Appendix B
SUSTAIN Report Executive Summary

Reprinted with permission from SUSTAIN.



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--> Appendix B SUSTAIN Report Executive Summary Reprinted with permission from SUSTAIN.

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--> SHARING UNITED STATES TECHNOLOGY TO AID IN THE IMPROVEMENT OF NUTRITION Results Report on the Vitamin C Pilot Program Submitted to the U.S. Agency for International Development for Consideration by the Committee on International Nutrition of the National Academy of Sciences Prepared by SUSTAIN (Sharing United States Technology to Aid in the Improvement of Nutrition) Peter Ranum Program Director Françoise Chomé Deputy Program Manager September, 1997 Second Edition SUSTAIN 1400 16TH STREET, N.W. · Box 25 · WASHINGTON . D.C. 20036 202 328-5180 · FAX 202 328-5175 · SUSTAIN@SUSTAINTECH.ORG

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--> Executive Summary This report contains the results of the USAID Vitamin C Pilot Program for use by USAID in consultation with the National Academy of Sciences to determine appropriate vitamin C fortification levels in food commodities used in U.S. food aid programs. The Vitamin C Pilot Program, initiated in March 1996, was designed to produce, provide, and evaluate food aid commodities with increased levels of vitamin C fortification. Using standard procedures, USAID's Food for Peace program procured two commodities for the pilot program. These commodities, corn soy blend (CSB) and wheat soy blend (WSB), were provided to Tanzanis and Haiti at higher levels of vitamin C. SUSTAIN provided technical advice and monitored and evaluated the results of the program. The report details the following monitoring results: 1.   The uniformity of vitamin C distribution in the products at five plant sites. Vitamin C distribution at each plant site varied from plant to plant and within any given production run. The variability was particularly evident in CSB, which is produced by a continuous process. WSB, while produced in much more limited quantities, is processed by a batch system and showed more uniformity. The ability of the different plants to control the amount and variation of vitamin C added to the commodities was dependent on the type of processing equipment, plant design, and quality control procedures used in each plant. 2.   The stability of vitamin C from point of production to distribution of CSB shipped to India and of WSB shipped to Haiti. The time involved for shipping, transport, and storage (nine months for Haiti and five months for India) resulted in very little loss of vitamin C. The WSB with the conventional level of added vitamin C that was sent to Haiti showed a small (13%) but significant (p<.01) loss of vitamin C. The WSB with the high level of added vitamin C and the CSB sent to India showed no significant (P>>.05) change in vitamin C.1 3.   The variation of vitamin C distribution within bags after shipping and handling to Haiti and Tanzania. Within-bag variation was tested after shipping and handling by sampling bags at two recipient sites from the top, middle, and bottom of the bag. There was variation among samples taken from the three bag locations but the variability was consistent throughout the bag, indicating that there was no systematic stratification or concentration of the vitamin within one part of the bag. 1   The pilot CSB procurement sent to Tanzania could not be tested for vitamin C because the distribution of added micronutrients in this pilot procurement was not uniform. Therefore, it was deemed impractical for purposes of means comparisons; consequently, a procurement of conventional CSB shipped to India was substituted.

