ILSI Conference on Micronutrient Fortification of Foods Science

ILSI Conference on Micronutrient Fortification of Foods: Science, Application & Management Options to Deliver Fortified Products to the Public 8 January 2011 - New Delhi, India Dr. Manfred Eggersdorfer Senior Vice President Nutrition Science & Advocacy DSM Nutritional Products

Options to deliver fortified products to the public: Agenda I. The Need for Food Fortification II. Options for Fortification III. Regulatory and Market Factors IV. DSM‘s Engagement V. Summary and Outlook DSM Nutritional Products 1

I. The Need for Food Fortification DSM Nutritional Products

Need fortification: Worldwide ~ 2 billion people are affected by Hidden Hunger Hot Spots DSM Nutritional Products 3

Hidden Hunger is defined as. . . “ Deficiencies in essential micronutrients (vitamins & minerals) in individuals or populations which negatively impact on health, cognition, function, survival, and economic development “ SIGHT AND LIFE Expert Panel, Bangkok 2009 Worldwide, over one third of deaths among children under 5 years of age is associated with malnutrition. DSM Nutritional Products 4

What is the impact of Hidden Hunger? Annual lives lost 1. 1 mio children <5 years 5 Annual lives impaired 18 mio babies born mentally impaired 600, 000 stillbirths 350, 000 children go blind 150, 000 babies born with neural tube defects 115, 000 women during pregnancy Vit. A & Zinc deficiencies Iron deficiency anemia DSM Nutritional Products Maternal iodine deficiency Vit. A deficiency Maternal folate deficiency

Micronutrient deficiency is a huge financial burden… Global impact estimated by Unicef (2004) Micronutrient deficiencies cost globally 180 bio US$ in the next 10 years: • in China 2, 8 bn US$ and • in India 6, 0 bn US$. „UNICEF and the Chinese Ministry of Health announced that China’s massive drive to reduce the damage done by vitamin and mineral deficiency, particularly to children, is paying rich dividends for China’s economy. It expects that efforts to protect its 250 million inhabitants now suffering from “hidden hunger” could boost GDP by $86 billion over the next ten years. ” DSM Nutritional Products 6

… and is seen as the greatest challenge in the 21 st century worldwide Ø More than 60 % of healthcare costs and disabilities are due to lifestyle related diseases Ø Cardiovascular diseases, diabetes, high cholesterol, osteoporosis, overweight are some of the key health issues related to nutritional factors Ø These issues are not alone a topic of the industrialized countries like the US, Europe, Japan and so on, but also in India, China and all over the world Prevention of chronic diseases and the compression of the disability period will be the greatest public health challenge of the 21 st century. DSM Nutritional Products 7

Micronutrients (vitamins and minerals) are essential for many functions and health 8 Good Health Normal Brain Growth Normal Growth Strengthening immune system Vitamins & Minerals that are only needed in small amounts, but are essential for … Healthy Babies Healthy aging Good Performance They cannot DSM Nutritional be produced by the body and have to come from the diet Products

Food fortification is a key approach to achieve adequate micronutrient intake Codex General Principles for the Addition of Essential Nutrients to Foods Fortification / Enrichment: Addition of one or more essential nutrients to a food whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population or specific population groups. Any fortification program should be based on a demonstrated need for increasing the intake of an essential nutrient in one or more population groups, e. g. • clinical or subclinical evidence of deficiency, • estimates indicating low levels of intake of nutrients or • possible deficiencies likely to develop because of changes taking place in food habits “ Probably no other technology available today offers as large an opportunity to improve lives and accelerate development at such low cost and in such a short time ” (source: Enriching Lives, The World Bank) DSM Nutritional Products 9

Food fortification is powerful and can be implemented in existing diets Advantages • Potentially rapid improvements in micronutrient status of population • Reasonable cost, especially with existing technology and local distribution networks • Requires no changes in existing food patterns or in individual compliance Requirements • Fortified food consumed in adequate amounts by target population • Fortificants that are stable and well absorbed, but do not affect sensory properties of foods • Preferably, centrally processed food vehicles • Government and food industry partnership DSM Nutritional Products 10

