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188 ADDRESSING MYTHS AND MISCONCEPTIONS ABOUT

Addressing Myths and Misconceptions about Rice Fortifcation

Helena Pachón Introduction Fortifcation Initiative, USA Concerns, myths, and misconceptions exist regarding the benefts and safety of rice fortifcation. This paper addresses Cecilia Fabrizio, Jennifer Rosenzweig these concerns by presenting information from the global ex- World Food Programme Regional Bureau for Asia perience as well as evidence based on rice and wheat four fortifcation.

Key Messages “ The fortifcation of staple ∙ Rice fortifcation is safe. ∙ Where rice is the and micronutrient and condiments has been safely used defciencies are widespread, rice fortifcation has great for more than 90 years to help reduce potential to signifcantly contribute to the reduction of micronutrient defciencies. However, on its own it cannot micronutrient defciencies” eliminate all micronutrient defciencies in a population: in the most vulnerable groups, e.g., pregnant and lactating women and preschool children, additional Is rice fortifcation safe? interventions such as supplementation are required. The fortifcation of staple foods and condiments – a strategy ∙ Micronutrient defciencies afect all socioeconomic used for more than 90 years – has been proven safe and efec- groups. Therefore, where micronutrient defciencies tive in signifcantly contributing to the reduction of micronutri- are widespread, rice fortifcation benefts all ent defciencies. As with other food fortifcation, rice fortifca- socioeconomic strata of society. tion is safe because the type and levels of micronutrients added ∙ Rice fortifcation and biofortifcation difer as to the type, are calculated based on the following: number and levels of micronutrients in rice, and as to when they are included in rice. In biofortifcation, the ∙ The recommended daily intake of specifc process of fortifying occurs during the crop production micronutrients by age group and gender, as a person’s phase, or prior to the harvest. In rice fortifcation, the age, gender and physiological status infuences their daily fortifcation is done post-harvest and can add more types requirements for healthy body functions and higher levels of micronutrients. ∙ The highest level of intake that is likely to pose no risks ∙ When fortifed with multiple micronutrients, is of adverse efects in an age and gender group, more micronutrient-rich than brown, parboiled, or non- which is referred to as the tolerable upper intake level (UL). fortifed white rice. The fortifcation levels are chosen so that the UL is not ∙ With a few exceptions, any variety of rice can be fortifed. exceeded when fortifed food is consumed ∙ Current can produce fortifed rice ∙ The level of specifc micronutrients typically consumed that tastes, smells and looks the same as non-fortifed rice, by the target population and retains its when prepared using various ∙ The daily/regular quantity of rice consumed by cooking methods. the target population RICE FORTIFICATION IN AMERICA ADDRESSING MYTHS AND MISCONCEPTIONS ABOUT RICE FORTIFICATION 189

This information is used to calculate the gap between the mi- figure 1: Percentage of non-pregnant Vietnamese women cronutrients consumed and the micronutrients required by spe- (15–49 years) with defciency, by socioeconomic group. cifc groups. This gap is used to determine which micronutrients, and how much of the specifc micronutrient, will be included in Nutrient Defciencies Afect all Socioeconomic Strata (SES) fortifed rice. In other words, the level of micronutrients added All Could Beneft from Fortifed Rice

is calculated such that the additional micronutrients provided 25 in fortifed rice will provide the greatest number of individuals 20.7 in the target population with adequate intake, without causing 20 intake above the UL by those who consume large quantities of 15.1 the fortifed rice. Fortifed rice flls the micronutrient gap, with- 15 out promoting excess intake. 11.9 11.9 11.2

Percent 10 It is important to remember that:

∙ The type and levels of micronutrients are set in such a 5 manner that even groups consuming large quantities of

fortifed rice will not exceed the UL. For example, in some 0 countries, the typical adult consumes up to 400 or 500 g 1 (lowest SES) 2 3 4 5 (highest SES) of rice per day. In this case, the micronutrients are added Adapted from¹ at a level that ensures that micronutrient intakes from all dietary sources are below the UL, taking a daily rice consumption of 400–500 g into consideration. Thus, the pregnant women, but cannot fully meet their needs. Children micronutrients consumed in fortifed rice will be under the age of two years also have relatively high micronutri- at a safe level. ent needs to support their growth and development. However, ∙ Specifc population groups have higher micronutrient they can only consume small quantities of food in comparison to needs than others. For example, pregnant women are adults, so the additional micronutrients received by eating forti- recommended to take iron/ or multiple micronutrient fed rice will not be sufcient to fll their gap in micronutrient in- supplements to meet their micronutrient requirements. take. Therefore other simultaneous micronutrient interventions This remains safe, and is recommended even when are necessary to increase the micronutrient intake of these target they are consuming fortifed foods. This is because their populations. For more information on addressing ob- micronutrient requirements are much higher than those jectives, please refer to the contribution by Rudert et al (p. 193). of the average population. The same holds true for young children who also may be taking A or other micro- “ Fortifed rice can help meet nutrient supplements. A young child also consumes much smaller quantities of rice than healthy adults in the the needs of pregnant women and same population. This, combined with their relatively of young children, but cannot fully high micronutrient needs, means that young children are not at risk of exceeding their UL with fortifed rice. meet their needs”

