America’s Public Health Policies: The Good, the Bad, and the Ugly

Loopholes in nutrition labeling laws regarding fortified products and enriched supplements

By Roberta H. Anding, MS, Baylor College of Medicine and Texas Children’s Hospital
Edited by Kate Findley and proofread by Angela Shoemaker, Wondrium Daily

Have you ever noticed at the grocery store that many products from orange juice to cereals are fortified with vitamins? This is a result of public health policies enacted in the last hundred years. Professor Roberta Anding walks us through some of these policies—some beneficial, others with unintended consequences.

Woman reading nutritional facts in grocery store
Public health policies during the 20th century have improved the health of Americans, although nutrition labeling for dietary supplements does not always meet the burden of purity, safety, and efficacy issues. Photo by Goksi / Shutterstock

Public Health Policies and Fortification

Many public health policies in the 20th century have significantly improved our well-being. In 1924, salt was fortified with iodine, which greatly reduced the number of Americans who developed goiters, which are abnormal enlargements of the thyroid gland. Beginning in 1933, milk was first fortified with vitamin D to prevent rickets. 

In the 1940s, policies were enacted to establish a standard of identity for foods claiming to be enriched. If a product was classified as enriched, it must contain thiamine, niacin, riboflavin, and iron. 

Many products that we see on the shelves today such as bread, white rice, and cereal are enriched with these missing nutrients. Keep in mind that with grains, when the product was milled and the outer bran layer was removed, a lot of nutrients that were naturally occurring in that food were lost, and now we add them back by enriching these foods.

In the response to the science linking folic acid deficiency in pregnant women to neural tube defects in that developing fetus, a standard of identity was updated to include that nutrient as part of an enrichment program in 1998. This was a major public health initiative. 

It took a long time to get this 1998 initiative enacted because scientists had to evaluate the risks and benefits associated with folic acid enrichment. The benefits have been significant in terms of reducing the number of neural tube defects, spina bifida, and anencephaly, which were major public health concerns for pregnant women.

Why DSHEA Backfired

Nutrition labeling laws, school lunch mandates, and dietary guidelines for Americans are all examples of public health policies intended to improve the health of Americans. However, not all policies have the intended outcome, and the most notable is the Dietary Supplement Health and Education Act (DSHEA) of 1994

The DSHEA gives manufacturers the ability to make what is called a “structure/function claim,” such as “calcium can contribute to bone health.” This product cannot say “calcium prevents osteoporosis.” The latter is a disease claim, while the former links structure and function. 

“I think this piece of legislation had a good intention, but no one really thought about the consequence, and some of the problems that we have with dietary supplements in this country now are related to the Dietary Supplement Health and Education Act (DSHEA),” Professor Anding said. 

This measure has shifted the burden of purity, safety, and efficacy from the manufacturer to the Food and Drug Administration (FDA). That is not the way pharmaceuticals are regulated in this country. 

Pharmaceuticals must show purity, safety, and efficacy before they can reach the market, but that is not true with supplements. In fact, it’s the reverse—the FDA has to prove a supplement is dangerous versus the manufacturer proving it is safe.

This presents a challenge for the American consumer when it comes to deciding whether or not a product is trustworthy. A 2015 study published in the American Journal of Public Health found that supplements often have limited efficacy, can be contaminated by dangerous compounds such as carcinogens, and may contain unlisted ingredients. 

Star Caps Controversy

One product that had been all over the news is called Star Caps. As a weight loss aid, it had an undeclared diuretic which was linked with electrolyte abnormalities. Many Americans already at their limits for diuretics took this supplement because there was no warning on the label, endangering their health.

“In my world of professional sports, we’ve had six NFL players that will be suspended because they were taking this product because it’s banned by the NFL,” Professor Anding said. “They are not allowed to take a diuretic in order to make weight, and so now these men will lose 25 percent of their salary for something that they didn’t know had an undeclared diuretic.”

Therefore, the DSHEA ended up having negative unintended consequences. Many of these public health policies, however, have greatly benefited the American people. 

This article was edited by Kate Findley, Writer for Wondrium Daily, and proofread by Angela Shoemaker, Proofreader and Copy Editor for Wondrium Daily.

Professor Roberta H. Anding is a registered dietitian and Director of Sports Nutrition and a clinical dietitian at Baylor College of Medicine and Texas Children’s Hospital. She also teaches and lectures in the Baylor College of Medicine’s Department of Pediatrics, Section of Adolescent Medicine and Sports Medicine, and in the Department of Kinesiology at Rice University.