Food fortification Q&A

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Why implementing Decree 09 is so important?

The issuance of the Decree 09/2016/ND-CP was based on strong evidence that the country needs to step up actions to address severe micronutrient deficiencies among the Vietnamese population.

Viet Nam is among the group of 19 countries remaining in the world with iodine deficiency. The Multiple Indicator Cluster Survey of 2011 indicated that only 45% of households in Viet Nam were consuming iodised salt, which is also far below the 90% global recommendation on universal salt iodisation. Additionally, nearly 30% of children under 5 and 37% of pregnant women are anemic. Zinc deficiencies are very high for children (69%) and pregnant women (80%). While Iodine deficiency is a significant cause of intellectual disabilities in children, and stillbirth and miscarriage in women, Iron deficiency increases the risk of maternal death and poor fetal development and impairs motoric and cognitive development in children and productivity for adults, and zinc deficiency increases the incidence of diarrhea, the risk of acute respiratory infection and child mortality.

In Viet Nam, the main source of dietary salt and wheat flour intake comes from processed food and meals consumed outside the home. Thus, mandatory food fortification as regulated in the Decree 09 is to ensure public health, and is not detrimental to business and industry. Fortification has proven to have dramatic and positive effects on both individuals and nations. The best-known example is the drive for Universal Salt Iodization, which succeeded in increasing access to iodized salt from 20% of households in 1990 to 70% today, dramatically reducing global goiter rates and cases of cretinism.

We strongly recommend the Government to fully implement Decree 09, including ensuring the processed foods are made with iodized salt and fortified wheat flour, and that companies are supported to ensure compliance. Food producers and distributors should be supported by clear guiding regulations on compliance requirements and the use of fortified ingredients. This mandatory food fortification as regulated in the Decree 09 is not detrimental to business and industry. Moreover, businesses can apply for exemption in the rare cases when negative impacts on final products or sales are proven.

Why mandatory use of iodized salt in processed foods?

WHO recommended use of iodized salt in food processing (1) is – “All food-grade salt used in household and food processing should be fortified with iodine as a safe and effective strategy for the prevention and control of iodine deficiency disorders in populations living in stable and emergency settings (strong recommendation)”.

Iodization of salt for food processing was recommended because in many countries, the population consumes the majority of salt through processed foods.

In Viet Nam, only 6% of salt is consumed directly as table salt. 75% is consumed through salty condiments like seasoning (bot canh, bot nem), fish sauce, soya sauce, and instant noodles.(2)

Is there any negative impact or change to fortified food products?

Fortification of widely consumed staple foods and condiments, such as salt, vegetable and wheat flour, is a globally recognized and highly cost-effective strategy for increasing nutrient intakes without the requirement to change eating behaviors or substantial government budget.(3)

There is internationally-proven evidence that the use of iodized salt has no negative impact on the final product’s colour, taste and smell.(4) WHO also recommends the fortification of wheat flour when industrially produced flour is regularly consumed by large population groups in a country.(5)

What are other countries’ experience?

The United States and Switzerland have fortified foods since the 1920s, when iodine was first added to salt. The fortification of oil-based products dates back to the same era, when food producers began adding Vitamin A to margarine to mirror the levels naturally occurring in butter, which it was beginning to replace. In the 1930s and 1940s, the United States began adding thiamin, niacin, riboflavin, and iron to flour, and vitamin D to milk. Since the 1940s, wheat and other flours have been fortified in numerous countries, both to replace micronutrients lost in processing and as a public health intervention. The fortification of sugar with Vitamin A started in Central America in the 1970s and has spread to many countries, including Zambia and Nigeria. Beginning in the 1980s, UNICEF led a campaign to achieve Universal Salt Iodization.

According to on the legislation database of the Global Iodine Global Network, fortification of salt, wheat flour and vegetable oil is mandatory in 108, 85 and 29 countries respectively, and 98 of the 108 countries that currently have mandatory legislation for edible salt iodization, including the requirement to use iodized salt in processed foods (6) and 100% of the 85 countries that have mandatory wheat flour fortification. ASEAN member states who have mandatory of salt iodization include 12 countries: Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Viet Nam. Of these, except Brunei and Singapore, all eight countries require the use of iodized salt for processed foods (In Malaysia the legislation currently applies to two states). In Asian countries in general, the following additional countries have legislation for mandatory salt iodization, including for processed foods: Afghanistan, China, Fiji, Kiribati, Mongolia, Nepal, Papua New Guinea, Solomon Islands, and Sri Lanka. Bangladesh and India also have mandatory salt iodization but it excludes salt for food processing.(7)

Philippines salt iodization legislation allows exemptions of processed foods negatively affected by use of iodized salt; no exemptions have ever been requested.

Other than health, what are benefits of investment on food fortification?

