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--> Executive Summary It is estimated that the requirement worldwide for grain, simply to maintain current food consumption and meet emergency needs, will double in the next decade. In some regions, most notably sub-Saharan Africa and South Asia, the stagnation of nutritional improvement combined with a rapid rise in population has resulted in an actual increase in the total number of malnourished children. Most of sub-Saharan Africa is now worse off nutritionally than 10 years ago. Globally, nearly 200 million children under 5 years of age continue to be malnourished. At the same time, global food aid deliveries have declined continuously since 1993. The United States contributes a variety of food commodities to global food aid through the Food for Peace Program authorized by Public Law (P.L.) 480, Title II and administered by the U.S. Agency for International Development (USAID). These commodities include cereal grains (corn, wheat, rice, sorghum), pulses (peas, bean, lentils), vegetable oils, and a variety of milled cereal and blended products (e.g., wheat flour, corn meal, soy flour). In 1996, approximately 1.7 million metric tons (MT) of food aid commodities valued at more than $840 million were distributed through Title II programs. In addition to general protein-energy malnutrition (PEM), international food relief organizations are focusing increased attention on the global incidence of micronutrient deficiencies. Deficiencies of vitamin A, iron, and iodine are widespread in developing countries. Deficiencies of micronutrients such as vitamin C, niacin, and thiamin have occurred in localized areas, primarily in Africa and South Asia. To address some of these micronutrient deficiencies, two blended, fortified commodities are produced for distribution in the Food for Peace Program, corn-soy blend (CSB) and wheat-soy blend (WSB). These blended foods consist of a mixture of the appropriate cereal
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--> (gelatinized cornmeal or wheat flour and wheat protein concentrate), defatted soy flour, and soybean oil; they are fortified with 6 essential minerals and 11 vitamins, including vitamin C. These foods are provided as ration supplements to refugees and internally displaced persons in camps and to recipients of development aid programs that are targeted largely towards mothers and children. The United States supplied 84 percent of the total fortified, blended foods used worldwide in 1996. The current level of vitamin C fortification of CSB and WSB (40 mg/100 g) is based on the 1974 National Research Council (NRC) recommendations for children up to 11 years of age, by assuming an intake of 100 g of blended cereal per day. However, the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) recommend a minimal requirement of 20 mg of vitamin C per day for children up to 5 years of age and 30 mg for adults; the United Nations High Commissioner on Refugees (UNHCR) recommends 27 mg of vitamin C per day. Background and Charge to the Committee Beginning in fiscal year (FY) 1993, U.S. congressional appropriations committees urged USAID to increase the amount of vitamin C added to CSB and WSB from 40 mg/100 g of cereal blend to 90–100 mg/100g of cereal blend. The stated purpose of the increased vitamin C fortification of these blended foods was to improve the health of food aid recipients, particularly new mothers and infants, and to reduce the need for, and cost of, later medical interventions. An initial study commissioned by USAID on various options for appropriate micronutrient fortification recommended that vitamin C fortification not be increased until additional information was obtained on the stability of vitamin C during transport, storage, and preparation. The FY 1996 Senate Appropriations Committee 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 the results. In response, USAID initiated 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 requested that the Institute of Medicine (IOM) address the cost-effectiveness and advisability of scaling up vitamin C fortification of these blended food aid commodities to improve recipients' diet, nutrition, and health. The Committee on International Nutrition—Vitamin C in Food Aid Commodities of the Food and Nutrition Board was constituted in response to this request. The committee was charged with review of the proposed pilot program, examining it for soundness of scientific and technical design in relation to (1) monitoring the presence and stability of vitamin C in food aid commodities and (2) assessing the dietary intake of vitamin C, nutritional status, and health status of recipients. Based on this review, the committee prepared a brief report Vitamin C in Food Aid Commodities: Initial Review of a Pilot Program (IOM,
