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Choosing a processed food to be fortified
Advocacy and collaboration
Using the research results
Florentino S. Solon
Florentino Solon is President and Executive Director of the Nutrition Centre of the Philippines (NCP) in Manila, Philippines.
Mention of the names of firms and commercial products does not imply endorsement by the United Nations University.
The search for a suitable vehicle for vitamin A fortification in the Philippines led in 1991 to Star Margarine, a hydrogenated margarine product that had been popular in the country since 1931. The initial study to determine the stability of b-carotene and vitamin A (retinol palmitate) in the product showed high percentages of vitamin A retention and good thermal stability, as indicated by high vitamin A recovery after being heated. Later, a double-blind, randomized community trial to determine the effects of consumption of non-refrigerated vitamin A - fortified margarine on the vitamin A status of three- to six-year-old children also showed an increase in mean serum retinol in the experimental group and a decrease in the control group after six months of daily consumption of the product. The multiple adjusted increment over control was 2.4 mg/dl (p<.001). The prevalence of low serum retinol (<20mg/dl) decreased from 25.7% to 10.1% in the experimental group but remained unchanged in controls (26.7% to 27.7%) (p<.01 at six months). Although its vitamin A content has been increased so that each serving of one tablespoon provides 100% of the recommended dietary allowance for Filipino young children, the marketed product has remained affordable to consumers and has been made more accessible by reducing container sizes. It has also received the Department of Health seal of recognition as a product that meets national fortification standards. The fortification of Star Margarine exemplifies the close collaboration of government and non-governmental organizations, industry, academics, and other sectors in confronting a public health problem.
Vitamin A deficiency continues to be a public health problem in the Philippines, as evidenced by the 34% subclinical prevalence of the disorder. The vitamin A intake of the population is low in both urban and rural areas, and what vitamin A is consumed is mostly in the form of provitamin A carotenoids. This situation is further compounded by low fat intake and high prevalences of infections and parasitic infestations [1,2].
The Philippine Plan of Action for Nutrition, a vital part of the governments Medium-Term Development Plan, addresses the malnutrition problem through five impact programmes: food security, micronutrient supplementation and food fortification, credit assistance for livelihood, nutrition education, and food assistance . An interagency, multisectoral National Micronutrient Action Team was organized to formulate and implement the national micronutrient programme, including food fortification - the addition of essential micronutrients to processed foods. The National Micronutrient Action Team is assisted by the Vitamin A Expert Group, as well as expert groups on iron and iodine, supported by international agencies and local non-governmental organizations .
In announcing the governments micronutrient policies and programmes, the President met with food manufacturers and issued directives for the support of pertinent public institutions . The policy is to fortify priority staple foods on the basis of national nutrition surveys. It specifies the fortification of salt with iodine; margarine, cooking oil, wheat flour, and sugar with vitamin A; and wheat flour and rice with iron [3, 4]. The recent national nutrition survey revealed that of 25 commonly consumed foods, 11 are potentially fortifiable, 7 of them with vitamin A: sugar, oil, bread, monosodium glutamate, soy sauce, milk, and rice .
Reflecting upon lessons learned more than two decades ago during the fortification of monosodium glutamate with vitamin A in the Philippines, researchers chose margarine as the food to be fortified . Margarine was fortified with vitamin A in Denmark as early as the 1930s, which reportedly contributed to the elimination of xerophthalmia.
Star Margarine, a product that does not require refrigeration, has been popular in the Philippines since 1931, before the advent of electricity in most parts of the country. The margarine is centrally produced and has high potential for wide consumption, especially by the poor or groups at high risk for vitamin A deficiency. A nationwide market survey conducted by the manufacturer in 1988 revealed that the margarine was consumed by a large majority (94%) of the population, 89% of whom had an annual income under 15,000 pesos (US$1 = 38 pesos). Consumption was higher among people from rural areas than those from cities. The margarine was eaten mostly with bread (88%) and rice (28%), as well as being used for frying (23%), sauteeing (11%), and other cooking methods .
