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Abstract
Introduction
History of rice fortification in the Philippines
Technology
Studies
Current status
Problems and constraints
Future prospects
References
Rodolfo F. Florentino and Ma. Regina A. Pedro
The authors are affiliated with the Food and Nutrition Research Institute, Department of Science and Technology, Manila, Philippines.
Mention of the names of firms and commercial products does not imply endorsement by the United Nations University.
Rice, the staple in all regions in the Philippines, is an excellent vehicle for fortification. The Food and Nutrition Research Institute developed the technology for the fortification of rice with iron, using ferrous sulphate as the fortificant. A prototype machine was manufactured for the production of iron-fortified premix with a capacity of 200 kg per hatch. A study on iron bioavailability showed a significant increase in the amount of iron absorbed with iron-fortified rice. A clinical trial conducted with 173 schoolchildren for six months showed a greater increase in haemoglobin in subjects who received iron-fortified rice than in those who did not. The problems and constraints that arise with rice fortification include the added cost of fortification (estimated at 2.5% of the cost of rice), which would probably be passed on to the consumer, and the presence of numerous rice mills throughout the country, which may pose difficulties in enforcement. Nevertheless, when carried out in large rice mills, fortification of rice with iron could reach a significant portion of the population.
Micronutrient malnutrition is now the focus of the world’s nutrition community because of its largely covert deleterious effects on large portions of the population, including physical and mental deformities, high risk of infection, low work productivity, and increased mortality in young children: hence the term “hidden hunger.” Iron deficiency is the most widespread of the micronutrient deficiencies. Over 2,000 million people in practically all countries of the world are affected [1].
In the Philippines, 50% of children 6 to 11 months of age and more than 40% of pregnant and lactating women and the elderly are anaemic [2].
Several control measures against iron deficiency have been identified and are being carried out to a varying extent in different countries. Iron supplementation has been shown to be a successful intervention in the short term, but problems of limited outreach and sustainability as well as poor compliance constrain its implementation on a large scale. The nutritional improvement of the food supply and the alleviation of poverty, coupled with the modification of diets through nutrition education, offers a more permanent alternative, but it will take a long time before that objective is realized. On the other hand, fortification, a strategy geared towards improving the nutritional quality of the food supply, has been found to be effective and feasible when the vehicle chosen is widely consumed by the population at risk. Thus, efforts to fortify rice with iron have been pursued in the Philippines as a medium-term strategy for the control of nutritional anaemia, mainly by the Food and Nutrition Research Institute (FNRI).
In the Philippines rice is an excellent vehicle for fortification, because Filipinos are basically rice-eating people regardless of income. Rice is the staple food in all regions of the country, although it is commonly combined with corn in the central Philippines. It is consumed in relatively constant amounts by each age and sex group. The average daily consumption is 308 g overall and 143 g for children six years of age or younger [3]. People with low income consume proportionately more rice than those with higher incomes. However, people in low-income groups are more at risk for both protein-energy malnutrition and micronutrient malnutrition. Therefore, if fortified rice was distributed to the general population, it would reach practically every Filipino.
Another advantage of rice is that its consumption is not restricted in people with certain medical conditions, unlike other potential vehicles such as sugar (restricted in people with diabetes) and fish sauce, fish paste, and salt (restricted in people with renal disorders and hypertension).
However, rice cultivation and milling in the Philippines, as in other developing countries, are not centralized. Rice is cultivated predominantly in small farms and milled in some 11,000 rice mills throughout the country. Home pounding still accounts for a small portion of rice consumption among some farming households who cannot afford milling fees. Such issues thus need to be addressed in the design of the delivery system. However, as suggested by Austin [4,5], decentralized milling could permit geographical targeting and reduce overcoverage.