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--> 1996). For the present report, the committee's specific charge was to assess the results of the pilot program; determine the advisability of increasing vitamin C fortification to improve recipients' diet, nutrition, and health; and determine the cost-effectiveness of increased vitamin C fortification of food aid commodities compared with other means of delivering vitamin C. Methods The committee met twice during the study. At the first meeting, an open session was held with representatives from USAID, SUSTAIN, the U.S. Department of Agriculture, the Food and Drug Administration, the Kellogg Corporation, and Protein Grain Products International. The committee reviewed SUSTAIN's proposed pilot program and prepared a preliminary report. Committee staff conducted an extensive literature search to attain a more global view of the reported incidence of scurvy in refugee populations, the effects of vitamin C on iron absorption, and other potential health effects of vitamin C supplementation. At the second meeting, the committee reviewed SUSTAIN's final report of the results of the pilot program, conducted a videoconference with USAID and SUSTAIN representatives, and teleconferenced with a representative of the United Nations' World Food Programme for further insights into global food aid needs. Additional information was obtained on the tonnage of CSB and WSB produced, their distribution in development versus emergency relief programs, and cost information on various methods of providing vitamin C. These activities provided the committee with the information on which it based its deliberations. Conclusions Dietary deficiency of vitamin C eventually leads to scurvy. Clinical signs of scurvy include swollen or bleeding gums, petechial hemorrhages, joint pain and swelling, and follicular hyperkeratosis. These symptoms are associated with plasma (or serum) vitamin C values of less than 0.2 mg/dl. Minimum dietary levels ranging from 6.5 to 10 mg per day have been reported necessary to prevent clinical signs of scurvy. These same levels have been found to produce marked improvement of mild clinical signs of scurvy; however, higher doses (32 mg up to 600 mg per day) were needed for more rapid improvement of symptoms and saturation of body stores. Scurvy outbreaks have occurred among refugee populations entirely dependent on emergency relief rations that provide less than 2 mg of vitamin C per day per person. The greatest number of outbreaks occurred in the 1980s in Somalia. Except for a recurring mild scurvy outbreak among Bhutanese refugees in Nepal, all other outbreaks in the past two decades have been in
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--> refugee camps in the greater Horn of Africa (Ethiopia, Kenya, Somalia, Sudan). The reason for this localized occurrence is not clear, but it may be due to the location of these camps in isolated areas away from local populations and markets and on land unsuitable for cultivation. Thus, the need for higher vitamin C fortification of CSB or WSB would be sporadic and localized. Only a small proportion (7 percent) of U.S.-supplied CSB and WSB is designated for emergency feeding programs in East Africa, where scurvy has been reported. Thus, fully 93 percent of the cost of adding more vitamin C to blended, fortified foods as a strategy for preventing scurvy would be wasted. If a fixed dollar amount is assumed available for the purchase of food aid commodities, increasing the vitamin C content to 90 mg/100 g—at an estimated increased cost of $6.33/metric tons (MT)—would lead to forgoing the provision of fortified blended commodities as a supplement (30 g per person per day) in emergency food aid to approximately 425,800 recipients. This situation is not conducive to improving their nutrition and health status. Alternative approaches for the prevention of scurvy should be explored where the availability of locally produced vitamin C-rich foods is low. Furthermore, results of SUSTAIN's pilot program identified unacceptable variability in the fortification levels of vitamin C in CSB, which raises serious questions about the ability of manufacturers to meet specified nutrient levels in the final product. None of the four CSB plants sampled consistently achieved target fortification levels, and two of them were outside specifications almost 60 percent of the time. Given the pervasive problem of lack of uniformity, the committee believes it would be inappropriate to increase any micronutrient fortification of these commodities without better manufacturing controls. Information from the pilot study indicates that vitamin C losses during shipping and storage are not a concern, but losses of vitamin C during cooking may be a major limiting factor, ranging from a low of 52 percent up to as much as 82 percent lost. However, data for vitamin C losses during cooking were not conclusive because of a number of variables introduced, particularly the variability of vitamin C concentration in the starting blends and the very limited number of samples analyzed. In addition, although iron deficiency appears to be a much more widespread problem than scurvy in emergency feeding situations, the use of higher levels of vitamin C fortification to enhance iron absorption is not a cost-effective method of improving iron status. Even if the current cost of fortifying blended foods with iron ($1.61/MT) could be cut in half, the net effect of improving iron absorption through the addition of vitamin C would still be a cost increase of $5.52/MT.
