Flour Fortification in the Northwest Provinces

 ------Proposal to GAIN 

Executive Summary

The extent and magnitude of micronutrient deficiencies

According to the 2000 national nutrition surveillance data the prevalence of iron deficiency anemia in China is about 20% among all population groups.  The prevalence of anemia among women of childbearing age is 27.5% in urban areas and 41.2% in rural areas.  Among 6 month old infants the prevalence is 28% in urban areas and 50% in rural.  Among iron deficient mothers 31.8% had infants that were also iron deficient and among iron replete mothers only 18.8% has infants who were iron deficient (Chen et. al, 2001).  According to the 1992 national nutrition survey the prevalence of IDA in men increases with age with a 12% prevalence in 40-49 year old men and a 38.5% prevalence in men over 80 years of age (Ge et al., 1996). 

A recent study conducted in 1,000 school children (6-17 years old) in Shanghai (Sun et al. personal communication 2002) showed that the overall anemia prevalence was 21.6%, but with significant rural (24.3%) and urban (17.2%) differences. Further comparison between anemic and non-anemic children revealed that iron status (indicated by serum iron, transferrin saturation, total iron binding capacity) of the anemic children was significantly poorer than the non-anemic children. Serum lead level was significantly higher in the anemic children.  However, there were no significant differences in serum folate, vitamin B12 and copper levels and prevalence of fecal parasites between the two groups.

Proposed food vehicles and fortification levels as well as projected coverage and protection

In proposed program, flour will be selected as vehicle for fortification. Flour is consumed widely in China and it is second largest staple food for Chinese. The national average of flour consumption in China is 178.4 g/ref.man/day.  There are three features of flour consumption in China. The first one is that people in west consumes much more flour than does people in rest of country. The second one is the low income people consumes more flour than middle and high income people. And the third one is that rural population consumes more flour than their urban counterpart. Anemia prevalence is much higher in northwest region, low income population and rural area. So, flour is the best vehicle for fortification to reach the targeted population. Other advantages of flour fortification include well-established international experience and no technical barrier. The proposed program will be multi-micronutrient fortification program. The fortificants and level of fortification are listed in Table ES1.

Projected Coverage and Protection:

In five years, the program will cover five northwest provinces, i.e. Xinjiang, Qinghai, Gansu, Ningxia and Shaaxi and  7 west provinces including inner Mongolia, Tibet, Yunnan, Guizhou, Guangxi, Sichuan and Chongqing. Half of population in northwest provinces and five percent population in other west provinces will be protected by the proposed program. In absolute term, there will be 49 million at-risk population under the coverage of the proposed program.

Summary of proposed goals, objectives and activities including monitoring and evaluation of the fortification program;

Goal

The goal of the project is to reduce the prevalence of micronutrient deficiencies in China by wheat flour fortification and to launch nationally of iron-fortified wheat flour..

Objectives

·        Production and distribution of fortified flour by 300 factories by the end of year five; amounting to 7,240,000 tons, which is between 5-6 percent of the total annual national output.

• By the end of year five cover with fortified wheat flour a population of 59 million, among them 49 million from risk areas.

·        By the end of year  five reduce the prevalence of deficiency of micronutrients by at least 30 percent in the targeted population .

·        Through phased implementation beginning in 2003, generate widespread consumer participation and educate the population about micronutrients and fortified foods through a social marketing plan that. Through this campaign and additional education and advocacy: activities, by the end of 2004, assure that 80 percent of the at-risk population is knowledgeable about the benefits of consuming fortified flour in reducing micronutrient deficiency.

·        By year three of the project assure compliance with current knowledge and international regulations and standards by revising and updating food regulations and standards concerning the enrichment and fortification of foods.

·         By year five significantly upgrade and centralize the flourmill industry in China, including more centralized production and achievement of a higher compliance rate with national hygiene standards.

·        By year three establish a quality control system (including GMP, HACCP) that will be implemented by the flourmill industry and a government inspection system throughout the country.

Monitoring:

A monitoring system to examine the effectiveness of the fortification program will be established and gradually expanded throughout the 5-year program period.

Financial Summary of Support Requested from GAIN and Other Funds

The funds requested from GAIN are part of a matrix of financial sources that will feed into the project and lead toward sustained production of fortified wheat flour in China. Table ES2 sows the outline of these financial sources.