Rice enrichment in the Philippines began in the mid-1940s, when it was first conceived by Dr. R.R. Williams, the discoverer of vitamin B1 and then by the Secretary of Health of the Philippines, Dr. Juan Salcedo, Jr. At that time, the process for adding thiamine, niacin, and iron to rice had been developed by Hoffman-La Roche. Also during this time, beriberi was a major public health problem in the country, and with the development of technology to fortify rice with thiamine, a promising solution to the beriberi problem presented itself.
In 1946 experiments on rice fortification in the Philippines began. Preliminary feeding trials among government employees, members of the armed forces, and children in welfare institutions showed that rice enriched with thiamine, niacin, and iron was acceptable with regard to colour, taste, odour, palatability, and digestibility. A larger-scale pilot test of rice fortification was done in the province of Bataan. Rice was enriched at the mill and the household levels in half of the province, while the other half served as control. Significant reduction in mortality from beriberi was noted in the experimental area after one year of implementation, and the virtual elimination of mortality from beriberi was recorded in the second year. The prevalence of the disease was drastically reduced as well.
The success of the Bataan Rice Enrichment Experiment led to the enactment of the Rice Enrichment Law in 1952, which required that all rice millers and wholesalers enrich the rice they milled or traded. The rice millers, however, saw the law as a way for their total production and thus their taxable income to be monitored, since every 50-kg bag of premix that they obtained from a government centre indicated 200 bags of rice milled. Non-compliance by rice millers was a major setback to the enforcement of the law. Moreover, since rice millers and traders constituted a formidable bloc in the country’s political structure, the political will to enforce the law also wavered. This was coupled to the high cost of monitoring for compliance by retailers throughout the country. Thus, rice enrichment died a natural death. Fortunately, by the end of the 1950s, beriberi had all but disappeared from the country. To this day, the law has not been repealed.
Interest in rice fortification was revived in the early 1980s because of recognition of the efficiency of food fortification for the control of micronutrient deficiencies, including iron-deficiency anaemia, which is rampant in the country. Therefore, the FNRI modified and adapted the technology used in the government’s previous attempt to fortify rice with ferrous sulphate.
Payumo et al. [6] of the FNRI established the technical process of fortifying rice with iron using ferrous sulphate as the fortificant and a suitable coating treatment that minimized nutrient losses (9%) due to washing of grains in preparation for cooking. At a fortification level of 12 mg of iron per gram of premix rice and a 1:200 ratio of premix to ordinary milled rice, the enriched rice was rated acceptable even after six months of storage at room temperature. The study by Marzan et al. [7] of iron absorption with different levels of iron-fortified rice showed that at a 0.5% level of fortification (1:200), about 12% iron absorption was achievable among normal adult males.
Meanwhile, through the Philippine Plan of Action for Nutrition (PPAN), the Philippines committed itself to reduce significantly, if not eradicate, micronutrient malnutrition, specifically deficiencies in vitamin A, iron, and iodine. The PPAN identified food fortification as among the interventions the country would vigorously pursue.
Initially, the national rice-fortification programme planned to implement a fortification level of 12 mg of iron per gram of premix rice, which aimed to provide 100% of the recommended dietary allowance (RDA) for iron, given a 1:200 mixing ratio with ordinary milled rice and a per capita consumption of 300 g of rice per day. However, adults, and sometimes adolescents and children, may consume more than 300 g of rice per day and may, therefore, get more than 100% of the RDA from iron-enriched rice. Apprehensions with regard to iron overload among healthy persons led the FNRI to redefine the objective of iron fortification in rice by providing a significant percentage of the RDA for iron but not significantly more than 100% for any age group. Thus, in the current iron-fortification programme, a fortification level of 6 mg of iron per gram of premix rice added to ordinary milled rice at a ratio of 1:200 (i.e., 5 g of premix to 1 kg of ordinary milled rice) is being maintained, thus providing each segment of the population with a significant proportion of the RDA for iron, as shown in table 1.
The coating has also undergone reformulation in view of the ban on the use of some of the original ingredients. This has affected iron retention to some extent, particularly due to the loss of iron during the rinsing of rice grains prior to cooking. Initial estimates of iron losses after rinsing and cooking of enriched rice ranged from 11% to 45% in an ongoing study at FNRI [8].