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--> 4.   The stability and presence of vitamin C after food preparation by recipients in a regular program in Haiti and an emergency program in Tanzania. Retention of vitamin C added at conventional levels was between 17 and 32% in CSB gruel samples and was 27% in WSB gruel samples. Gruel samples containing 14% CSB or WSB are the most common foods prepared from these commodities, accounting for 62% of the 39 prepared food samples collected. CSB and WSB containing low levels (below 24 mg(100g) of vitamin C lose nearly all of the vitamin C during cooking. Conversely, the higher vitamin C levels allowed cooked food to retain some vitamin C at the time of consumption. The retention at high levels of added vitamin C was 56% in CSB gruel and 32% in WSB gruel. In the refugee camps in Tanzania, the next most common food made from CSB was "ugali," which contains 40% CSB. It showed an average vitamin C retention after cooking from 36 to 74% for ugali prepared with CSB containing high levels of vitamin C. In Haiti, the second most cooked dish made from WSB contained 80% WSB. This dish showed a mean vitamin C retention of 18% with WSB containing the conventional level of vitamin C and a mean retention of 33% with WSB containing the high level of vitamin C. 5.   A projection of the increased cost to the Food for Peace Program of increased levels of vitamin C. The current price of the ethyl cellulose coated vitamin C used in conventional CSB and WSB (40mg/100g) is $9/kg or $3.69/MT of fortified CSB or WSB. The price of vitamin C fluctuates and is currently quite low compared to past years, when the cost was twice as high. If the ethyl cellulose coated vitamin C level of the commodities was increased from its present level of 40 mg/100g of commodity to 90 mg/100g, the cost would increase by $6.33/MT. Part of this cost increase can be attributed to having to use a more dilute vitamin premix, resulting in higher storage and shipping expenses. These results are fully detailed in samples and analyses shown in the appendices. The report also presents supplemental information requested by the Committee, on International Nutrition of the National Academy of Sciences. Reports of scurvy outbreaks have been confined, except in rare occasions, to refugee populations in East Africa where refugees are largely dependent on food aid. SUSTAIN's literature search did not identify cases of scurvy that were attributed to food aid in regular development programs. General rations containing inadequate vitamin C, combined with a lack of diversity of food sources, have been named as the primary factors for outbreaks of scurvy in displaced and famine-affected populations. Other characteristics are lack of ability to cultivate or trade for other food sources, remoteness and inaccessibility, cultural factors affecting food acceptance and age and physiological status (pregnancy and lactation) of individuals in these situations. Many authors recommend 6 to 10 mg of vitamin C a day as a minimum requirement to prevent clinical mainfestation of scurvy. The amount of vitamin C provided by CSB or WSB, containing 40 mg/100g of vitamin C at the point of consumption, when provided at a ration of 30 grams of CSB or WSB per day, would be 3.6 mg/day given a 30% cooking retention.

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--> Until 1994, fortified careal blends such as CSB and WSB were only occasionally provided in the general ration to refugees in East Africa when high prevalence of scurvy was determined. Most reported outbreaks of scurvy occurred before 1990. Fortified blended foods are now more routinely provided in emergency food aid program. Use of vitamin C tablets was not found to be a practical method for preventing vitamin C deficiency in refugee populations. Based on current production, increasing the level of vitamin C in all CSB and WSB produced to 90 mg/100g while keeping the current budget constant would reduce the tonnage produced by 4,662 metric tons and reduce the number of persons could be fed a ration of 30 grams per day for a year by 425,797. This report also includes information on alternative bagging, use of antioxidants, alternative forms of vitamin C, and iron fortification. Alternative forms of packaging are under consideration by the U.S. Department of Agriculture (USDA). USDA's primary interest in evaluating alternative packaging materials is to improve the strength of the bag rather than improving the micronutrient protection. Improved vitamin C protection does not appear necessary: this study showed relatively low levels of vitamin C degradation after shipping, handling, and storage. A discussion of alternate forms of iron that might reduce the oxidation of vitamin C is also included in this report. However, this report also notes that further testing would be needed to determine the feasibility, acceptability, and cost of incorporating these other sources of iron into CSB and WSB. The form of vitamin C currently used in CSB and WSB contains 97.5% ascorbic acid with a 2.5% ethyl cellulose coating. There are alternative forms of vitamin C now available with coatings of different types and thickness. These may provide better protection during food preparation than the current product, but no studies have been done to determine that. There we also other chemical forms of vitamin C with improved heat stability that are used in aquacultur, but none have been approved for human feeding.

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--> I. Objective This activity provided technical information to the U.S. Agency for International Development (USAID) Vitamin C Pilot Program, which was designed to produce, provide, and evaluate food aid commodities that we fortified with increased levels of vitamin C. SUSTAIN specified the premix, recommended the pilot production quantity, and advised on field site selection. SUSTAIN also monitored and evaluated product quality, production costs, and vitamin C stability from the point of manufacture to the point of distribution and consumption. Two vitamin C fortified commodities used in the USAID Food for Peace Program were evaluated: corn soy blend (CSB) and wheat soy blend (WSB). This report presents results for use by USAID and the Committee on International Nutrition (CIN), Institute of Medicine of the National Academy of Sciences (NAS), to determine whether vitamin C levels in U.S. food aid commodities need to be increased.

