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--> Vitamin C Fortification of Food Aid Commodities Final Report Committee on International Nutrition—Vitamin C in Food Aid Commodities Food and Nutrition Board Board on International Health INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1997
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--> NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the Office of Health and Nutrition, United States Agency for International Development, Cooperative Agreement No. DPE-5951-A-00-0035-00. The opinions expressed in this report are those of the Committee on International Nutrition and do not necessarily reflect the views of the sponsor. International Standard Book No. 0-309-05999-2 Additional copies of Vitamin C Fortification of Food Aid Commodities: Final Report are available for sale from theNational Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area) or visit the NAP's on-line bookstore at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www2.nas.edu/iom. Copyright 1997 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
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--> COMMITTEE ON INTERNATIONAL NUTRITION—VITAMIN C IN FOOD AID COMMODITIES LINDSAY H. ALLEN (Chair), Professor, Department of Nutrition and Program in International Nutrition, University of California at Davis KENNETH H. BROWN, Professor, Department of Nutrition, and Director, Program in International Nutrition, University of California at Davis GUS (BUD) COCCODRILLI, Vice President, Worldwide Scientific Relations, Nutrition, and External Technology, Kraft Foods, Inc., Tarrytown, New York JEAN-PIERRE HABICHT, James Jamison Professor of Nutrition Epidemiology, Division of Nutritional Sciences, Cornell University, Ithaca, New York BARBARA P. KLEIN, Professor, Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign GEORGE P. McCABE, Professor and Head of Statistical Consulting, Department of Statistics, Purdue University BEATRICE L. ROGERS, Professor and Dean for Academic Affairs, School of Nutrition Science and Policy, Tufts University MARIE T. RUEL, Research Fellow, International Food Policy Research Institute, Washington, D.C. Study Staff MARY I. POOS, Study Director (beginning April 1997) CAROL W. SUITOR, Study Director (through March 1997) DIANE R. JOHNSON, Project Assistant CARLOS GABRIEL, Financial Associate
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--> FOOD AND NUTRITION BOARD CUTBERTO GARZA (Chair), Division of Nutrition, Cornell University, Ithaca, New York JOHN W. ERDMAN, Jr. (Vice-Chair), Division of Nutritional Sciences, College of Agriculture, University of Illinois at Urbana-Champaign LINDSAY H. ALLEN, Department of Nutrition, University of California, Davis BENJAMIN CABALLERO, Center for Human Nutrition, The Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland FERGUS M. CLYDESDALE, Department of Food Science, University of Massachusetts, Amherst ROBERT J. COUSINS, Center for Nutritional Sciences, University of Florida, Gainesville MICHAEL P. DOYLE, Department of Food Science and Technology, Center for Food Safety and Quality Enhancement, The University of Georgia, Griffin JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital and Departments of Medicine and Community Health, Tufts Medical School and School of Nutrition Science and Policy, Boston, Massachusetts SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas CHARLES H. HENNEKENS, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts JANET C. KING,* University of California, Berkeley, and U.S. Department of Agriculture Western Human Nutrition Research Center, San Francisco SANFORD A. MILLER, Graduate School of Biomedical Sciences, University of Texas Health Science Center, San Antonio ROSS L. PRENTICE, Division of Public Health Sciences, Fred Hutchison Cancer Research Center, Seattle, Washington A. CATHERINE ROSS, Department of Nutrition, The Pennsylvania State University, University Park ROBERT E. SMITH, R.E. Smith Consulting, Inc., Newport, Vermont VIRGINIA A. STALLINGS, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Pennsylvania VERNON R. YOUNG,*† Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge Ex-Officio Member STEVE L. TAYLOR, Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln Institute of Medicine Council Liaison HARVEY R. COLTEN,* Northwestern University Medical School, Chicago, Illinois * Member, Institute of Medicine. † Member, National Academy of Sciences.