In 1990 the dean of the Johns Hopkins University School of Hygiene and Public Health advocated the fortification of margarine with vitamin A by the Procter & Gamble Company in Cincinnati, Ohio, USA, when he learned about its Philippine product line Star Margarine. During a trip to Manila, the dean met with officials of the Philippine branch of Procter & Gamble to discuss the possibility of fortifying Star Margarine with vitamin A.
The manufacturer wanted to maintain its market dominance and to improve the nutrient content of the product further. Executives of the manufacturing firm met with officials of the Nutrition Centre of the Philippines to discuss collaboration in the fortification of the margarine.
Two options were raised during the discussion. The first one involved undertaking a quick feasibility study of increasing the amount of vitamin A in the margarine. Should the results of the study prove acceptable, the fortified margarine was to be launched immediately on the market. This option was initially favoured by the manufacturer.
The second option was to undertake a stability study and then a field trial to assess the effects of consumption of fortified margarine on the vitamin A status of pre-school children. This option, however, meant extending the study from six months to one year, with added financial and time constraints along the way. In spite of this fact, the second option was chosen. Both parties were convinced that a field trial could enhance the acceptability of the fortified margarine as beneficial to peoples health, particularly those at risk of micronutrient deficiencies. Taking the second option resulted in a series of collaborative efforts between and among agencies in the Philippines and abroad. The manufacturer provided the necessary financial support, while the Nutrition Centre of the Philippines was the principal investigator in the field trial. Johns Hopkins University assisted in the research design of the field trial. The project was endorsed by the Philippine Department of Health.
Johns Hopkins also sent an expert in high-performance liquid chromatography to train the staff of the Department of Biochemistry at the University of the Philippines College of Medicine and the Food and Nutrition Research Institute to perform an in-country analysis of serum retinol. However, the Philippines was beset at that time by an energy crisis, and daily power failures occurred almost nationwide, which made it necessary to perform serum retinol analysis by high-performance liquid chromatography outside the Philippines. The analysis was eventually performed at the Institute of Nutrition at Mahidol University in Salaya, Thailand, and resulted in regional cooperation for biochemical analysis. The Department of Epidemiology and Biostatistics at the University of the Philippines College of Public Health conducted the statistical analysis and the interpretation of the results of the field trial.
The vitamin A content of the margarine was increased by 300 mg retinol equivalents (RE) (from 131 to 431 Ug RE) per serving (approximately 1 tablespoon, equivalent to 15 g), or about 115% of the recommended dietary allowance (RDA) for three- to six-year-old Filipino children. Each serving also contained 3 mg thiamine, 50 mg cholecalciferol, and 326 mg b-carotene as a colourant. The results of the stability study showed vitamin A retention to be 107%, 87%, and 58% after one, four, and eight months of storage under ambient conditions in the Philippines, respectively. The vitamin A recovery after heating the fresh margarine at 100°C for 5 minutes was 97%; the recovery was 83% when the margarine was cooked for 15 minutes at 177°C.
A double-blind field trial was conducted by the Nutrition Centre of the Philippines to assess the effects of the consumption of vitamin A-fortified margarine on the vitamin A status of children three to six years of age in rural Cavite, Southern Luzon. The children of six villages were randomly assigned in a 2:1 ratio to groups receiving either vitamin A-fortified (experimental, N=353) or non-fortified (control, N=350) margarine (250 g/week, or ~2 tablespoons/child/day), containing 431 mg RE (377 mg RE as retinyl palmitate and 54 mg RE as b-carotene) or 0 mg RE, respectively. The daily margarine intake per child was -27 g in the experimental group and ~ 24 g in the control group .
After six months, the mean serum retinol had increased from 26.4 to 28.8 mg/dl in the experimental group but had decreased from 26.6 to 25.1 (mg/dl among the controls (p<.001 at six months). The multiple adjusted increment over controls was 2.4 mg/dl (p <. 001). The prevalence of low serum retinol (<20 1mg/dl) decreased from 25.7% to 10.1% in the experimental group but remained unchanged in controls at 26.7% to 27.7% (p<.01 at six months) (fig. 1). In a follow-up assessment, no children from the experimental group had developed xerophthalmia, but 1.4% and 1.8% of the children in the control group developed night-blindness and Bitots spots, respectively. The trial showed that consumption of vitamin A-fortifred margarine significantly improved the vitamin A status of pre-school Filipino children .