Can rice fortifcation eliminate micronutrient defciencies in the entire population? Is fortifed rice only needed by low-income groups? Rice fortifcation can signifcantly contribute to the reduction of Although micronutrient defciencies are more prevalent among micronutrient defciencies. For safety reasons, the fortifcation lower socioeconomic groups, defciencies also occur in higher-in- levels are calculated such that the additional micronutrients come groups, urban populations, obese individuals, and individ- provided in fortifed rice will provide the greatest number of in- uals with higher-than-average education. For example, as shown dividuals in the target population with adequate intake, without in the 2000 Vietnamese National Nutrition Survey (see Figure 1), causing excessive intake. On its own, this level of fortifcation iron defciency was highest among women from the lowest socio- cannot eliminate all micronutrient defciencies among all seg- economic group (20.7%). However, at least 11% of women from ments of the population. For example, a pregnant woman has higher socioeconomic groups were also iron defcient, even in signifcantly higher micronutrient needs than a man of the the highest income group.1 This demonstrates that fortifying rice same age. Fortifed rice can contribute to meeting the needs of with iron can beneft all strata of society who consume rice. 190 ADDRESSING MYTHS AND MISCONCEPTIONS ABOUT RICE FORTIFICATION

figure 2: Profle of select micronutrients in white rice, , parboiled white rice, and fortifed white rice.4

White rice Brown rice Parboiled white rice Fortifed white rice

8

7

6

5

4

mg/ 100 g rice 3

2

1

0

Iron Thiamin Vitamin B₆

What is the diference between fortifed Why not encourage consumption of brown rice and biofortifed rice? or instead of fortifed white rice? Rice fortifcation and biofortifcation are two diferent ap- White rice is widely consumed, and when fortifed, can have a proaches to make rice more nutritious. They can safely coexist signifcantly higher micronutrient content than non-fortifed as part of a strategy to improve micronutrient health. The dif- rice, including brown or parboiled rice. Therefore, there is a ference lies in when and how micronutrients are added, and greater potential to improve micronutrient health by fortifying the type, number and level of micronutrients that can be in- white rice than from increasing consumption of brown or par- corporated.2 boiled rice. In rice fortifcation, micronutrients are added afer the rice has been harvested. For example, folic acid, niacin, “ When fortifed, white rice B₁ (thiamin), B₆ (pyridoxine) B₁₂ (cobalamin), A (retinol), D (cholecalciferol), E (tocopherol), iron, zinc and can can have a signifcantly higher be added without changing the appearance of the rice. For ad- micronutrient content ditional information, please refer to the contributions by de Pee et al (p. 143), Montgomery et al (p. 159) and Rudert et al than non-fortifed brown or (p. 193). parboiled rice” Biofortifcation increases the micronutrient content through breeding or genetic modifcation (GM). Therefore it occurs before harvesting the crop. An example of biofortifca- Figure 2 shows the micronutrient content (iron, zinc, thia- tion is , which expresses β-carotene.3 In practice, min, niacin and vitamin B₆) for non-fortifed rice (white, brown a limited number of nutrients are increased in biofortifed rice and parboiled) and fortifed white rice.4 The content of folate varieties at any one time, and research is ongoing to increase and vitamins A and B₁₂ are not shown because they are absent their levels. Currently, only non-GM rice cultivars with higher or negligible in all types of rice except fortifed rice. The data iron or zinc levels are available. Genetically modifed Golden demonstrates three points: Rice containing provitamin A has not been released on the market. 1. Milling removes much of rice’s naturally In addition, the levels of nutrients that are added to rice occurring nutrients can be much higher with fortifcation than with biofortifcation. 2. Parboiling retains a signifcant level of some nutrients However, once a rice variety is biofortifed, no additional pro- 3. Brown rice is relatively iron- and zinc-rich compared cesses are needed afer harvesting to increase nutrient levels. to non-fortifed white rice RICE FORTIFICATION IN LATIN AMERICA ADDRESSING MYTHS AND MISCONCEPTIONS ABOUT RICE FORTIFICATION 191