II. Options for Fortification DSM Nutritional Products

Three types of food fortification are in place Conventional fortification • • Staple foods (flour, sugar, milk, oil, rice) Dairy (milk, yoghurt) Spreads (margarine) Condiments (salt) Home fortification • Crushable/soluble tablets • Powder • Spreads Bio-fortification • Agricultural products (rice, maize, sweet potato, …) DSM Nutritional Products 12

Food fortification has a successful track record an many countries 13 Long history in many countries for successful control of deficiencies of vitamins A, D, several B vitamins, iodine and iron. 1923: Mandatory iodization of salt in Switzerland USA; now available in most countries. 1933: Mandatory fortification of flour with Vitamin B 1 in Canada and virtual elimination of Beriberi. 1941: Mandatory fortification of flour with Vitamin B 3 in the USA and virtual elimination of pellagra early 40 ies: Fortification of cereal products with Vitamin B 1, B 2 and B 3 became common practice in many countries. 1954: Flour fortified in Chile with B-vitamins and iron. Country has now very low prevalence for anaemia. 1974: Beginning of sugar fortification with Vitamin A in Guatemala. Vitamin deficiency diminished to one third. 1992: Wheat and maize flour fortification in Venezuela. Vitamin A sufficiency in general population and important reduction in anemia in children. 1998: Folic Acid fortification mandated in the USA. Now implemented in 60 countries. 2000: Vitamin D fortification of milk and dairy products in US and Canada started DSM Nutritional Products

Nutri. Rice® : from staple food to nutritious food Nutri. Rice® is made of natural rice with micro-encapsulated vitamins in reconstituted rice kernels via extrusion • Looks, tastes and cooks exactly like ordinary rice. • Fortified kernels deliver the added micronutrients to the consumer. • Kernels can be customized in shape, color and micronutrient composition. Nutrients • Vitamin A (Retinyl-palmitate) • Vitamin B 1 (Thiamine chloride HCl) • Vitamin B 2 (Riboflavin) • Vitamin B 12 (Cyanocobalamine) • Niacin • Iron … and others Inclusion levels: can be adapted to nutrient requirements DSM Nutritional Products 14

Efficacy of Nutri. Rice demonstrated in school children in India Group 1 MMN fortified rice ~300 g cooked rice (=100 g dry uncooked rice) Group 2 MMN fortified rice high iron 15 Group 3 Unfortified rice 6 days/wk; Sep-Feb 2009/10 Total of 134 days Significant improvements in B-vitamin status, physical performance, and hemoglobin level among school children in Bangalore having consumed fortified rice for 6 months. DSM Nutritional Products

Home fortification provides benefit of full micronutrient basket 16 • Since mid-1990 s, efforts to add micronutrients to foods at household level; in particular to complementary foods for young children • Micronutrient powder concept: - Fortification of locally available food - provides essential micronutrients - no change in the color, texture or taste of the food • Combination of supplementation and fortification • Types of products: - Soluble or crushable tablets - Micronutrient powder (Mix. Me™) - Micronutrient-rich spreads (Nutri. Butter™) More costly than mass fortification but useful for improving local foods fed to infants and young children where fortified complementary foods are not available DSM Nutritional Products

Bio-fortification is an emerging technology building on GM plants • Breeding and genetic modification of plants to improve their nutrient content e. g. , cereals, legumes, potatoes, maize • More science required to prove efficacy and effectiveness of bio-fortified foods Current concerns about safety, cost, acceptability and impact on environment limit development and penetration DSM Nutritional Products 17

A number of crops are currently investigated for bio-fortification Crop Nutrient Orange sweet potatoes β-carotene/pro-vitamin A (‘Golden’) Rice β-carotene/pro-vitamin A, iron, zinc ‘Orange’ Maize β-carotene/pro-vitamin A Bananas β-carotene/pro-vitamin A Beans iron Cassava β-carotene/pro-vitamin A Pearl millet iron Wheat zinc However due to regulatory and other reasons most of the developments did not make it to the market yet. DSM Nutritional Products 18