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--> II. Background Corn soy blend (CSB) and wheat soy blend (WSB) products are highly nutritious, low-cost, fortified foods that are used to deliver a wide array of macro-and micronutrients in the P.L. 480, Title II, Food for Peace Program. In fiscal year 1996 (October 1995 through September 1996), 238,300 metric tons (MT) of CSB and 11,310 MT of WSB were programmed for development activities and emergency activities such as refugee camp food distribution (USAID Annual Food Assistance, Report, 1996). These blended cereal-based foods are partially precooked, which allows them to be easily incorporated into a number of different food preparations by recipients. CSB and WSB are fortified with six essential minerals and eleven vitamins. This fortification account for 13% of the product cost. Like other P.L. 480 commodities, CSB and WSB are procured for USAID by the U.S. Department of Agriculture (USDA) Export Operations Division/Farm Service Agency. Currently there are seven different commercial companies approved by USDA to produce these commodities. According to USDA guidelines, commodities must be produced in the United States under inspection by the USDA Grain Inspection, Packers and Stockyards Administration/Federal Grain Inspection Service (FGIS). An FGIS representative is present during commodity production and takes samples for analysis. Chemical and physical tests are run on these samples to determine compliance with specifications for the finished CSB/WSB. These routine tests include some nutritional analyses (protein, fat, moisture content, crude fiber), but they do not include tests for any of the added vitamins or minerals. Vitamin levels we not included in final product specifications. USDA composition specifications for CSB and WSB are contained in Appendix A. CSB and WSB have vitamin C added in the ratio of 40 mg for every 100 g of commodity. The form of vitamin C currently used contains 97.5% ascorbic acid with a 2.5% ethyl cellulose coating. In September 1995, the U.S. Senate and House Appropriations Committees recommended that a pilot program be established to provide commodities with a 90 mg/100g fortification level (Foreign Operations, Export Financing and Related Programs Appropriations Bill, 1996, S.Rpt 104–143). The operational component for the Vitamin C Pilot Program was implemented by the USAID Food for Peace Office in the Bureau of Humanitarian Response. It involved procuring, producing, and providing CSB with high and conventional levels of vitamin C to refugee. camps in Tanzania and providing WSB with conventional and high levels of vitamin C to development program in Haiti, using the usual program procedures for P.L. 480 Title II food aid. The monitoring and evaluation component of the Vitamin C Pilot Program was conducted by SUSTAIN under a cooperative agreement with USAID. SUSTAIN, through the USAID Global Bureau's Office of Health and Nutrition in cooperation with the Program, Planning,

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--> and Evaluation office for the Bureau of Humanitarian Response (BHR), monitored the uniformity, stability and physical availability of vitamin C in the commodities from three selected country programs. In cooperation with the World Food Program (WFP), private voluntary organizations (PVPs), and USAID missions, SUSTAIN collected dry commodity samples in three countries. SUSTAIN also collected information about the local food preparation of the commodities and cooked samples in two countries, and determined vitamin C retention after cooking by testing samples of prepared food collected at recipient sites in these two countries. The protocol for this activity was reviewed by an Advisory Panel of experts drawn from government, food relief agencies, and the food industry (Appendix B). These experts are knowledgeable in the fortification, stability, and testing of vitamins in these types of foods. This Advisory Panel met twice: once on April 18, 1996, to review the call forward request and sampling strategy, and again on May 17, 1996, to review the protocol. A statistical subgroup of the Advisory Panel, made up of statisticians and quality control experts of the food industry, advised on statistical matters and interpretation of the results (Appendix B). They met on May 3, 1996, to review the statistical plan of the study and to recommend the number of samples to be collected, and again on April 25, 1997, to discuss the statistical analysis of the results. Recommendations and suggestions from these meetings have been incorporated into this report. A protocol was designed and submitted to the Committee of International Nutrition (CIN) of the Institute of Medicine, National Academy of Science. Agreement on the protocol and recommendations by the CIN were presented to USAID in December 1996.