In the course of the field trial, the manufacturer began a social marketing campaign emphasizing the importance of vitamin A to the human body. The information was disseminated through 30-second radio and television spots with no mention of the fortified margarine product. The publicity did mention, however,
FIG. 1. Prevalence of low serum retinol among study children: proportion of pre-school children with serum retinol levels <20 mg/dl at baseline (gray bars) and after six months (black bars) of consumption of vitamin A-fortified margarine (experimental) or non-fortified margarine (control) that the messages were sponsored by the manufacturer and the Nutrition Centre of the Philippines.
Soon after the successful field trial, the manufacturer launched its improved, vitamin A-fortified margarine. At the same time, the manufacturer embarked on a full-scale multimedia campaign advertising the product. Three months after the market launching, sales of the fortified margarine had increased by about 20% over the same period in the preceding year .
The volume of production of Star Margarine in 1993, the first year of fortification, was 4 million kilograms . In 1996, three years after the products first appearance on the market, the volume of production increased to 5 million kilograms . This substantial increase was evident despite the transition period brought about by the change in company ownership. The margarine brand is now owned by Philippine Dairy of the San Miguel Corporation, the largest food-manufacturing company in the country. The new owner took over the previous owners commitment to maintain and strengthen the high-quality fortification standards of the margarine.
Affordability and accessibility to low-income groups
As a result of the field trial, the Nutrition Centre of the Philippines recommended that the manufacturer create an affordably priced pack of the fortified margarine for the benefit of low-income groups. The manufacturer developed the micro-nutripac, a 15-g package that held one serving of the fortified margarine containing 100% of the RDA for vitamin A and that sold for only US$0.07. This enabled people from lower-income groups to buy a serving of the fortified margarine for as few as two people, paying only about 1% of a daily wage earners disposable income for the day.
The margarine was the first product in the Philippines to receive recognition for its high-quality fortification standards from the Department of Health. For the first time, a product was allowed to carry the Department of Health logo with the words Accepted by the Department of Health on the label. The label also stated in fine print, The only margarine clinically tested by the Nutrition Centre of the Philippines. From this initial Department of Health stamp of approval evolved the Sangkap Pinoy seal, which has become the official mark of recognition for high-quality fortified food products. Sangkap Pinoy, which literally means Filipino or indigenous ingredients, was the Department of Healths rallying cry in its campaign against micronutrient malnutrition. In fact, the observance of National Micro-nutrients Day was called Araw ng Sangkap Pinoy, or ASAP. Since Star Margarine first earned the Sangkap Pinoy seal, the government has undertaken a multimedia campaign to generate awareness of the Sangkap Pinoy seal and its importance for promoting food fortification as a major strategy in the national nutrition programme. The Sangkap Pinoy seal is now placed on all fortified food products that meet the high fortification standards set by the government.
A processed food product that is awarded the Sangkap Pinoy seal may, however, lose the privilege of carrying it on its label if the product is found to be lacking in quality. The Department of Healths Bureau of Food and Drug Administration performs regular quality assurance tests to determine whether a product is still worthy of the seal. Despite these inspections, the Sangkap Pinoy seal is still vulnerable to abuse by food-manufacturing companies and advertising agencies. Products that are not staple foods, do not sell well, or are categorized as having empty calories can be conveniently fortified with a nutrient to qualify for a Sangkap Pinoy seal, which can then help increase sales. A trend towards the proliferation on the market of such processed food products dignified with a Sangkap Pinoy seal and preferred by consumers over more nutritious food items such as fresh milk and eggs is possible.