TABLE 1. Daily amount of iron provided to different population groups by fortified rice
|
Group |
Iron (mg) |
% RDA |
|
Pre-school children |
3.6 |
40.0 |
|
Schoolchildren |
7.5 |
63.0 |
|
Adult men |
13.5 |
113.0 |
|
Adult women |
9.9 |
40.0 |
|
Pregnant women |
10.5 |
26.0 |
|
Lactating women |
11.4 |
50.0 |
1. The fortificant (FeSO4) is prepared and mixed with the coating solution in a suspension tank;
2. The contents of the suspension tank are pumped into a rotating mixer;
3. The fortificant and coating solution are sprayed over rice kernels in the mixer;
4. The fortified rice grains are dried.
Field trials in Gen. Natividad, Nueva Ecija
Following the development of the technology by FNRI and during an Advocacy Forum to End Hidden Hunger in June 1993, Fidel V. Ramos, President of the Philippines, endorsed iron-fortified rice as a vehicle to control iron deficiency in the country. Also at the conference, the Secretary of Health, Dr. Juan Flavier, referred to enriched rice as FVRice (fortified vitamin rice), a generic term to indicate fortification with one or more of the micronutrients vitamin A, iron, and iodine. Thus, iron-fortified rice has come to be known as FVRice-iron. During the same forum, the governor of Nueva Ecija, a major rice-producing province in the Philippines, took up the challenge and invited the government to pilot the rice-fortification programme in his province. This led to the launching of the FVRice-Iron Programme during the province’s foundation day on 3 September 1993.
As part of the launching of FVRice in Nueva Ecija, a field trial of FVRice-iron was carried out for six months in one nutritionally depressed municipality of Nueva Ecija. The trial involved 20 families in each of four barangays of Gen. Natividad, Nueva Ecija. The families were provided with a six-month supply of FVRice-iron rice premix with instructions on how to prepare the rice in the kitchen. The haemoglobin levels in preschool children were measured at baseline and at six months. The results showed a significant reduction in the prevalence of anaemia among the children, from 88.8% at baseline to 73.5% after consumption of the rice for six months. Mean haemoglobin at baseline (10.3 ± 1.6 g/dl) also increased significantly after three months of intervention (11.2 ± 1.4 g/dl).
Pilot test in 15 municipalities
In 1995 FVRice-iron rice premix was sold by the Nueva Ecija Grains Retailers Association in 5-g and 25-g sachets in 15 pilot municipalities. These municipalities were identified by the Provincial Health Office of Nueva Ecija as nutritionally depressed. A 5-g FVRice-iron rice premix sachet is intended to be mixed with 1 kg of ordinary rice, whereas the 25-g sachet will enrich 5 kg of rice. A social marketing and promotion campaign was jointly carried out by the private manufacturer of the FVRice-iron rice premix and the local nutrition committee of each municipality, together with the Nutrition Service of the Department of Health and the FNRI. In Gen. Natividad, Nueva Ecija, the women’s group has actively taken part in selling FVRice-iron premix through the Socio-Economic Assistance component of the Barangay Integrated Development Approach for Nutrition Improvement (BIDANI).
Clinical trials of FVRice-iron in Dasmarinas, Cavite
In 1994 clinical trials of FVRice-iron were also carried out in a public elementary school to determine the effect of daily consumption for six months on the iron status of schoolchildren. The trials involved 173 elementary-school children 9 to 12 years of age, who were randomly assigned to the experimental and control (unfortified rice) groups. Iron-fortified rice was prepared using a 1:100 ratio of premix to rice, so that one serving of 100 g of rice contained more or less the amount of iron a child would obtain from one day’s intake of iron-enriched rice prepared with premix and ordinary rice at a ratio of 1:200. The ratio should have been 1:50 or 1:75, but the noticeable greyish colour and distinct odour of the fortified rice were unacceptable. The iron-fortified rice used in the study thus provided 5.33 mg Fe/100 g or an average of 38% of the RDA. The rice was served daily during school days at lunch time.