II. Program Background and Proposed Leadership based on Requirements of the GAIN RFP

Profile of the National Food Fortification Alliance (NFFA) in China

Food fortification programs in China are organized and implemented under the National Nutrition Improvement Program, of which the State Development Planning Commission and the Ministry of Health are the two responsible ministries. In order to have better coordination among various ministries and related organizations in food fortification activities, a National Food Fortification Alliance was established in 2000. The major players of the NFFA have been jointly working for more than three years on the program to fortify wheat flour, soy sauce and cooking oil. The background of forming the NFFA can be divided into policy and program aspects. Policy aspects include the National Plan of Action for Nutrition for China issued by the State Council on December 5, 1997 which has several provisions devoted to food fortification. For example, Provision 5.10 stipulates: Increase the production of micronutrient-rich processed cereal products and nutrient-fortified foods in compliance with national standards; Provision 23.4 stipulates: To meet the demand of the consumer, food industry shall put the development of nutrient fortified foods and cereal products into its priorities. In July 2000, the Ministry of Health, Ministry of Education, Ministry of Agriculture and State Administration of Sports submitted a report to the State Council concerning the Improvement of Physique and Health Status in Children and Youth that also emphasized food fortification. Exerts from that report include the following examples: In the report’s Action plan – Item 3, Specific measures 4, it stipulates: “The fortification of wheat flour, soy sauce, complementary food and staple foods in school lunches and  in the report’s Program Aspects, it states: “the launch of soy sauce and wheat flour fortification (pilot production and distribution have been started since June, 2002) needs multi-sectoral government support and multi-institutional collaboration.”

The China NFFA has carried out several types of activities such as meetings, research and preparation of documents, press releases, etc. For example, the NFFA agreed on the fortificants to be used to fortify major food vehicles including wheat flour (multiple nutrients), soy sauce (iron), complementary foods (multiple nutrients) and cooking oil (vitamin A). The Ministry of Health and the State Bureau of Grains have jointly issued several documents on the wheat flour fortification in “reforestation areas”

NFFA Organizations and their roles are shown in Table II. 1.

A profile of the Executing Agency is provided in Table 5

Qualifications and capacity of the Executing Agency: China Center for Public Nutrition and Development (CCPND)

Two important mandates of the China Center for Public Nutrition and Development (CCPND) are (1) to develop the national strategy for nutrition improvement and (2) to coordinate cross-sector nutrition efforts.

The CCPND has built strong expertise in coordination, management, monitoring and evaluation for the proposed program through its previous experience in several major projects: The CCPND serves as co-leader of the Asian Development Bank (ADB) sponsored RETA project whose activities included a comprehensive evaluation of the status and the consequence of micronutrient deficiencies in China. RETA is also developing a multipart Country Investment Plan for Food Fortification in China

Design and management of a pilot flour fortification project in China’s reforestation area is another activity of the CCPND. This project is a multi-sector nutrition improvement efforts and marks the beginning of large-scale public nutrition intervention in China. CCPND successfully coordinated the development of the pilot project with its multiple stakeholders including work with community representatives in target communities. This proposed project is essentially a scale-up of the pilot project.

CCPND was also designated by UNICEF to coordinate its in-country cooperation on nutrition which involves many institutions. The CCPND was entrusted by SDPC to lead a program aiming at integrating nutrition into the national economic and social development plan, which aims toward a new mechanism for committing the Government to nutrition improvement actions. That project involves intensive policy dialogues and coordination among different departments of government. Through these activities, CCPND has established its leading role in China’s National Food Fortification Alliance and shares good working relations with each of the key stakeholders of this nutrition improvement program.  In conclusion, CCPND is fully capable of undertaking the coordination, management and monitoring of the proposed program.

The current role of the proposed EA organization within the NFFA

The CCPND, the proposed Executive Agency, currently plays a leading role within the NFFA. Its role includes the following:

·        Responsibility  for developing national strategy for nutrition improvement.

·        Designing the action plans needed to guide and carry out the agreed strategies.

·        Coordinating cross-sector nutrition efforts.

·        Facilitating policy development to create an enabling regulatory environment for nutrition fortification.,

·