Keys to sustainable food fortification programs in ...nutritionfoundationofindia.org/NNP...

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Assoc. Prof. Visith Chavasit

Institute of Nutrition, Mahidol University

Thailand

Keys to sustainable food fortification programsin developing countries

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MIRONUTRIENT DEFICIENCIES

- Damage to health

- Learning ability

- Working performance

HIDDEN HUNGER


- People’s quality of life

- Social

- Economic status

Impacts of micronutrient deficiency to a nation


Region

IDD

At

Risk1

IDD

Affected

(Goitre)1

Vitamin A

At Risk2

Vitamin A

Affected

(Xerophth

lamia)2

Iron

deficient or

anemic3

Africa 181 86 52 1.0 206

Americas 168 63 16 0.1 94

South-East Asia 486 176 125 1.5 616

Europe 141 97 -- -- 27

Eastern

Mediterranean173 93 16 0.1 149

West Pacific 423 141 42 0.1 1058

Total 1572 655 251 2.8 2150

WHO/UNICIF/ICCIDD (1994)1. WHO/UNICEF (1995)2. WHO(1992b)3.

ESTIMATED NUMBERS OF PEOPLE (IN MILLIONS) AT RISK

AND AFFECTED BY THE THREE MAIN FORMS OF

MICRONUTRIENT MALNUTRITION


Diet

Diversification

Supplementation Fortification

Strategies for the control

of micronutrient

malnutrition


Comparison of annual cost-effectiveness

estimates between countries

Phillips M. et al., 1994


Food Fortification can be

one the best choices


The very first food

fortification program

Salt iodization

Sustainable in many countries

WHO/UNICEF/ICCIDD, 2001


NUTRIFICATION

Addition of essential nutrients

to improve the nutritional value of

a food


FORTIFICATION

STANDARDIZATIONRESTORATION

ENRICHMENT

Definitions


STANDARDIZATION

RESTORATION

Addition of essential nutrients to

replace losses that occur during

food manufacture, storage and

handling

Addition of essential nutrients a

food to compensate for naturally

occurring variations in nutrient

levels

Definitions


ENRICHMENT

FORTIFICATION

Addition of essential nutrients

to levels higher than those

naturally found in a food

Addition of essential nutrients to

a food

Definitions


Effect of enrichment of flour on beriberi in

Newfoundland, 1931-49

Aykroyd WR, 1949


Effect of enrichment of flour on deaths from

pellagra in the United States, 1938-54

Miller DF, 1978


Enriched rice in Japan


Factors to be considered before starting

a food fortification program

Target

population

Fortificants

Impact of the program after

distribution of the fortified product

Country’s malnutrition

problem

Food vehicles

Fortification

level

Food and Agriculture Organization 1996; Lotfi and others 1996; Blum 1997


Source of information for MNM

• Deficiency problems in other countries

with similar backgrounds

• Clinical reports from local health offices,

hospital and research studies

• Cross-section survey : National nutrition

survey


Vitamin D deficiency


Population

Consuming

Processed

Food

How often?

How much?

Defining the Intervention:

What is Coverage and Protection?


Population

At-Risk

of MNM

Population

Consuming

Processed

Food

Relating Problem and Intervention

Overlap of vehicle and Risk


What is the size of the overlap of

At-Risk and Fortified vehicle?

Great Impact

Some Impact

Good Impact

Questionable


Affordable

price

Staple

food

Distribute

to all parts

No further

severe

cooking

No changes

in sensory

Centrally

producedIdeal Food

Vehicle

Normally

consumed



Large Scale Soy Sauce Production in China

Province Factories Sales Production

# RMB %Total MT %

Shandong

Guangdong

Jiangshu

Sichuan

Liaoning

Henna

Jinling

Shanxi

Yunnan

Guangxi

Hunan

Nei Menggu

Xinjiang

Ningxia

Hainan

Xizhang

116

96

171

254

95

96

67

19

51

48

79

62

16

4

5

1

119587

141420

49134

41157

24980

18448

13283

3968

7205

12179

11327

5010

2583

1161

157

0

18.3%

21.6%

7.5%

6.3%

3.8%

2.8%

2.0%

0.6%

1.1%

1.9%

1.7%

0.8%

0.4%

0.2%

0.0%

0.0%

537899

359082

230938

164759

137562

77040

60378

52126

40992

37813

35554

32364

20756

6476

5272

0

17.8%

11.9%

7.7%

5.5%

4.6%

2.6%

2.0%

1.7%

1.4%

1.3%

1.2%

1.1%

0.7%

0.2%

0.2%

0.0%


Production Capacity of Wheat Flour in China

Number Mills Capacity Annual

Capacity

%Total

Capacity

75 >100,000* 22,500,000 2.1%

480 50,000-100,000 36,000,000 3.4%

1,500 25,000-50,000 56,250,000 5.4%

7,500 12,500-25,000 150,000,000 14.3%

98,000 <12,500** 784,000,000 74.8%

China: Small Mill Share of Total Capacity 75%

* Large Mill Average 300,000 MT ** Large Mill Average 8,000 MT


Wheat flour in Thailand

• 8 modern large wheat flour millers

• Wheat flour consumption :