After six months there was a significantly greater increase in haemoglobin among both boys and girls in the experimental group than among those in the control group (table 2). At the same time, there was a significant reduction in the proportion of children with haemoglobin deficiency, as well as an increase in the proportion of those with normal levels after consumption of iron-fortified rice an average of four to five days per week (taking into consideration the children’s absences during the study period). There was also a significantly greater increase in the proportion of children with low to deficient serum ferritin in the control group than in the experimental group.
TABLE 2. Mean increase in serum haemoglobin of children after six months of consuming iron-fortified or unfortified rice
|
|
Increase in serum haemoglobin - g/dl (N) |
||
|
Sex and age (yr) |
Unfortified rice |
Iron-fortified rice |
|
|
Males |
0.8a |
1.0a |
|
|
|
9 |
1.0 (16) |
0.9 (13) |
|
|
10 |
0.7 (11) |
0.9a (12) |
|
|
11 |
0.6 (6) |
1.1a (10) |
|
|
12 |
- |
- |
|
Females |
0.6a,b |
1.1a,b |
|
|
|
9 |
0.6a(18) |
1.0a (18) |
|
|
10 |
0.6a (21) |
1.0a (15) |
|
|
11 |
0.5b (20) |
1.5a,b (11) |
|
|
12 |
- |
1.0 (2) |
|
Total |
0.6a,b |
1.0a,b |
|
A logistic regression analysis revealed that the chance of improving iron status and reducing the prevalence of anaemia was 2.3 times higher among schoolchildren fed iron-fortified rice an average of four to five days a week than among those given unfortified rice. It is likely that a greater impact would have been achieved through daily intake of fortified rice in a predominantly anaemic population.
Bioavailability study
The bioavailability of iron from unfortified (meal A) and FVRice-iron-fortified (meal B) meals was determined by simultaneous determination of 59Fe and 55Fe in blood in 20 healthy human subjects. FVRice-iron was prepared by mixing 1 part of premix rice to 200 parts by weight of ordinary rice. The total iron content of the FVRice-iron alone (uncooked) was 5.71 mg/100 g, and 2.84 mg/ 100 g when given as a mixed diet. The geometric mean iron absorption from meal A was 6.88%, significantly higher than the 5.41% absorption from meal B. However, the amount of iron absorbed increased significantly from 0.30 to 0.40 mg (p <. 01) when the total non-haem iron content was considered. Consumption of 120 to 150 g of rice daily might satisfy about 65% to 81% of the iron requirements for one- to three-year-old children, thus exceeding the goal of 40% to 50% of the RDA for this age group. Fortification of rice with iron in the form of ferrous sulphate seems to be effective, supplying an appropriate amount of absorbable iron.
A prototype machine for the production of iron premix with a capacity of 200 kg per batch has been developed for the rice-fortification programme by the FNRI. Moreover, the technology for the manufacture of the iron premix is currently being transferred to the Food Development Centre (FDC), an agency under the umbrella of the National Food Authority (NFA). At present, the FDC is preparing to pilot the mixing of premix rice in NFA’s Valenzuela mill, which supplies NFA rice to metropolitan Manila.
To provide the basis for the design of social marketing strategies, research is currently being conducted in collaboration with the Nutrition Service of the Department of Health. Some findings from this research are already being implemented in the programme design.
Fortified foods are expected to cost more than unfortified foods. For iron-fortified rice, the added cost is estimated to be 2.5% more than the cost of unfortified rice. At the prevailing price of rice in the market today, this will add a minimum of 0.40 pesos (US$0.02) to the price. Initial findings of the ongoing Formative Research on Fortified Foods, which includes rice, indicate that mothers may purchase fortified rice in spite of its higher cost if they are made to recognize the advantages. Since both fortified and unfortified rice will probably be available during the initial years of the rice-fortification programme once it is implemented, consumer demand will need to be strongly oriented towards the fortified product by well-tested marketing techniques.