No major problems were encountered in the fortification of the margarine, from its formulation with vitamin A, stability tests, and field trial to its full distribution through normal market channels. The technology is appropriate: vitamin A is soluble and stable in oil, even under storage and at high temperatures, and it is compatible with other nutrients such as vitamin B1 and D3. Above all, the vitamin A in the margarine is bioavailable and effective in improving the vitamin A status of young children. The additional cost of the fortificant is minimal: US$0.01 per 100 g of margarine or about US$0.001 per 15-g serving. These factors, including the fact that the manufacturer decided upon, initiated, and implemented the vitamin A fortification, assure the sustainability of the effort.
Since the original fortification of margarine with vitamin A in the Philippines, five new brands of margarine have emerged on the market, all of them fortified with vitamin A although containing less than the level found in Star Margarine. A recent market survey conducted by the manufacturer showed that the consumption of Star Margarine among people with annual incomes under 15,000 pesos increased from 89% in 1988 to 91% in 1996. The consumption increased despite the presence of the five other margarine brands, which are priced lower than Star Margarine by as much as US$0.03 to US$0.08. However, the consumption of Star Margarine among people with annual incomes over 15,000 pesos decreased from 11% in 1988 to 9% in 1996 [7,9].
The fortification of margarine with vitamin A shows that even in the absence of legislation or regulations, the manufacturer is capable of initiating the fortification of processed foods with micronutrients and sustaining the effort. Similar efforts by industry have also occurred in other parts of the world . The manufacturer is actively supporting the Philippine Nutrition Programme by fortifying its margarine with vitamin A. In this regard, the manufacturer deserves some encouragement and incentives, which might be delivered in the form of support through strong national policy initiatives or an executive order from the President directing government institutions to help manufacturers undertaking fortification efforts so that the populations consumption of fortified foods is enhanced. In such cases, legislation may not be needed.
The fortification of Star Margarine with vitamin A is an example of how government and non-governmental organizations, industry, academics, and other sectors can work together and share skills and resources for the solution to public health problems. Advocacy efforts resulted in the cooperation of the food-manufacturing sector in allowing the use of its resources for the solution of a micronutrient-deficiency problem.
1. Food and Nutrition Research Institute. Fourth National Nutrition Survey, 1993. Bicutan, Taguig, Metro Manila: FNRI/Department of Science and Technology, 1994.
2. World Health Organization. Indicators for assessing vitamin A deficiency and their application in monitoring and evaluating intervention programmes. Micronutrient Series 96.10. Geneva: WHO, 1996.
3. National Nutrition Council. Medium Term Plan for the Philippine Food and Nutrition 1993-1998. Makati, Metro Manila: NNC, 1994.
4. National Nutrition Council. Philippine Plan of Action for Nutrition. Makati, Metro Manila: NNC, 1994.
5. Department of Health. Remarks of His Excellency, President Fidel V. Ramos. In: A report on the advocacy meeting in ending hidden hunger. Heroes Hall, Malacanang Palace, Manila: Department of Health, 10 June 1993.
6. Solon F, Latham MC, Guirriec R, Florentino R, William-son DF, Aguilar J. Fortification of MSG with vitamin A: the Philippine experience. Food Tech 1985;39:71-7.
7. Procter & Gamble Philippines. Star Habits Study. Makati, Metro Manila: Procter & Gamble Philippines, 1988.
8. Solon FS, Solon MA, Mehansho H, West KP Jr, Sarol J, Perfector CS, Nano TC, Sanchez L, Isleta M, Wasantwisut E, Sommer A. Evaluation of the effect of vitamin A-fortified margarine on the vitamin A status of pre-school Filipino children. Eur J Clin Nutr 1996;50:720-3.
9. Philippine Dairy Products Corporation. Survey of usage, attitude and image study. Makati City, Metro Manila: Philippine Dairy Products Corporation, 1996.
10. Mehansbo H. Report on the stability study of beta-carotene and vitamin A on the new margarine product. Cincinnati, Ohio, USA: Procter & Gamble, 1993.
11. Nestel P. Food fortification in developing countries. Washington, DC: US Agency for International Development, 1993.