III. Regulatory and Market Factors DSM Nutritional Products

Intended reach and target groups define fortification approach • Mass/universal fortification Wide consumption by general population; often mandatory. • Targeted fortification Consumption by specific population subgroup, e. g. for children or displaced populations; mandatory or voluntary depending on public health problem • Market-driven fortification Food manufacturers voluntarily fortify foods; always voluntary, but governed by regulatory limits. WHO/FAO Guidelines 2006 Choice between mandatory or voluntary fortification depends on national/regional circumstances DSM Nutritional Products 20

Criteria governing the selection of mandatory or voluntary fortification 21 Six key factors determine whether mandatory or voluntary fortification is the most appropriate option Factor Mandatory Voluntary Public health risk Higher / more affected Lower / fewer affected Food industry Centralized, well organized Smaller, more diverse Consumer awareness/ demand Not necessary Essential Political environment (choice) Not necessary Essential Food consumption patterns Fortified food widely consumed Variety and accessibility essential Fortification approach Mass/universal Market-driven Proactive communication and advocacy on role of fortification is a joint task of policy makers, regulatory DSM Nutritional Products bodies, food industry and nutrition scientists

Costs fortification are low relative to achievable benefits DSM Nutritional Products 22

Three market channels offer different dynamics and solutions 23 FOOD ASSISTANCE CHANNEL (WFP, NGOs, PDS*) buy and distribute FOOD PROCESSORS Manufacture sell and RETAIL CHANNELS sell to consumers FORTIFIED FOODS INSTITUTIONAL CHANNEL WORKPLACE, HOSPITALS, SCHOOLS buy and distribute PDS: Public Distribution System, in India = DSM Nutritional Products Integrated Childhood Development Service (ICDS) delivered in Anganwadi Centers HOUSEHOLDS

IV. DSM’s engagement DSM Nutritional Products

WFP and DSM partnered to fight malnutrition: Objectives of partnership 1. WFP and DSM 2. WFP 3. DSM Increase Micronutrient in WFP food basket Advocacy and awareness ‘DSM Pride’ – Engaging employees and their families Employee Development DSM Nutritional Products Strengthen DSM’s Corporate and Brand Reputation 25

DSM brings nutrition competence, WFP global 26 reach and distribution management into the partnership 2007 2010 -2013 d Foo n le tap icatio ) S tif e For tri. Ric (Nu 20 -25% WFP DSM is playing a FOOD FORTIFIED to launch Fo Blen rtified d (CSB ed Foo d +, CS B++ ) 70 -100% WFP Enriching General critical strategic role in enabling WFP FOOD Food Baskets* with the approach at the global level FORTIFIED Micronutrients Micron utrient Powde (+Phyt r ase) lly cia ed, e Sp ulat ds o m for ied fo tif for * Include. Nutritional Products fortified blended food, oil, salt DSM cereals, pulses, legumes,

Jointly with IOF we develop a global Vitamin D deficiency map and actions to overcome issue DSM Nutritional Products 27

In summary: DSM is balancing business and social responsibility Partnering Involvement Nutrition Improvement Program Business Recognition DSM Nutritional Products 28

V. Summary and Outlook DSM Nutritional Products

Options to deliver Fortified Products to the Public 30 Summary and Outlook • Faster and more sustainable progress is needed to overcome Hidden Hunger and to achieve MDGs by 2015 • Food Fortification can be the most sustainable and cost-effective option to enhance micronutrient consumption in a population • Technologies for mandatory and voluntary food fortification are available • A joint approach by policy makers, regulatory bodies, nutrition scientists and private companies is required DSM Nutritional Products

Back up DSM Nutritional Products 31

Conventional fortification has a strong track record 32 • Long history in industrialized countries for successful control of deficiencies of • vitamins A and D • several B vitamins (thiamine, riboflavin and niacin) • iodine • iron • Salt iodization introduced in early 1920 s in both Switzerland USA; now available in most countries • From early 1940 s, fortification of cereal products with thiamine, riboflavin and niacin became common practice • Margarine fortified with vitamin A in Denmark • Milk fortified with vitamin D in USA • Foods for young children fortified with iron - substantially reduced risk of iron-deficiency anemia in this age group • Folic acid fortification of wheat adopted by Canada, USA and Latin America • In the less industrialized countries, fortification is an increasingly attractive option • Success of programs to fortify sugar with vitamin A in Central America - vitamin A deficiency reduced considerably; similar initiatives in sub-Saharan Africa. DSM Nutritional Products