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--> Board Staff ALLISON A. YATES, Director GAIL SPEARS, Administrative Assistant CARLOS GABRIEL, Financial Associate
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--> BOARD ON INTERNATIONAL HEALTH BARRY R. BLOOM (Cochair),* Howard Hughes Medical Institute, Albert Einstein College of Medicine, Bronx, New York HARVEY V. FINEBERG (Cochair),* Harvard School of Public Health, Harvard University, Boston, Massachusetts JACQUELYN CAMPBELL, The Johns Hopkins University School of Nursing, Baltimore, Maryland JULIO FRENK,* Fundación Mexicana para la Salud, Mexico, D.F. DEAN T. JAMISON,* Center for Pacific Rim Studies, University of California, Los Angeles, California EILEEN T. KENNEDY, Center for Nutrition Policy and Promotion, U.S. Department of Agriculture, Washington, D.C. ARTHUR KLEINMAN,* Harvard Medical School, Harvard University, Boston, Massachusetts BERNARD LIESE, Health Services Department, The World Bank, Washington, D.C. WILLIAM E. PAUL,* National Institute of Allergy and Infectious Diseases and Office of AIDS Research, National Institutes of Health, Bethesda, Maryland ALLAN ROSENFIELD, Columbia University, School of Public Health, New York, New York PATRICIA ROSENFIELD, The Carnegie Corporation of New York, New York, New York THOMAS J. RYAN, Boston University School of Medicine, and Senior Consultant in Cardiology, Boston University Medical Center, Boston, Massachusetts Ex-Officio Member JOHN H. BRYANT* (retired) Moscow, Vermont WILLIAM H. FOEGE* Task Force on Child Survival, The Carter Center, Emory University, Atlanta, Georgia DAVID P. RALL* (Institute of Medicine Foreign Secretary), National Institute of Environmental Health Sciences (retired), Washington, D.C. Institute of Medicine Council Liaison JUNE E. OSBORN,* Josiah Macy, Jr., Foundation, New York, New York Board Staff CHRISTOPHER P. HOWSON, Director HEATHER CALLAHAN, Administrative/Research Assistant SHARON GALLOWAY, Financial Associate * Member, Institute of Medicine.
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--> Preface 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).
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--> 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
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--> 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. LINDSAY H. ALLEN, CHAIR COMMITTEE ON INTERNATIONAL NUTRITION—VITAMIN C IN FOOD AID COMMODITIES
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--> Contents Executive Summary 1 Background and Charge to the Committee 2 Methods 3 Conclusions 3 Recommendations 5 Research Recommendations 6 1 Introduction 9 The Committee's Task 13 The Study Process 14 2 Vitamin C: Needs and Functions 17 Prevalence of Scurvy 18 Vitamin C Requirements 20 Other Functions of Vitamin C 21 Vitamin C and Iron Absorption 21 3 Cost-Effectiveness Analysis 23 Effectiveness 23 Cost 26 Cost-Effectiveness Estimate 27 4 Results of the Vitamin C Pilot Program 37 Summary of the Pilot Program 37 Major Findings of the Pilot Program 41 5 Critique of the Pilot Program 47 Uniformity of Blended Commodities 47
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--> Capability of the Production Process to Meet Product Specifications 48 Stability of Vitamin C During Transport and Storage 49 Vitamin C Cooking Losses 50 6 Conclusions and Recommendations 53 Conclusions 53 Recommendations 58 References 63 Appendixes A Legislative Language for Increased Vitamin C Fortification 67 B SUSTAIN Report Executive Summary 73 C Letter from the United Nations World Food Programme 81 D Biographical Sketches 85 List of Tables and Boxes Tables 1-1 Ingredient Composition of Corn-Soy Blend (CSB) and Wheat-SoyBlend (WSB) 10 1-2 Selected Nutrient Composition of Corn-Soy Blend (CSB) 10 1-3 Selected Nutrient Composition of Wheat-Soy Blend (WSB) 11 3-1 Possible Consequences of Added Cost from Higher Vitamin C Levels 28 4-1 Summary of Vitamin C Retention After Cooking 41 4-2 Tanzania Samples—CSB Food Preparations, Vitamin C Data 43 4-3 Haiti Samples—WSB Food Preparations, Vitamin C Data 45 5-1 Summary of Food Preparation Samples Collected in Selected Countries 50 Boxes 4-1 Schedule of the CSB Special Procurement from Production to Distribution in the Refugee Camps of Western Tanzania 40 4-2 Schedule of the WSB Special Procurement from Production to Distribution in Haiti 40