In 2008, some of the world’s top economists, including five Nobel laureates, analyzed the costs and benefits of various public health interventions. Their conclusion: fortification is one of the most cost-effective interventions that exist to address micronutrient malnutrition. Depending on the food and the specific vitamins and minerals added, fortification costs only $0.05 to $0.25 per person per year. Gains in productivity and savings to a nation’s healthcare system are many times this cost. In Tanzania, for example, the World Bank calculates that deficiencies in iron, Vitamin A, and folic acid cost more than $518 million (2.65% of GDP). The food fortification program being launched there is expected to yield $8.22 in benefits for each dollar spent.

A global report in 2009 showed that every dollar spent on salt iodization and flour fortification would result in benefits of more than US$ 10.(9)

Is there any harm to business sales and industry? How much will it cost the companies to implement food fortification?

Food fortification, including use of fortified food ingredients in processed foods, is already the global norm, with no detrimental impacts upon the final food product or business profitability and sales. Food fortification contributes to a smart and healthy population, which benefits society and national development, including competitiveness.

According to international experience, the cost of fortification is very low compared to the fluctuations in the global prices of raw materials. The costs for fortification will include cost of fortificants, but when all companies would have the same costs of fortification, it is acceptable to consumers. Fortified foods have health and nutrition value added so it will increase the competiveness of the industry.

Other possible questions at implementation level:

  • Consumers want to have choice about whether they have fortified food or not? Why are you making this mandatory?

    Mandatory fortification is more effective at achieving a public health benefit. Voluntary fortification has been possible in Viet Nam since 2003 – however there are still very few fortified foods on the market. Making fortification mandatory is the most fair for both businesses and consumers. Businesses all have the same increased expense, and poor as well as rich consumers will have access to fortified foods.
  • I think it would be better if you make food fortification voluntary and industry and the government should promote consumption of fortified food.

    The global experience is that voluntary fortification, even with promotion, does not benefit the majority of the population. Consumers do not choose foods because they are more nutritious. When salt iodization was made mandatory in Viet Nam the proportion of households consuming iodized salt fell from more than 90% to 45%. Only a very small proportion of fish sauce and wheat flour is currently voluntarily fortified, despite it being legally possible for many years in Viet Nam.
  • Can we add other nutrients in addition to those in the legislation?

    Only the nutrients indicated in this Decree and the National Technical Regulation on Micronutrient Fortified Food QCVN 9-2:2011/BYT may be added to foods listed in these two documents.
  • Do companies need a laboratory for testing the nutrient content of fortified food?

    No. We recommend that you implement necessary internal quality assurance processes to produce a quality fortified product. For example, this would include documentation of fortification through regular checks in your process control. Chemical quick tests can also be used for wheat flour and salt that will tell you if iodine or iron is in your end product. However, these tests will not tell you the amount of the fortificant in your product. To do this you may want to send your products to external certified laboratories for full quantitative testing. If you plan to test many samples quantitatively in a laboratory you may consider it worthwhile to establish your own laboratory. Many large factories have a laboratory for product quality control and development but it is not a requirement. We understand that quantitative analysis can be expensive so it is important that each business has Good Manufacturing Practices in place that document fortification during the production process.
  • Is the government going to train us how to fortify properly?

    Most salt, wheat flour and vegetable oil producers in Viet Nam are large, sophisticated industries with internal expertise on fortification. Some of you may already be fortifying now for some of your customers. If you do not have any experience multiple organizations and private companies are able to provide training or technical advice on fortification. Usually the companies that sell the fortificants will provide technical advice. Associations such as the International Association of Operative Millers can provide advice for wheat flour millers. Fortification resources are also available from organizations such as the Food Fortification Initiative, the Iodine Global Network, and the Global Alliance for Improved Nutrition.

References:
(1)WHO. Guideline: fortification of food-grade salt with iodine for the prevention and control of iodine deficiency disorders. Geneva: World Health Organization; 2014.
(2)National Institute of Nutrition. Investigation of dietary sodium intake and sources in adults, aged 25-64 years. 2010
(3)http://www.who.int/nutrition/publications/micronutrients/9241594012/en/
(4)http://www.who.int/nutrition/publications/guidelines/fortification_foodgrade_saltwithiodine/en/
(5)http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fortification/en/
(6)Global Fortification Data Exchange (Accessed 31 May 2018)
(7)Iodine Global Network legislation database, updated 26 March 2017
(8)The Implementing Rules and Regulations of Republic Act 8172. An Act promoting salt iodisation nationwide and for related purposes. “All food manufacturers/processors using food-grade salt are also required to use iodized salt in the processing of their products and must comply with the provisions of this Act not later than one (1) year from its effectivity: Provided, That the use of iodized salt shall not prejudice the quality and safety of their food products: Provided, however, That the burden of proof and testing for any prejudicial effects due to iodized salt fortification lies on the said food manufacturers/processor.”
(9)FFI, GAIN, MI, USAID, The World Bank, UNICEF. Investing in the future; A united call to action on vitamin and mineral deficiencies. Global Report 2009. (http://www.unitedcalltoaction.org/)

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