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

DSM Nutritional Products 1 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 I. The Need for Food Fortification

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

DSM Nutritional Products 4 Hidden Hunger is defined as... Worldwide, over one third of deaths among children under 5 years of age is associated with malnutrition. “ 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

DSM Nutritional Products 5 What is the impact of Hidden Hunger? 1.1 mio children <5 years 600,000 stillbirths 115,000 women during pregnancy Vit. A & Zinc deficiencies Iron deficiency anemia Iron deficiency anemia Maternal iodine deficiency Vit. A deficiency Maternal folate deficiency 18 mio babies born mentally impaired 350,000 children go blind 150,000 babies born with neural tube defects Annual lives lost Annual lives impaired

DSM Nutritional Products 6 Global impact estimated by Unicef (2004) Micronutrient deficiency is a huge financial burden… „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 $86 billion over the next ten years.” Micronutrient deficiencies cost globally 180 bio US$ in the next 10 years: in China 2,8 bn US$ and in India 6,0 bn US$.

DSM Nutritional Products 7 … and is seen as the greatest challenge in the 21 st century worldwide  More than 60 % of healthcare costs and disabilities are due to lifestyle related diseases  Cardiovascular diseases, diabetes, high cholesterol, osteoporosis, overweight are some of the key health issues related to nutritional factors  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 8 Micronutrients (vitamins and minerals) are essential for many functions and health Normal Growth Healthy aging Healthy Babies Strengthening immune system Good Health Good Performance Normal Brain Growth Vitamins & Minerals that are only needed in small amounts, but are essential for … They cannot be produced by the body and have to come from the diet

DSM Nutritional Products 9 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 10 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 II. Options for Fortification

DSM Nutritional Products 12 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 13 Food fortification has a successful track record an many countries 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 and USA; now available in most countries. 1933:Mandatory fortification of flour with Vitamin B1 in Canada and virtual elimination of Beriberi. 1941:Mandatory fortification of flour with Vitamin B3 in the USA and virtual elimination of pellagra early 40ies: Fortification of cereal products with Vitamin B1, B2 and B3 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 14 NutriRice ® : from staple food to nutritious food Nutrients Vitamin A (Retinyl-palmitate) Vitamin B1 (Thiamine chloride HCl) Vitamin B2 (Riboflavin) Vitamin B12 (Cyanocobalamine) Niacin Iron … and others Inclusion levels: can be adapted to nutrient requirements NutriRice ® 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.

DSM Nutritional Products 15 Efficacy of NutriRice demonstrated in school children in India Group 1 MMN fortified rice Group 2 MMN fortified rice high iron Group 3 Unfortified rice 6 days/wk; Sep-Feb 2009/10 Total of 134 days ~300 g cooked rice (=100 g dry uncooked rice) 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 16 Home fortification provides benefit of full micronutrient basket Since mid-1990s, 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 (MixMe™) - Micronutrient-rich spreads (NutriButter™) 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 17 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 18 A number of crops are currently investigated for bio-fortification CropNutrient 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 III. Regulatory and Market Factors

DSM Nutritional Products 20 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 21 Six key factors determine whether mandatory or voluntary fortification is the most appropriate option FactorMandatoryVoluntary Public health riskHigher / more affectedLower / fewer affected Food industryCentralized, well organizedSmaller, more diverse Consumer awareness/ demand Not necessaryEssential Political environment (choice) Not necessaryEssential Food consumption patternsFortified food widely consumed Variety and accessibility essential Fortification approachMass/universalMarket-driven Criteria governing the selection of mandatory or voluntary fortification Proactive communication and advocacy on role of fortification is a joint task of policy makers, regulatory bodies, food industry and nutrition scientists

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

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

DSM Nutritional Products IV. DSM’s engagement

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

DSM Nutritional Products 26 DSM brings nutrition competence, WFP global reach and distribution management into the partnership % WFP FOOD FORTIFIED % WFP FOOD FORTIFIED Enriching General Food Baskets* with Micronutrients * * Include cereals, pulses, legumes, fortified blended food, oil, salt Micronutrient Powder (+Phytase) Specially formulated, fortified foods Fortified Blended Food (CSB+,CSB++) Staple Food Fortification (NutriRice) DSM is playing a critical strategic role in enabling WFP to launch the approach at the global level

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

DSM Nutritional Products 28 In summary: DSM is balancing business and social responsibility Recognition InvolvementPartnering Business N utrition I mprovement P rogram

DSM Nutritional Products V. Summary and Outlook

DSM Nutritional Products 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 Options to deliver Fortified Products to the Public

DSM Nutritional Products 31 Back up

DSM Nutritional Products 32 Conventional fortification has a strong track record 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 1920s in both Switzerland and USA; now available in most countries From early 1940s, 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 33 Folic acid fortification of flour is a success story for many countries 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 34 Rice Innovations drive new opportunities in staple food fortification 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 (NutriRice) With micro-encapsulated vitamins in re- constituted 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 35 Efficacy of NutriRice demonstrated at Dandelion Migrant Worker School, China Fortified food commodities consumed: NutriRice (B1, B2, FA, niacin, Zn, Fe, BC), NaFeEDTA-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 36 … 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

DSM Nutritional Products 37 A number of technical and societal pre-requisits have to be fulfilled for successful bio-fortification 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 38 Both, mandatory and voluntary fortification require regulatory guidance 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 39 Costs for fortification are low relative to achievable benefit Copenhagen Consensus 2008

DSM Nutritional Products 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”. Feike Sijbesma receives 2010 Humanitarian of the Year Award DSM‘s commitment to CSR honored by WFP and UN