The Success of Fortification of Sugar Héctor Cori Nutrition Science Director Latinoamérica London, November 30, 2016.
Vitamin A
Functions Vitamin A is essential for Embryogenesis, growth and development Differentiation of cells Vision Immunity Fertility Intact epithelia
Tolerance Safety and Deficiency Deficiency symptoms Delayed growth and development Night-blindness Ocular lesions and xerophthalmia Cutaneous lesions (dry and rough skin) Impaired immune functions Destruction of epithelial tissue (i.e. in lungs, intestines) Keratomalacia (reversible) before treatment Diseases strongly associated with Vitamin A deficiency measles respiratory tract infections urinary tract infections diarrhea Improved cornea 1 month after treatment with high dose Vitamin A
Deficiency is Still Common in Africa, Asia and some South American Countries (preschool age children) WHO report 2009
Micronutrient intake in Western countries is not according recommendations Germany United States Barbara Troesch, Birgit Hoeft, Michael McBurney, Manfred Eggersdorfer and Peter Weber Published in British Journal of Nutrition 2012, 108, pp 692-698 United Kingdom The Netherlands Source: Troesch et al BJN 2012
What is the impact of Hidden Hunger? 1.1 mio children <5 years Annual lives lost Annual lives impaired 18 mio babies born mentally impaired 600,000 stillbirths 115,000 women during pregnancy 350,000 children go blind 150,000 babies born with neural tube defects Vit. A & Zinc deficiencies Iron deficiency anemia Iron deficiency anemia Maternal iodine deficiency Vit. A deficiency Maternal folate deficiency Source: WHO, WFP, S&L
We cannot be successful nor can we call ourselves successful in a society that fails Feike Sijbesma, CEO DSM Page 7
From cod liver oil to industrial production 1946
Successes in food fortification 1923: Mandatory iodization of salt in Switzerland. 1933: Mandatory fortification of flour in Canada and virtual elimination of Beriberi in Newfoundland. 1941: Mandatory fortification of flour in the USA and virtual elimination of pellagra 1954: Flour fortified in Chile with B-complex and iron. Country has very low prevalence of Iron Deficiency Anaemia. 1974: Beginning of sugar fortification in Guatemala. VAD diminished to one third. Concomitant improvement of iron parameters in the population. 1992: Wheat and maize flour fortification begins in Venezuela. Vitamin A sufficiency achieved in general population and important reduction in anaemia achieved in children. 1998: Folic Acid fortification mandated in the USA. 19% reduction in NTDs achieved. 2000: Folic Acid fortification mandated in Chile. Besides a 41.6% reduction in NTDs, increase in serum folate and decrease in homocysteine were also recorded. 1930 2005
Intended reach and target groups define fortification approach Choice between mandatory or voluntary fortification depends on national/regional circumstances WHO/FAO. Guidelines on food fortification with micronutrients. 2006.
Example: mandatory fortified staples with multiple nutrients Fortified Staples 1 (20) 2 (12) 3 (7) 4 (2) 5 (1)
Chile: Flour fortification with folic acid diminishes neural tube defects 18 17 16 14-40% 12 10 10,1 8 6 4 2 0 Before After NTD/10,000 Hertrampf et al. Nutrition Reviews, Vol. 62, No. 6
Criteria for food fortification The food vehicle should be consumed by practically all the population; The daily intake of the carrier food should be essentially constant; Fortification should not alter the organoleptic characteristics of the vehicle; Production and processing of the food vehicle should be centralized; The cost of the fortification should be economical; The nutrient is stable in the vehicle under normal conditions of storage and use; There is reasonable assurance that no excess intake will be induced. http://archive.unu.edu/unupress/food/v192e/ch07.htm
Sugar Fortification Technology
Sugar premix preparation
Premix addition points Page 17
Pre-school Children with low Serum Retinol Levels 40% 40% 35% 30% 27% 25% 20% 15% 10% 5% 0% 13% 1967 1996 Honduras Before Fortification Guatemala After Fortification 15% 1965 1995 &1987 O. Dary. Montreal, 1997.
Vitamin A Status and Sugar Consumption of Preschoolers (Guatemala, 1995) 25 20 15 10 5 0 45 42 40 20 38 - - - - - - - - - - - - - - - - - - - - - - - - - - -18 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -35 - - - - - - - - - 27 13 12 18 15 0 6-11 12-23 24-35 36-47 48-59 Plasma Retinol <20 mcg/dl (%) Estimated sugar consumption/day (g) 30 25 20 15 10 5 0 age (mo) Source: Guatemalan National Survey and INCAP intake data. Courtesy Dr. Omar Dary
Nicaragua: Sugar fortification improves vitamin A content in breast milk 2.3 2.28 2.2 2.1 2 1.9 1.8 1.7 1.91 2000 2001 Wallace C et al. 2004. XII IVACG meeting. Retinol in milk
Effect of vitamin A fortification of sugar on iron metabolism in preschool children in Guatemala Percentage Distribution Serum Iron 45 40 35 30 25 20 15 10 5 0 Initial 2 Years <50 µg/dl 50-75 µg/dl >75 µg/dl Mejía, LA, Arroyave, G, 1982.
Cost Effectiveness of Vitamin A Intervention Programs Annual Cost per Person Covered (USD) Dietary Education and Gardening 3.63 Supplementation (Only Preschoolers) 1.52 Sugar Fortification "at risk only" 0.98 Sugar Fortification 0.37 Sugar Fortification "Targeted Approach" 0.2 0 0.5 1 1.5 2 2.5 3 3.5 4 Source: O. Dary. Modified from USAID/Latin American and Caribbean Health and Nutrition Sustainability Project, 1991 Annual Cost per Persone Covered (USD)
Cost-Effectiveness of micronutrient interventions Intervention Region Cost/Person/ Year (USD) Benefit/ Cost Ratio Vitamin A Supplementation S/E Asia, Africa Central Asia Latin America 1.20 1.60 2.60 17:1 13:1 8:1 Zinc Supplementation S/E Asia, Africa Central Asia Latin America 1.00 1.35 2.20 13.7:1 10:1 6:1 Salt Iodization 0.05 30:1 Flour Fortification 0.12 8:1 Source: Copenhagen consensus 2008.
Sugar Fortification Worldwide
Lessons learned Advocacy and Promotion Nutritional gaps, consequences, stakeholder commitment Legislation and Regulations fortification law, standards of identity, technical regulations Technological Development Quest for better compounds and technology Quality Assurance and Control Cooperative instead of punitive Monitoring and Evaluation Program monitoring and impact evaluation Cost Analysis Who pays for investments and fortificant? Sustainability of Supply Adequate financial, institutional and political environment Sustainability of Demand Awareness of population on benefits of fortification MOST: Vitamin A Sugar Fortification in Central America Experience and Lessons Learned
Micronutrient Impact Through Programs Vitamin A 23% reduction in under-five mortality rates 70% reduction in childhood blindness Iodine 13-point increase in IQ Iron 20% reduction in maternal mortality Zinc 6% reduction in child mortality 27% reduction of diarrhoea incidence in children Folate 50% reduction in severe neural tube birth defects, such as spina bifida A united call to action on vitamin and mineral deficiencies (2009)
1+1>2: Multisectorial alliances maximize the chances to unlock human potential 27