While the nutrient content of fortifed rice is dependent on Is fortifed rice acceptable to consumers? the amounts added, fortifed rice has the potential to ofer much The acceptability of fortifed rice depends on the fortifcation higher levels of key nutrients such as iron, zinc, , folic , the type and levels of nutrients added, and consum- acid and vitamin B₁₂. er preferences. All rice fortifcation technologies aim to make In addition, the consumption of fortifed white rice does not fortifed rice taste, smell, and look the same as non-fortifed rice. require a change in existing behaviors, as would be the case if A recent study that compared rice fortifed using extrusion consumption of brown or parboiled rice were to be increased. technology with non-fortifed rice evaluated six sensory pa- While there is little data on brown rice consumption in Asian rameters (appearance, color, texture, odor, taste, and overall countries, the 2009 US National Health and Nutrition Survey5 acceptability) among Indian children 8–11 years of age.6 The found that, afer years of promotion, only 2.9% of children children ranked each sample with a score of 1 (worst) to 5 (best). and 7.7% of adults consumed the recommended daily level of As shown in Figure 3, the fortifed and non-fortifed rice were at least three ounce equivalents (which includes statistically indistinguishable on all six sensory parameters. In brown rice). This fnding is in line with lessons learned from addition, all sensory parameters were rated over 4 points, sug- wheat four and salt fortifcation to the efect that communica- gesting strong acceptability for both types of rice. This study tion alone without additional behavior change activities does shows that consumers perceive fortifed rice to taste, look, and not increase consumption of a specifc food. smell similar to non-fortifed rice.

Are the nutrients in fortifed rice retained “ The acceptability of fortifed rice afer preparation and cooking? depends on the fortifcation technology, When produced using extrusion or rinse-resistant coating tech- the type and level of nutrients, nologies, fortifed rice will retain nutrients through various preparation and cooking conditions, including washing and and consumer preferences” cooking in excessive water that is later discarded. The micronu- trients in the fortifed kernels produced with extrusion technol- ogy are evenly distributed throughout the kernels. Therefore, Can any variety of rice be fortifed? the nutrients are adequately sealed and adequately retained The rice fortifcation technology of dusting can be used to for- through preparation and cooking. However, when fortifed rice tify all varieties of rice, although this technology is not recom- is produced using dusting or coating that is not rinse-resistant, mended. For coating and extrusion, most varieties of rice can be nutrients will be lost if the rice is washed prior to cooking. There fortifed; however, this will require tailoring of fortifed kernels is ongoing additional research in this area to further identify po- accordingly. For more information on rice fortifcation technol- tential diferences in nutrient retention between diferent rice ogy, please refer to the contribution by Montgomery et al (p. 159). preparation and cooking methods and fortifcation technologies.

figure 3: Acceptability scores for fortifed and non-fortifed rice among Indian children aged 8–11 years.

Best acceptability Fortifed rice Non-fortifed rice

5

4

3

2 Aacceptability score 1

0 Worst acceptability Appeareance Color Texture Odor Taste Overall Adapted from⁶ 192 ADDRESSING MYTHS AND MISCONCEPTIONS ABOUT RICE FORTIFICATION WFP/ Francisco Fion Francisco WFP/

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An indigenous mother carrying her baby, Guatemala 2012

References “ Fortifed rice is acceptable to 1. Laillou A, Van Pham T, Tran NT et al. Micronutrient defcits consumers, as virtually any variety are still public health issues among women and young children in Vietnam. PLoS One 2012;7(4): e34906. doi:10.1371/journal. of rice can be fortifed” pone.0034906. 2. Nestel P, Bouis HE, Meenakshi JV et al. Biofortifcation of staple food crops. J Nutr 2006;136:1064–7. Conclusion 3. Ye X, Al-Babili S, Klöti A et al. Engineering the provitamin A Fortifed rice is safe and acceptable to consumers. Fortifcation (β-carotene) biosynthetic pathway into (carotenoid-free) levels are set such that the additional micronutrients consumed rice endosperm. Science 2000;287:303–5. will provide the greatest number of individuals in the target pop- 4. USDA Nutrient Data Bank. http://ndb.nal.usda.gov/ndb/search/list ulation with adequate intake, without causing excessive intake. 5. Reicks M, Jonnalagadda S, Albertson AM et al. Fortifed rice is acceptable to consumers, as virtually any variety Total dietary fber intakes in the US population are related of rice can be fortifed and, if properly produced, will taste, smell to whole grain consumption: results from the National Health and look the same as non-fortifed rice. Fortifed white rice may and Nutrition Examination Survey 2009 to 2010. Nutr Res be more readily acceptable to consumers than less micronutrient- 2014;34(3):226–234. rich types of non-fortifed rice, such as brown or parboiled rice. 6. Radhika MS, Nair KM, Kumar RH et al. Micronized ferric However, fortifed rice should be part of a larger micronutrient pyrophosphate supplied through extruded rice kernels improves intervention strategy, as population groups with higher nutrient body iron stores in children: a double-blind, randomized, needs, such as pregnant and lactating women, will require ad- placebo-controlled midday meal feeding trial in Indian school- ditional interventions to meet their micronutrient needs. children. Am J Clin Nutr 2011;94(5):1202–10.