Food Fortification: The evidence, ethics, and politics of adding nutrients to food

276 Pages·2013·1.64 MB·English

by  Mark Lawrence

Food Fortification
This page intentionally left blank
Food Fortification
The evidence, ethics,
and politics of adding
nutrients to food
Mark Lawrence
Associate Professor and Director Food Policy Unit,
World Health Organization Collaborating Centre for
Obesity Prevention, Deakin University
1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2013
The moral rights of the author have been asserted
First Edition published in 2013
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
British Library Cataloguing in Publication Data
Data available
ISBN 978–0–19–969197–5
Printed and bound by
CPI Group (UK) Ltd, Croydon, CR0 4YY
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-pregnant
adult who is not breast-feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
Dedication
This book is dedicated to Anita, Sarah, and Robert:
you are constant sources of love, support, and inspiration.
Foreword
It is my pleasure to provide some introductory comments on this important
piece of scholarship from Mark Lawrence. It seems almost too obvious to need
to say that we should all do whatever we can to address malnutrition, and in
particular undernutrition in children, that has such devastating long term con-
sequences. The solution should most obviously be driven by a preventive pub-
lic health approach to ensure children grow well and do not need to be ‘treated’.
Yet waiting until there is an acute problem does seem to be the norm before
action begins. Starting from a public health or clinical treatment perspective
makes a difference to the view as to how to address the problem; and acute
needs usually take precedence over long-term solutions. But the on-going fail-
ure to build in prevention and to adopt a public health approach leads to the
continuing need for an acute treatment model. So long term, ideally young
women before they are pregnant and children in the first two critical years of life
should have reliable access to enough good quality food, clean water, and basic
health care needs. These are basic human rights. All agree, yet this does not
seem to be enough to make it happen. Failure to address this is unacceptable.
In the context of this book, the question to address is what is the best way to
ensure reliable access to enough good quality food to meet energy and nutrient
needs. Over the last twenty years there has been a shift of emphasis away from
social and community development driving a public health approach that
seeks to ensure access to good quality food, to a more medicalized treatment
approach which argues that it is not possible to ensure nutrient needs are met
by diet alone. The preferred approach has been supplementation. At the same
time, but with varying and uneven success and effort, fortification and plant
breeding have also been worked on as ways to improve nutrient intakes. It is
important to understand how this change in emphasis came about.
These important questions are at the heart of this very important book. For
the first time, as far as I am aware, Mark Lawrence has set out in this book a
rational framework for asking these questions and the scholarship in this book
provides important answers.
This book is not a technical manual about how to do food fortification. This
book is about more fundamental issues that need to be addressed before actu-
ally rushing into food fortification. Lawrence asks the big questions about food
fortification: what are the public health benefits, risk, and ethical considerations
of food fortification and alternative policy interventions; and how and why are
food fortification policies made?
FOREWORD vii
By using case studies within a conceptual framework the book reveals many
important insights that, as far as I am aware, nobody else has previously uncov-
ered about why food fortification is or is not used to address major public
health nutrition problems. Key among these insights, for me, is that it is impor-
tant to ask some basic questions as to what causes the problem fortification is
seeking to address. If the problem is caused by a lack of a specific nutrient
because of the degradation of the nutrient content of the soil in which a food is
grown, or upon which animals graze, then it seems logical to seek ways to add
that lost nutrient back into the food chain. If the aim of food fortification is to
‘treat’ a nutrient related medical problem, the symptoms rather than the cause,
then there may be a different set of questions to ask as to whether fortification
is the best way to address this problem. Mark Lawrence asks three important
questions when assessing the appropriateness of food fortification policy: how
to specify and measure public health risk; how to specify and measure ethical
considerations; and how to compare scientific uncertainties and ethical con-
siderations across the possible policy solutions against background plausible
policy options. Thus, for each problem the key issues to consider are: what are
the different policy options to address the problem; what are the public health
benefits and risks for each option; and what are the ethical considerations for
each policy option. In Section 2 of the book, Mark uses this framework in three
case studies: universal salt iodization; mandatory flour fortification with folic
acid; and mandatory milk fortification with vitamin D. For each case study in
addition to using the above framework he also explores the actors, activities,
and agendas that have been engaged in the area of work.
In the third and last section of the book, Mark Lawrence draws conclusions
and provides some insights as to the way forward. One size does not fit all—the
responses to key public health nutrition challenges need to be appropriate to
the local circumstances that cause the problem. This requires scholarship at the
local level to understand the problem and think about relevant and appropriate
local solutions, particularly if the aim is to address local inequalities. Carrying
on doing the same things in the same way as we are currently doing does not