Folic acid fortification of flour is a success story for many countries 33 Decline in the prevalence of neural tube defects (NTDs) following folic acid fortification of flour South Africa: -31% USA: -26% Canada: -54% Australia: -26% Saudi Arabia: -60% Chile: -43% In 2009, 51 countries had regulations written for mandatory wheat flour fortification programs that included folic acid. DSM Nutritional Products

Innovations drive new opportunities in staple food fortification 34 Sugar fortification To insure a fortification level of 50, 000 IU/g of vitamin A in sugar a novel vitamin A palmitate formulation is attached to the surface of sugar crystals. Rice fortification (Nutri. Rice) • With micro-encapsulated vitamins in reconstituted rice kernels via extrusion; • the concentrated vitamin/mineral „rice premix“ can be mixed with natural rice grains (1: 100); • good organoleptic properties (shape, taste, color) and high vitamin retention during cooking DSM Nutritional Products Rice

Efficacy of Nutri. Rice demonstrated at Dandelion Migrant Worker School, China Fortified food commodities consumed: Nutri. Rice (B 1, B 2, FA, niacin, Zn, Fe, BC), Na. Fe. EDTA-fortified soy sauce, VA-fortified cooking oil: 8 mo feeding • • Malnutrition rate -50% B-vitamin deficiencies VAD -51%, iron deficiency anemia -82%, zinc deficiency -58% Improved school attention, cognitive & academic performance and physical strengths including aerobic capacity DSM Nutritional Products 35

… the only implemented example is Orange Sweet Potatoes (OSP) in Africa Daily consumption of 100 g of Orange Sweet Potatoes can provide 125 g of RAE, approx. 50% EAR for a young child http: //sacatomato. com/sweet-potato-festival-and-botany-lesson DSM Nutritional Products 36

A number of technical and societal pre-requisits have to be fulfilled for successful bio-fortification 37 • Increased micronutrient content of food staples through plant breeding (GM and non-GM) • Growing bio-fortified plants must be a financially attractive for the farmer compared to traditional plants • Consumption of bio-fortified foods has to result in measurable and significant improvement of nutritional status • Bioavailability of extra micronutrients bred into the food staples has to be established • Bio-fortified crops have to be culturally and sensory acceptable to target population • Poor malnourished people have to eat bio-fortified foods in sufficient quantities DSM Nutritional Products

Both, mandatory and voluntary fortification require regulatory guidance 38 • We see a diversity in national public health goals with different approaches to regulation of food fortification • In most industrialized countries, food fortification parameters are established by law • At other end of spectrum, fortified foods are produced without any form of governmental guidance or control at all • Generally it is recommended that all forms of food fortification is appropriately regulated to ensure safety and health benefit to target groups By providing a higher level of certainty, mandatory fortification is more likely to deliver a sustained source of fortified food for the relevant population group and, in turn, a public health benefit DSM Nutritional Products

Costs fortification are low relative to achievable benefit DSM Nutritional Products Copenhagen Consensus 2008 39

DSM‘s commitment to CSR honored by WFP and UN 40 UN WFP Executive Director Josette Sheeran: “We are really pleased that DSM wants to share its outstanding expertise to address malnutrition with us. You can help increase awareness on the issue of global hunger, as will the active involvement of DSM employees in the partnership. ” Secretary General of the United Nations Ban Ki-Moon: “the private sector is among the main stakeholders on hunger and nutrition. Nearly 1 billion people go hungry every day – an unprecedented number. Business is a partner from emergency food aid to long-term agriculture, from our road map for nutrition to our Committee on World Food Security”. DSM Nutritional Products Feike Sijbesma receives 2010 Humanitarian of the Year Award