Over the past 5 years, there has been considerable interest and focus on micronutrient fortification of rations provided in international food relief programs. The United States makes significant contributions to food aid authorized by Public Law (P.L.) 480, Title II as the Food for Peace Program. This program is administered by the U.S. Agency for International Development's Bureau of Humanitarian Response (BHR).

Beginning in fiscal year 1993, congressional appropriations committees urged the U.S. Agency for International Development (USAID) to more than double the amount of vitamin C added to blended commodities exported through P.L. 480, Title II programs (Foreign Operations, Export Financing, and Related Programs Appropriations Bill, 1993, S. Rpt. 102–419; 1994, S. Rpt. 103–142) (see Appendix A). The commodities that were targeted for increased fortification were corn-soy blend (CSB) and wheat-soy blend (WSB)—the only commodities that are fortified with vitamin C. These blended foods are also fortified with an array of other vitamins and minerals and require minimal cooking. The stated purpose of the increased vitamin C fortification of these blended foods was to improve the health of food aid recipients and reduce the need for, and cost of, later medical interventions (Foreign Operations, Export Financing, and Related Programs Appropriations Bill, 1994, S. Rpt. 103–142). Supplemental rations of these highly fortified, blended foods are provided to refugees and displaced persons in camps and to beneficiaries of development feeding programs that are targeted largely toward mothers and children. The 1995 congressional appropriations conference report asked for information on the cost of increased fortification and the stability of vitamin C throughout the shipping process (Making Appropriations for the Foreign Operations, Export Financing, and Related Programs for the fiscal year ending September 30, 1995, Conference Report, 1995, H. Rpt. 103–633).

The stability of vitamin C (L-ascorbic acid) is of concern because this is the most labile vitamin in foods. Its main loss during processing and storage is from oxidation, which is accelerated by light, oxygen, heat, increased pH, high moisture content (water activity), and the presence of copper or ferrous salts. Oxidative losses also occur during food preparation, and additional vitamin C may be lost if it dissolves into cooking liquid that is then discarded.

In 1995, the Senate Appropriations Committee Report 104–143, "Foreign Operations, Export Financing, and Related Programs Appropriation Bill, 1996," directed USAID to initiate a pilot program to increase the vitamin C content of CSB and WSB to 90 mg/100 g and to report on the results (Appendix A). In response, USAID set up a cooperative agreement with the organization SUSTAIN (Sharing United States Technology to Aid in the Improvement of Nutrition) to devise and implement the pilot program. USAID also asked the Institute of Medicine (IOM) to form a committee to address the cost-effectiveness and advisability of increasing the level of vitamin C used to fortify the food aid commodities CSB and WSB. The Committee on International Nutrition—Vitamin C in Food Aid Commodities was constituted in response to this request.

The committee's overall task was to address the cost-effectiveness and advisability of scaling up Title II commodity vitamin C fortification to improve recipients' diet, nutrition, and health. The committee's initial report, Vitamin C in Food Aid Commodities: Initial Review of a Pilot Program (IOM, 1996), addressed the first part of its specific tasks. In particular, it reviewed the pilot program designed by SUSTAIN, presented recommendations for its improvement, and identified additional types of information needed to complete the overall task. The committee emphasized the potential value of collecting data from emergency feeding programs, as well as from development programs, and of collecting samples on-site to determine vitamin C losses during food preparation. It requested additional data on cost, and on the prevalence of scurvy and insufficient vitamin C and iron intakes in populations that receive blended foods.

SUSTAIN had access to the IOM's initial report as it completed its pilot program. SUSTAIN and USAID presented Results Report on the Vitamin C Pilot Program (Ranum and Chomé, 1997) to the Committee on International Nutrition shortly before the committee's second meeting. That report covers the following topics: the uniformity of vitamin C distribution in WSB and CSB at five plant sites; the stability of vitamin C from point of production to distribution in both CSB shipped to India and WSB shipped to Haiti; the variation of vitamin C distribution within bags after shipping and handling; cooking methods and the retention of vitamin C following food preparation by recipients; and estimates of the cost of increasing vitamin C fortification from 40 to 90 mg/100 g. The report also provided responses to each of the special information requests submitted by the Committee on International Nutrition.

In the present report the committee reviews and evaluates the final report of the pilot program, determines the cost-effectiveness of scaling up vitamin C fortification, makes recommendations concerning the advisability of increasing vitamin C fortification, and discusses alternative mechanisms for providing vitamin C to refugee populations at risk for vitamin C deficiency. The committee also

identifies areas in which additional research is needed to more effectively meet nutritional needs in emergency feeding situations.

The chair and the entire committee would like to express their sincere appreciation to the representatives of SUSTAIN, the U.S. Department of Agriculture, and USAID who met with the committee to answer questions about data in the SUSTAIN preliminary and final reports and provided additional information to the committee as it became available. The committee also thanks Judit Katona-Apte of the United Nations' World Food Programme, who provided information on emergency feeding programs. The committee expresses its gratitude for the staff assistance and support provided by the IOM. We are indebted to Carol Suitor, who served as study director for the initial committee report; Mary Poos, study director for the committee's final report; Diane Johnson and Geraldine Kennedo, senior project assistants; Mike Edington, managing editor; Claudia Carl, administrative associate for report review; and Carlos Gabriel, financial associate. The committee especially thanks Allison Yates, director of the Food and Nutrition Board; Karen Hein, executive officer; and Kenneth I. Shine, president of the Institute of Medicine. The work of the committee was made possible only by the contributions and support of these individuals.