make a lot of sense. If the learning from this book is applied more widely we
just may start to do things more effectively, or at the very least going about
developing programmes based on some a priori logical framework for better
decision making.
Barrie Margetts
Professor of Public Health Nutrition
Faculty of Medicine, University of Southampton
President, World Public Health Nutrition Association
Preface
In my academic role as a public health nutritionist, I am regularly confronted
with the challenge that is food fortification and its advantages and disadvan-
tages for public health. Students and the general public have long been advised
by nutritionists that a healthy diet is one that conforms to the principles of bal-
ance, variety, and moderation. Yet, in contemporary times how relevant and
accurate are these principles when one serve of a cereal product may be forti-
fied to provide a novel variety of nutrients and in greater amounts than exists
in a combination of foods from all other food groups? Does it matter if that
cereal product is also 40 % by weight added sugar?
As a member of the public and a parent, the challenges I face may be differ-
ent but they persist. Governments around the world are regulating to varying
degrees for the addition of iodine, folic acid, and vitamin D, among other
nutrients, to staple foods in their country’s food supply. It is increasingly likely
that people in many countries now are consuming a diet that regularly contains
at least one fortified food. These government activities are intended to provide
public health benefits though they will provide little health benefit for my
young children or myself and may confer some risk. Balancing the evidence for
benefits and risks, struggling with ethical dilemmas, and negotiating the poli-
tics associated with the competing views of actors, are constant themes in food
fortification. It is for this reason that this book is entitled F ood Fortification:
The Evidence, Ethics a nd Politics of Adding Nutrients to Food .
The idea for this book arose from my experiences with the evidence, ethics,
and politics of food fortification from several perspectives. When I was the
Acting Nutrition Director at the then Australia New Zealand Food Authority
(now Food Standards Australia New Zealand), the Authority was immersed in
two especially vexed food fortification debates — whether folic acid should be
added to staple foods to help prevent neural tube defects (see Chapter 6), and
whether food regulations should be relaxed to give food manufacturers more
control over fortifying and marketing their products. As the Leader of the
Australian delegation at a Codex (in effect the international food regulator)
nutrition committee meeting I witnessed similar vexed food fortification
debates at the global level and observed the power of certain food manufactur-
ers in influencing these debates. In contrast, when working as a nutritionist in
Pacific Island countries and Vietnam I have had the opportunity to be involved
in projects in which food fortification has been a valuable policy option for
tackling food security concerns.
PREFACE ix
The purpose of this book is to present the findings of original research into
food fortification. The research aim was to provide insights into the public
health benefits, risks, and ethical considerations of food fortification as well as
understandings of its policy-making processes. It is intended that the achieve-
ment of this research aim will help students, practitioners, and policy-makers
identify how food fortification policy processes and subsequent policy out-
comes might be improved to further protect and promote public health.
A number of food fortification books are available. Typically the purpose of
such books is to describe food fortification interventions and the various tech-
nical details such as the regulatory conditions under which fortification might
occur. Other books (such as Allen L, de Benoist B, Dary O, Hurrell R (eds).
Guidelines on food fortification with micronutrients . Geneva: World Health
Organization and Food and Agricultural Organization; 2006. Available
from: h ttp://www.who.int/nutrition/publications/guide_food_fortification_
micronutrients.pdf ), provide practical guidance for designing and implement-
ing food fortification programmes. These perspectives are important. However,
they are not sufficient to gain an understanding of the interactions between
evidence, ethics and politics that help elucidate the benefits, risks and ethical
considerations associated with food fortification and how and why such poli-
cies are made.
The research presented in this book is cutting edge in that it helps fill this
current gap in our understanding of food fortification. The research is up to
date and peer-reviewed. To my knowledge it is the first food fortification inves-
tigation to strategically combine an evidence and ethics assessment with a
critical analysis of food fortification case studies. The book introduces a
novel conceptual framework that was used to systematically and robustly
organize the research. It then presents the findings from combined assessment
and critical analysis approaches that were used to investigate three topical food
fortification case studies. Insights from the research are then identified and
discussed.
The intended readership of the book is upper undergraduate- and postgraduate-
level students enrolled in food and nutrition, public health, health promotion,
dietetics, public policy, and medical courses, as well as practitioners in these
disciplines, researchers and policy-makers.
Food fortification is a vast and diverse public health topic. This book does
not attempt to provide a comprehensive assessment and analysis of all aspects
of food fortification. Necessarily decisions had to be made about setting
boundaries for the book’s scope. Food fortification is predominantly of two
types —m andatory food fortification and voluntary food fortification. This
book’s focus is on mandatory food fortification. This is because it is the food
fortification type that is managed by government as a technology for the