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--> Recommendations 1. The level of vitamin C fortification of blended food aid commodities should NOT be increased to 90 mg/100 g, but should be maintained at the current level of 40 mg/100 g. Based on the reported incidence of scurvy and the quantity of U.S.-supplied blended food commodities going to regions where scurvy has been reported, increasing vitamin C fortification of all CSB and WSB is not cost-effective. 2. Strengthen health surveillance systems in refugee camps to monitor population risks of vitamin C deficiency and scurvy and to initiate a timely response. Risk factors for vitamin C deficiency and scurvy should be monitored at the community and/or camp level. Some risk factors that have been identified as potentially useful for such monitoring include populations totally dependent on food aid (e.g., displaced and famine-affected populations); duration of stay in a refugee camp; seasonality: dry season and inability to cultivate; market failure, limited local supplies of fresh produce, or lack of resources to trade for other food sources; poor acceptance of donated foods, especially the blended, fortified foods, resulting from cultural preferences; and difficult access by relief organizations because of war or remoteness. At the individual level, risk factors include age and physiological status (young children, pregnant and lactating women, and the elderly have been found more susceptible). 3. Target identified populations at risk for scurvy with appropriate vitamin C interventions. There are several possible strategies to achieve increased vitamin C supplementation: (1) increased access to local foods and markets; (2) local fortification of commodities in the country or region where the emergency is occurring, as is currently practiced in some regions; and (3) use of vitamin C tablets if scurvy is already present. Alternatively, an increased total daily ration of conventionally fortified, blended food would be appropriate to an emergency feeding situation and would increase the intake of other important nutrients such as energy, protein, and iron, as well as vitamin C. Another possibility might be for USAID's Bureau of Humanitarian Response to investigate the logistics of managing two supplies of CSB and/or WSB, the conventionally fortified blends and a small proportion of highly fortified blends that would be targeted as part of the general ration only to situations where the risk of vitamin C deficiency is high and continues for several months. 4. Improve the uniformity of blended food aid commodities by implementing specific product and process procedures. Delivery of vitamin and mineral fortification via food aid commodities to target populations depends on the manufacturing facilities' ability to comply with formulation and finished product specifications. To improve the uniformity of blended food, the following remedial initiatives are recommended:
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--> Formulation document—a formal reporting of the formulation and ingredients used to generate a particular product or blend. Product specifications—instituting procedures for analytical quality control to monitor compliance with fortification levels defined by product specification. Inability of manufacturer to comply can result in loss of contract. Methods and sampling procedures—listing of all statistical process control procedures, analytical procedures, test methods, and appropriate sampling protocols. Operating guide—a formal document that provides a blueprint for operating a process. It includes a process description for each step, a review of normal operating conditions, control actions (the set of steps necessary to maintain a quality operation), and a discussion of the impact of each process step on product quality. Control plan—a master document that keeps track of a plant's record keeping. It lists the specification or test to be performed, the source of the authority for the test, who is responsible for conducting the test, the test frequency, where the test is recorded, what action to take, and where to file or who must receive the report. HACCP (Hazards Analysis Critical Control Points) plan—a preventive system to identify key areas of process control to avoid food safety risks. Measurements of improvement include analytical sampling and analysis of key fortification nutrients, regular audits of plant performance, maintenance of calibration records for all metering equipment, and maintenance of usage records for all vitamin and mineral premixes. Research Recommendations The committee has identified several areas in which additional research would be most helpful in alleviating potential vitamin C deficiencies and evaluating the appropriateness of any overall vitamin C fortification of U.S. commodities. 1. Research the epidemiology of vitamin C deficiencies. Ascertain the incidence of scurvy in displaced populations and analyze this according to the amount of blended, fortified foods received. The incidence of scurvy among those receiving blended foods at currently prescribed levels will permit assessment of the need to increase fortification or seek alternative approaches. Develop and validate predictors of populations at risk of vitamin C deficiency among refugees so as to institute local fortification. 2. Research and develop means to increase consumption of local foods rich in vitamin C. This may also be achieved by purchasing these foods for refugees, but it may be done more cost-effectively by decreasing barriers to barter and trade in refugee camps.
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--> 3. Research and evaluate appropriate ration sizes of blended foods. More information is needed on the amounts of blended foods distributed to those at risk for scurvy in displaced populations. Currently, no good information is available on actual quantities distributed. This may also indicate that much higher levels of fortification than are currently being considered would be necessary for those at most risk because they could be receiving smaller rations. 4. Research and evaluate methods for campsite vitamin C fortification. This would be the most cost-effective approach to fortification because the need is rare and the cost of vitamin C is relatively high. 5. Research alternative forms of vitamin C available for fortification. The limited data available on cooking losses when using the current ethyl cellulose-coated product indicate a need to develop other vitamin C products that are more stable to heating in dilute solutions.
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