As previously mentioned, rice milling in the Philippines is not centralized; there are numerous rice mills of varying capacities. Mandatory fortification will thus pose difficulties for enforcement. The requirement of additional equipment (e.g., precision feeders at the mills) may also pose a problem for smaller rice mills and perhaps even for larger ones as well.
Furthermore, home mixing in the kitchen will require the acquisition of skills in measuring and mixing. In focus-group discussions, the better-educated mothers expressed concern that this might be a problem for less-educated and illiterate mothers, who might have a greater need for fortified rice. The fortification of NFA rice, which is frequently consumed in lower-income households, addresses this concern to some extent. Nevertheless, education on proper measurement and mixing of iron premixes for home enrichment will need to be incorporated into social marketing and promotion activities.
It has been proposed that rice fortification in the Philippines will be implemented via mill enrichment and home enrichment. There are a number of rice mills in the country, many of them medium- to large-sized mills operated by the NFA, private or farmers’ cooperatives, or private individuals.
The NFA, which caters to about 10% of the market, particularly in low-income groups in urban areas and fishing and other non-rice-producing villages, has agreed to make iron-fortified NFA rice available to all consumers throughout the nation. To reach the remaining 90% of the market, enrichment in private mills and mills operated by cooperatives will be encouraged.
For the home-enrichment programme, the iron premix will be available through the usual retail system. This strategy is aimed at rural households and communities that may not have access to mill-enriched rice.
In addition to use in the household, iron-enriched rice, whether enriched at the mill or with an iron premix, will be distributed through the country’s Food Assistance Programme and Disaster Relief Operations as well as through school cafeterias, hospitals, and other institutions.
It is hoped that it will not be necessary to enact legislation mandating fortification by rice millers unless the fortification programme teeters on the edge of failure for the second time. Legislation providing incentives to rice millers to fortify is nevertheless welcome. And with all these, advocacy and social marketing will play very vital roles.
1. Food and Agriculture Organization/World Health Organization. Nutrition and development: a global assessment. Rome: FAO, 1992.
2. Food and Nutrition Research Institute. Fourth National Nutrition Survey. Manila: FNRI, 1993.
3. Food and Nutrition Research Institute. Third National Nutrition Survey. Manila: FNRI, 1987.
4. Austin JE. Cereal fortification: an overview. In: Austin JE, ed. Global malnutrition and cereal fortification. Cambridge, Mass, USA: Harvard University Press, 1977:1-9.
5. Austin JE. Community system structure. In: Austin JE, ed. Global malnutrition and cereal fortification. Cambridge, Mass, USA: Harvard University Press, 1977:35-44.
6. Payumo EM, Fabian E, Reyes P. Iron fortification of rice. In: Solon F, ed. Coordinated research programme for the control of nutritional anaemia in the Philippines. Metro Manila: Nutrition Centre of the Philippines, 1982:44-51.
7. Marzan AM, Anden AB, Yebra AE, Esnaola LI, Lansangan LM, Banaag F. Human iron absorption studies using different levels of fortified rice. In: Solon F, ed. Coordinated research programme for the control of nutritional anaemia in the Philippines. Metro Manila: Nutrition Centre of the Philippines, 1982:90-102.
8. Food and Nutrition Research Institute. Quarterly review of programmes and projects. Manila: FNRI, 1995.
9. Pedro MRA, Florentino RF, Bacos EF, Ungson BD, Duazo PL. Clinical trial of iron-fortified rice. Manila: Food and Nutrition Research Institute, 1995.
10. Valdez DH, Mallillin ACEM, Kuizon MD, Cabrera MIZ, Iron absorption from FVRice-iron fortified. Manila: Food and Nutrition Research Institute, 1995.
