individuals,
from enjoying a balanced diet. These may include, forinstance, lack of mobility (lack of transport or lack ofphysical mobility due to illness or infirmity), lack ofpurchasing power, and also a lack of understanding of basic
nutritional principles. Within the world’s most affluent
societies, there are individuals – whether in hospitals, carehomes or hospices, whether in substandard housing or
sleeping rough in the street, who do not have access to that
‘simplest’ thing, a healthy, balanced diet.

46

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

47

Screenshot from the USDA’s ‘Food Access Research Atlas’, showing food deserts in the US
Source: http://www.ers.usda.gov/data-products/food-access-research-atlas.aspx#.UVBiGELd7dk

The long-term consequences of inadequate nutrition
The long-term consequences of malnutrition and hidden
hunger in the developed world are significant. For example
inadequate and suboptimal vitamin D status alone is known
to be a risk factor for some cancers such as breast cancer,
prostate cancer, and several autoimmune diseases such as
multiple sclerosis, rheumatoid arthritis and type-1 diabetes.
An unhealthy, unbalanced diet rich in unsaturated fats,sugars and salts may contribute to a wide range of noncommunicable diseases such as cardiovascular diseases,
cancers, chronic respiratory diseases and diabetes.
In September 2011 the United Nations launched an effort to
tackle non-communicable diseases (NCDs) such as cancer
and diabetes with a summit meeting devoted to curbing thefactors, such as tobacco and alcohol use behind theoften-preventable scourge that causes 63 percent of alldeaths. The two-day high-level General Assembly meeting
adopted a declaration calling for a multi-pronged campaign
by governments, industry and civil society to set up by 2013
the plans needed to curb the risk factors behind the fourgroups of NCDs – cardiovascular diseases, cancers, chronic
respiratory diseases and diabetes.
As well as steps to curb the use of tobacco and alcohol, the UN
advocated steps to curb “the extensive marketing to children,
particularly on television, of foods and beverages that are highin saturated fats, trans-fatty acids, sugars, or salt.”
Vitamin D has important benefits in lowering the risk offractures, improving muscle strength, and reducing the risk ofa number of conditions and diseases. The benefit regarding the
reduction of fractures and the contribution to muscle strengthis well reported, while other benefits are still emerging,covering areas such as type 2 diabetes, cardiovascular disease,some types of cancers, strengthening of the immune system,
and autoimmune diseases such as multiple sclerosis.1,2Many people have a low level of serum vitamin D(measured as 25-hydroxy-vitamin D) owing to poor accessto natural sources of vitamin D. This may be attributable,
for instance, to factors such as an absence of cold-waterChapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

ocean fish from the diet, living largely indoors and therefore
getting insufficient exposure to sunlight, and inhabiting thehigh latitudes of the world. The reduction of the direct andindirect costs associated with the above-mentioned diseases
is based on randomized controlled trials using an intake of
200–800 IU vitamin D, which results in an adequate
vitamin D status.

developed world could be in the range of billions of euros.3
Economics aside it is, above all, a question of humanity. If
we took the rights of every individual to an adequate diet as
seriously as we take the issue of human rights, and if we
proclaimed these as loudly and often as we rightly do withregard to human rights, then the first big step towardmaking a change would be taken.

Assessments by various research groups indicate that thefinancial burden on direct and indirect healthcare costs
arising from inadequate micronutrient status in the

Hidden hunger across the life cycle
Newborns• Low birthweight• High mortality• Reduced mental
development• Often ill

Seniors• Often chronically ill• Lower life expectancy

ChildrenPoor Micronutrient Status
Adults• Stunting• Often ill• Small stature• High mortality• Lower resilience

Pregnant• Poor• High mortality• Malnourished • Frequent
perinatal• Limited
complications
productivity• Lower
performance

Adolescents• Stunted• Reduced mental andphysical performance• Often ill

UNICEF 2009

The economic impact of vitamin D deficiency
In developed countries, at least 10% of people in thegeneral population and up to 70% and more of individuals
in specific patient groups have blood vitamin D levels lying
in the deficiency range (e.g. 25- hydroxy vitamin D levels<30 nmol/L). Vitamin D deficiency is probably the mostfrequent micronutrient deficiency in developed countries. In
westernized societies, the economic burden of thehealthcare system is high and will further increase in future
due to demographic changes and the increasing proportionof elderly people.
In Europe, total expenditure on health varies between
6% (Eastern Europe) and more than 11% (Western
Europe) of gross domestic product. Thus, an estimatedannual amount of one trillion euros is spent on thehealthcare system in Europe. A recent meta-analysis ofpooled patient-level data from randomized controlled

trials provided convincing evidence that between 14%
and 30% of nonvertebral fractures can be prevented byadequate vitamin D supply. Based on these data it can becalculated that in Europe alone, fracture prevention by
supplementary vitamin D would result in cost savings ofapproximately five billion euros. There is some evidence
from genetic studies, prospective cohort studies andrandomized controlled trials that vitamin D may play arole in the prevention of type 1 diabetes, infections andcardiovascular-related deaths. Vitamin D may also
reduce the risk of exacerbations in patients with chronic
obstructive pulmonary disease and multiple sclerosis.
Although there is much uncertainty about the costsavings potential of adequate vitamin D supply, theamount may reach the binary billions range.
Source: Abridged from Economic impact of undernutrition: Vitamin D by
A. Zittermann, University Bochum and Bad Oeynhausen

48Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

Annual income and diet cost comparison

300

Undernourished persons (in millions)
1000

350
Cost for a healthy diet

800
250

Per million / people

Francs (in thousands)

49

200

150

100

600

400

200

Cost for a diet rich in energy

5000Very poor
near toKabindaVery poor
far awayfrom Kabinda

Poor

Mean
incomeWealthy

1969-71 1979-81 1990-92 1995-97 2003-05

2007

2010

Near East and North Africa

Latin America and Caribean

Rest of Africa

Asia

Fischer et al. 2008; input from FAOSTAT.fao.org 2011, 2012

Save the Children 2010

Trapped in the cycle of hunger, generation after generation
MalnourishedFemales

MalnourishedPregnancies

Highermaternal
mortality

Suboptimal
nutrition of
the child

Malnourished
Elderly

Reduced power
for childcare

Low Birth Weight
Malnourished
Newborns

ImpairedDevelopment
ChildrenHigher mortality

Higher mortality

Reduced physicaland mental
development

Reduced physicaland mental
development

Higher risk forchronic diseasein later life

Higher risk forchronic diseasein later life

ImpairedDevelopment
AdultsReduced physicalcapacity for labor

Stunting

Poor conditions
for education
Reduced economic
potential,
Reduced life
expectancy

Modified from: ACC/SCN 2000

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

My personal view
Hans Konrad Biesalski

Head of the Department of Biological Chemistry andNutrition, University of Hohenheim, Stuttgart, Germany

We have clear evidence that income isrelated to food security, and we havea range of data showing that abalanced diet is related to higher
income and higher education.
We need to evaluate food security, inparticular in females and young
children living in poverty, because inadequacy of
micronutrient supply during the short time period of the
1,000-day window may also in developed countries havean impact on further development and consequently on
the economic and health future of the child.
It may be that the magnitude of this problem isoverestimated in the developed world. Nevertheless, aslong as we lack data of sufficient quality on this subject,
this problem should concern us. Nutrition science isbased on molecular biology on the one hand and on
research related to obesity on the other. Both have an
excellent economically driven lobby. Malnutrition,
however, is not in the focus of nutrition scientists, eventhough its impact is as serious as is that of overnutrition.

Further reading
Biesalski, HK. Hidden Hunger. Berlin/Heidelberg,
Germany: Springer-Verlag, 2013.
Roman Vinas B, Ribas Barba L, Ngo J. Projectedprevalence of inadequate nutrient intakes in Europe.
Ann Nutr Metab 2011;59:84-95.
Wahl DA, Cooper C, Ebeling PR et al. A global
representation of vitamin D status in healthy
populations. Arch Osteoporos, 2012;7(1–2):155-172.
Bailey RL, Dodd KW, Gahche JJ et al. Total folate
and folic acid intake from foods and dietary
supplements in the United States: 2003–2006. Am J
Clin Nutr 2010;91:231–237.
Bischoff-Ferrari HA, Willet WC, Orav EJ et al. A
pooled analysis of vitamin D dose requirements for
fracture prevention. NEJM 2012;367:40–49.
Flynn A, Hirvonen T, Mensink GB et al. Intake of
selected nutrients from foods, from fortification andfrom supplements in various European countries.
Food Nutr Res 2009;53:1–51.
Bischoff-Ferrari H. Health effects of vitamin D.
Dermatol Ther 2010;23(1):23–30.
Fulgoni VL, Keast DR, Bailey RL et al. Foods,
fortificants, and supplements: where do Americans
get their nutrients? J Nutr 2011;141:1847–1854.
Grant WB, Cross HS, Garland CF et al. Estimatedbenefit of increased vitamin D status in reducing the
economic burden of disease in Europe. Prog Biophys
Mol Biol 2009;99:104–113.
Zittermann A, Kuhn J, Dreier J. Vitamin D status andthe risk of major adverse cardiac and cerebrovascular
events in cardiac surgery. Eur Heart J
2013;34(18):1358–64.
Zittermann A. The estimated benefits of vitamin D for
Germany. Mol Nutr Food Res 2010;54(8):1164–71.

50