ASSESSMENT OF IRON FORTIFICATION OF RICE AND IODIZATION OF SALT SOLD IN

SOME CITIES IN PNG

V J TEMPLE, N KYAKAS, S GRANT, J BAUTAU, H. KAI, D SIRI,

Micronutrient Research Laboratory BMS SMHS UPNG

JAMES TEIO & DIANA KAVE

Environmental Health NDOH PNG

PROJECT SPONSORED BY WHO via EH NDOH

(July to October 2019) 1

BACKGROUND

• Micronutrient deficiency “Hidden Hunger” is a major obstacle to sustainable development;

• Hidden Hunger (HH) increases the risk factors for disease burden, economic and social deprivation, because of its long ranging negative effects on vulnerable groups in the population [Lindsay 2000;

UNICEF/WHO 2012];

• It affects Public Health policies and strategies for prevention and control of Malaria, TB, HIV/AIDS and other diseases [UNICEF/WHO 2012, Temple 2012];

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Background cont…

• IRON & IODINE deficiencies are 2 examples of HH,

• Elimination or significant reduction of HH among women and children is a public health priority,

• Anaemia is world’s 2nd leading cause of disability among children, non-pregnant, pregnant and lactating women [WHO/UNICEF 2006, 2014];

• About 50% of all cases of anaemia are due to Iron deficiency [Steiger et al 2014, FFI 2014];

• Iron fortification of staple foods is the recommended long-term cost-effective strategies for control and prevention of Iron deficiency among at-risk group;

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Background cont…

• 2005 PNG National Nutrition Survey indicated anaemia prevalence of 40.0% [PNG NNS 2005];

• Legislation for mandatory fortification of white rice was introduced in PNG in 2007 [NDON 2007];

• According to the policy:

• 100g of white Rice must contain at least

• 0.5mg of Vitamin B1,

• 6.0mg of Vitamin B3,

• 3.0mg of Iron

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Background cont…

• Iodine deficiency is the world’s greatest single cause of preventable mental retardation [IGN 2007]

• Mild to moderate iodine deficiency in apparently healthy children can cause:

• Stunted growth,

• Impaired learning ability,

• Underperformance in school,

• Poor performance in psychometric tests,

• Impaired physical and cognitive functions

• Reduced capacity for critical thinking;

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Background cont…

• Iodine deficiency in adults causes:

• low work capacity,

• reduced productivity,

• dry scaly skin,

• tingling and numbness in extremities,

• forgetfulness,

• depression,

• personality changes,

• anemia,

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Background cont…

• Universal Salt Iodization (USI) is the strategy for control of Iodine deficiency;

• USI strategy was implemented in PNG in June 1995 with enactment of PNG Salt Legislation that prohibits importation, production and sale of non-iodised salt [Barter 1995]

• PNG Food Sanitation Regulation states that iodine content in salt should not be less than 30.0ppm (30mg of iodine per kilogram of salt) [NDOH 2007];

The Issues:

• Current situation with Iron fortification of white rice and salt fortification with Iodine raises some major questions:

• Are the different brands of white rice sold in PNG fortified with Iron?

• Rice can be fortified either by Kernels or Dusting technologies; what type of technology is used for fortification of white rice with iron in PNG?

• Are the different brands of salt sold in PNG adequately fortified according to PNG standard?

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Objectives

• Major objective of this project was to assess the extent of compliance with national fortification standards for rice and salt sold in some cities;

• Samples of all brands of rice and salt commonly sold in selected cities were collected, so as to determine the number of brands that are fortified according to the national standards;

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METHODOLOGY in brief:

• Qualitative assessment of Iron in white rice [FFI 2014]:

• Two techniques are used for fortification of

white rice with Iron;

• Fortification with Kernels,

• Fortification by Dusting,

• Standard Operating Procedure (SOP):

• Qualitative spot test was used to detect

presence of Iron in fortified white rice

(courtesy Food Fortification Initiative)

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METHODOLOGY in brief:

• WYD protocol used to quantitatively assess

Iodine content in salt;

• It measures amount of iodine in salt iodized

with Potassium Iodate or Potassium Iodide

• Amount of iodine is expressed in parts per million

(ppm):

• 1.0 mg iodine per kilogram of salt (mg/kg)

{1.0 mg/kg = 1.0 ppm};

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METHODOLOGY in brief:

• Qualitative assessment of Iron in white rice

• Standard Operating Procedure (SOP):

DIAGRAMS

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Fortified rice before spraying with SOP

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Rice fortified by Kernel after spraying with SOP

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Rice fortified by Dusting after spraying with SOP

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Rice fortified by Dusting and Kernel after spraying with SOP

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FINDINGS AND COMMENTS

• 149 rice samples were received,

• They were sorted using the brand codes and

names provided by the EHO NDOH;