20g/person/d low income families

100g/person/d high income families

National Food Fortification Committee of the Ministry of Public Health, Thailand, 2003


Cost of fortificant

per unit

Cost of the

fortificant

Effect on

sensory

Bioavailability

Stability

Concentration of

essential nutrient

Necessary

Information

Necessary Information of Fortificant



No or minimum

interaction with other

nutrients

No need for

complicated and/or

expensive

fortification

technology

Other

Information

Available quality

monitoring method

and system

Other Information to be Considered



Vegetable oil fortification in Thailand

+ Vitamin A palmitate

Puysuwan and others, 2007


Chelating agent

Encapsulation

Coating

Protection

Protection of Fortificant


Form of iron Iron content

(%)

Relative cost per

unit of irona

Iron reduced with H, 98.0 1

Reduced iron,

electrolytic

98.0 3

Ferrous sulphate,

anhydrous

31.6 2.6

Ferrous fumarate 30.6 3.4

Ferric orthophosphate 26.0 5.9

Ferric lactate 20.5 22.8

Ferrous gluconate 12.5 26.2

NaFeEDTA .3H2O 12.5 50.4

a= Iron reduced with H2 is the reference substance.

Relative cost considers cost and iron content

Food and Nutrition Board, National Research

Council. Recommended dietary allowances., 1989.

Chemicals and Cost


Cost of fortificant and processing aid in

double fortified fish sauces

Cost in US cents per bottle (750 ml)

Fortificant Cost

Ferrous sulphate + KI 0.38

NaFeEDTA + KI 1.82

Ferric ammonium citrate +KI 7.80

Ferrous lactate + KIO3 2.44

LOGOwww.themegallery.comA report of the International Anemia Consultative Group (INACG), 1993; Hurrell, 1985; Shah etal., 1977

Relative bioavailability of Iron salts


Vitamin A palmitate

106 IU/g: kg $ 353

Fortification level: 60 IU/g oil

Puysuwan and others, 2007


Instant noodles fortification in Thailand

Chavasit and Tontisirin, 1998

Fortificant :

Iodine Potassium iodide

Fe Elemental iron

Vitamin A Vitamin A palmitate

Cost of the premix

0.06 US cents/serving

Taxation

33% 1%


Dry

Mixing

Dissolution

in oil

Dissolution

in water

Adhesion

Fortification Technology


etc.

Coating Spraying

Extrusion

Fortification Technology


Multiple-fortified quick cooking rice

in Thailand

Examples of food fortification programs in

developing countries in Asia


Sweeten condensed milk in Thailand: vitamin A




Cooking oil in China: Vitamin A




Wheat flour in China: Iron & vitamins

Wheat flour in Indonesia: Iron & vitamins






Instant noodles in Thailand: Iron, Iodine, Vitamin A


Soy sauce in China: Iron

Fish sauce in Thailand: Iron, Iodine



Fish sauce in Vietnam: Iron

Salt fortification in most countries: Iodine


Mandatory Fortification

Voluntary Fortification

Food producers elect to fortify

foods

Government requires the

fortification of certain foods in the

interests of public health

www.mostproject.org

LOGOwww.themegallery.comwww.mostproject.org

LOGOwww.themegallery.com MOST/USAID, 2000: Voluntary fortification


“Nutrition Seal”

Regulation on Use


Test-kitPre-mix

fortificantStandard

Method

Quality Control of the Fortified

Products


Assurance during Production

Rapid method ????

Post marketing

Government, Social,

Consumer Protection

Agency

Quality Control of the Fortified Products


Impact Evaluation

Evaluate by methods

of different complexity and cost

In vitro method: dialyzability

low cost

Efficacy trials: stable isotope techniques

high cost

: in a population

large number of subjects

long time

Forbes and others, 1989; Allen and others,1997


Quick cooking rice in Thailand: Iron

Iron bioavailability study by using

stable isotope


Effectiveness evaluation

Impact of an intervention or program

in actual practice


Coverage of the fortified food in the

vulnerable population

as an indicator of program success

Salt iodization

Universal salt iodization


Government

Consumer

Food &

Pharmaceutical

Industries

Bilateral &

Multilateral

Organizations

NGO’s


WIN-WIN SITUATION

Industry

Consumer

Government

Sustainability of

Food Fortification Program


GOOD HEALTH

- Coverage

- Affordable

-Efficacy

Safety

- Sustainability

Jack BagrianskyKeystone Center

GOOD BUSINESS

- Volume

- Competitive Price

- Product Quality

- Profit


Conclusion

A solid partnership between industry,

government and academia focusing

on the benefits for consumers is one

of the key factors for the success of a

food fortification program

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Keys to sustainable food fortification programs in ...nutritionfoundationofindia.org/NNP...

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