• There were 21 different brands of rice;

• Rice samples were from 11 cities

• SOP was used to assess each rice sample for

presence of Iron;

• The 149 rice samples were sorted according

to the method used for iron fortification;

• Results obtained are presented in Table 1; 17

Table 1: Summary of rice fortification results for rice sold in 11 cities in PNG

Percent of Rice samples fortified by

CITIES Brands (N) Rice (N) DUSTING KERNEL MIXED NEGATIVE

HELA 2 2 0 50% 50% 0

GOROKA 13 13 15.4% 61.5% 15.4% 7.7%

POM 19 19 5.3% 68.4% 5.3% 21.0%

ALOTAU 9 9 11.1% 77.8% 11.1% 0

LAE 12 12 8.3% 66.7% 16.7% 8.3%

MADANG 14 15 13.3% 73.3% 6.7% 6.7%

VANIMO 6 6 50% 50% 0 0

KIMBE 11 11 0 90.9% 0 9.1%

BIALLA 9 9 22.2% 77.8% 0 0

RABAUL 15 35 22.9% 65.7% 2.8% 8.6%

KERAVAT 13 18 27.8% 50% 22.2% 0 18

FINDINGS AND COMMENTS

• In PNG, rice is commonly washed before

cooking; the major reason is to remove dust

and to ensure that the rice is clean;

• Washing of the rice and discarding the water

results in significant loss of the iron fortificant,

especially if dusting method is used;

• Show diagrams

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Water from unfortified rice washed once was sprayed with SOP

Water from rice fortified with Kernel washed once. Water sprayed with SOP

Water from rice fortified with Kernel: After 2nd wash. Water sprayed with SOP

Water from rice fortified with kernel. After 3rd wash. Water sprayed with SOP

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Water from unfortified rice washed once was sprayed with SOP

Water from rice fortified by dusting washed once. Water sprayed with SOP

Water from rice fortified by dusting: After 2nd wash. Water sprayed with SOP

Water from rice fortified by dusting. After 3rd wash. Water sprayed with SOP

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Iron fortification cont…..

• Our results underscore the urgent need to advocate for the inclusion of Iron fortification of wheat flour in the PNG Food Fortification policy;

• In PNG, the use of wheat flour in food preparation does not include washing the flour before cooking; thus, Iron fortification of flour has a greater potential in improving the Iron status of the population, than that of rice (which is commonly washed before cooking);

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Salt iodization

• Total of 50 salt samples were received;

• They were sorted using the brand codes and brand names provided by the EHO NDOH;

• Salt samples were from 7 cities excluding POM,

• Samples from POM were purchased by lab

• There were 16 different brands of salt;

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Salt iodization

• Results for iodine content in salt from 7 cities were sorted according to cut-off points in PNG Salt Legislation: Cut-off points used:

No Iodine: Iodine below 5.0mg/kg

Inadequate iodine: Iodine: 5.0 to 29.9mg/kg

Adequate iodine: Iodine: 30.0 to 50.0mg/kg;

Excess iodine: Iodine above 50.0mg/kg;

Criteria for interpretation of results:

For effective implementation:

Over 90% of salt samples MUST be adequately iodized 24

Table 2: % Distribution of iodine content in salt from 7 cities + POM

according to cut-off points in PNG salt legislation

Percent of salt samples with iodine content:

NO IODINE INADEQUATE ADEQUATE EXCESS

CITIES Salt

(N)

Brands

(N)

<5.0mg/kg 5 – 29.9mg/kg 30 – 50mg/kg > 50mg/kg

HELA 2 2 0 0 50% 50%

GOROKA 8 7 0 25% 37.5% 37.5%

ALOTAU 6 4 0 0 50% 50%

LAE 8 6 0 12.5% 50% 37.5%

MADANG 10 7 0 30% 50% 20%

KIMBE 10 10 10% 40% 40% 10%

RABAUL 6 3 16.7% 16.7% 33.3% 33.3%

POM 11 10 27.5% 27.5% 27.5% 18.2% 25

Salt iodization

• This criterion has not been fulfilled in any of the cities;

• The adequately iodized salt coverage was 50% in four cities at the time of this project;

• This indicates poor implementation of PNG Salt Legislation;

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Salt iodization • One generally accepted concept is that it is better

to consume salt containing more iodine that less iodine [UNICEF/WHO/ICCIDD 2007]

• Table 3 shows recalculation of the results for availability of iodized salt in the 7 cities + POM;

• This was done by combining salt samples with adequate and excess iodine;

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Table 3: Combined % distribution of adequate and excess iodine content in salt from the 7 cities

+ POM based on the cut-off points in PNG salt legislation

Percent of salt samples with iodine content:

No iodine Inadequate Adequate Excess Combined

CITIES Salt

(N)

Brands

(N)

<5.0mg/kg 5–29.9mg/kg 30–50mg/kg >50mg/kg (mg/kg)

HELA 2 2 0 0 50% 50% 100%

GOROKA 8 7 0 25% 37.5% 37.5% 75.0%

ALOTAU 6 4 0 0 50% 50% 100%

LAE 8 6 0 12.5% 50% 37.5% 87.5%

MADANG 10 7 0 30% 50% 20% 70.0%

KIMBE 10 10 10% 40% 40% 10% 50.0%

RABAUL 6 3 16.7% 16.7% 33.3% 33.3% 66.6%

POM 11 10 27.3% 27.3% 27.3% 18.2% 45.5% 28

Salt iodization

• Results show that the criterion was still not fulfilled by 5 of the 7 cities + POM, because the combined results were still below the 90% recommended coverage;

• POM was the lowest with 45.5, followed by Kimbe with 50%, followed by Rabaul with 66.6%, Madang with 70%, Goroka with 75%, and Lae with 87.5%.

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Salt iodization

• Results indicated that less than 55% of adequately iodized salt was available in shops in the 7 cities + POM at the time of collection of the samples;

• Adequate salt iodization remains the main strategy for achieving sustained IDD control, and global experience has demonstrated that the iodization of food grade salt is the most equitable, effective and sustainable strategy to ensure optimal iodine nutrition for all population groups

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REFERENCES • Lindsay H. Allen Ending Hidden Hunger: The history of micronutrient deficiency control:

Background paper of the World Bank-UNICEF nutrition assessment project, World Bank: Washington, DC, USA, 2000, 111 – 130.

• UNICEF The state of the world’s children 2012 children in an urban world www.unicef.org/sowc2012.

• VJ Temple. “Ending Hidden Hunger: Is there a weak link?” Guest Editorial: African Journal of Food, Agricultural, Nutrition and Development (AJFAND), December 2012, Volume 12, No. 7, 1 – 11. https://www.ajfand.net/Volume12/No7/GuestEditorial-Temple.pdf

• PNG NDOH, Food Sanitation Regulation, Statutory Instrument No. 01, Port Moresby 2007.

• Barter P. Pure Food Act (chap. 232) amendment of Pure Food Standards. Papua New Guinea National Gazette, Port Moresby 1995; G47.

• Food Fortification Initiative (FFI). Rice fortification’s impact on nutrition. Atlanta, USA: FFI, 2014. Available from www.FFInetwork.org.

• Sajid Alavi, Betty Bugusu, Gail Cramer, Omar Dary, Tung-Ching Lee, Luann Martin, Jennifer McEntire, Eric Wailes; Rice Fortification in Developing Countries: A Critical Review of the Technical and Economic Feasibility. A2Z Project Academy for Educational Development, April 2008, 1 – 75, www.a2zproject.org

• Georg Steiger, Nadina Muller-Fischer, Hector Cori and Beatrice Conde-Petit; Annals of the New York Academy of Sciences Issue: Technical Considerations for Rice Fortification in Public Health: Fortification of rice: technologies and nutrients. 2014, 1 – 11 doi: 10.1111/nyas.12418;

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REFERENCES • WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency Disorders and monitoring their

elimination: A guide for programme managers. Geneva: WHO/NHD; 2007. Available from: http://www.who.int/nutrition/publications/micronutrients/iodine_deficiency/9789241595827/en/.

• Zimmermann M, Boelaert K. Review: Iodine deficiency and thyroid disorders Lancet Diab Endoc. 2015;3(4):286-95.

• Eastman C, Zimmermann M. The Iodine Deficiency Disorders. Bethesda: National Center for Biotechnology Information, U.S. National Library of Medicine; 2018. Available from: http://www.ncbi.nlm.nih.gov/books/NBK285556/.

• Pearce E, Lazarus J, Moreno-Reyes R, Zimmermann M. Consequences of iodine deficiency and excess in pregnant women: an overview of current knowns and unknowns. Am J Clin Nutr. 2016;104 (Suppl):918S-23S.

• WHO, WFP, UNICEF; Preventing and controlling micronutrient deficiencies in populations affected by an emergency Multiple vitamin and mineral supplements for pregnant and lactating women, and for children aged 6 to 59 months: Joint statement by the World Health Organization, the World Food Program and the United Nations Children’s Fund; www.unicef.org/Joint_Statement_Micronutrients_March_2006.pdf

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Thank you!

The Issues cont…..:

• Nutritional objectives in PNG National Health Plan and Vision 2050, include the following:

• Reduction of Anaemia among women and children in the population;

• Elimination of IDD,

• Monitoring of the availability and utilization of adequately iodized salt at district and provincial levels;

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