SECTION III: Program Requirements

A. Micronutrient Deficiencies and Impact on Public Health: National Background

1. Using clinical, biochemical and/or dietary indicators, provide summary information on the micronutrient status of the population including key at-risk groups. This may include national surveys as well regional or local data. A guideline template is provided in Section IV. ? page
Micronutrient deficiencies are the main reasons for the malnutrition and chronic diseases. People live in poor and remote areas suffer serious nutrition problem. The data from national nutrition survey shows the prevalence of underweight children was 18% and prevalence of stunting children 32%. The investigation of health status of students in 1995 showed that malnutrition prevalence of 7-18 years old students were 26.9% and 38.3% for male and female respectively. The malnutrition prevalence of students increased 4.05 % in 1995 than that in 1985. National nutrition survey in 1992 also showed that:
Prevalence of calcium deficiency for total population averagely reaches about 50%. There is about 1/3 of the population in risk of IDD. IDA prevalence is 15-20% and children and women are risk groups. IDA of children and women can be over 50% in some poor areas. Intake of vitamin A of 2-5 years old children reaches 44.8%-68.7% of RDA. Intakes of vitamin B1 and vitamin B2 are under RDA.
People in west area of China suffer more serious nutrition problem than people from coast areas.

2. Provide relevant socio-economic and poverty situation that may constrain the provision of domestic resources to respond to micronutrient malnutrition. These include official indicators such as GNP per capita, poverty indices, or other information on the availability of domestic resources to address micronutrient deficiencies. A guideline template is provided in Section IV. ? page
The population of China is 1.275 billion according to the recent population census. In the past 24 years, great achievements have been made in poverty alleviation, and population under national income poverty line has been reduced from 33% to 3% during 1978 to 2001, e.g. about 30 millions of people, mostly in remote rural areas. Although these people are not starving, but general nutrition problems (e.g. growth retardation in children) and micronutrient deficiencies, including iron deficiency and iron deficiency anemia are common. On the other hand, the World Bank estimated that the Chinese population under the international income poverty line (one US dollar a day) was 18.8% in 2000. In the last ten years per capita GNP has been increased steadily to US$ 890 in 2000 (World Bank data), and the health expenditure was 5.1% GDP, which is low. Any "poverty" indices which describe how large the population "in need."

3. Describe the public health and nutrition context that suggest a potential to significantly
improve health outcomes and reduce mortality by providing additional micronutrients through food fortification. These include: under five mortality, maternal mortality, child growth indicators, coverage of current micronutrient interventions, vaccine coverage, access to primary health services and other factors. A guideline template is provided in Section IV. ? page
Along with the economic development and the achieved more than 90% of vaccination (DPT3, measles, and polio) coverage by the 30-years effort, infant mortality has been reduced to 32 per 1,000 live birth in 2000 from 85 per 1,000 in 1970, under-5 mortality reduced from 120 to 40 per 1,000 in 2000. Maternal mortality has been reduced to 56.20 per 100,000 after actions taken specifically in the past years. The national universal salt iodization program was initiated in early 1990s and the current conservative estimation of coverage is more than 91% household, and the goiter rate in students is now reduced to 8.3%, based on the national survey in 1998 (Source: Ministry of Health) .
But inequity still exists; in west China and poor rural areas, prevalence of underweight and stunting under 5-year old are double that of average rural areas, reaching 21.0% and 30.7% respectively. And the average diet of the poor areas is monotonous and mainly composed of cereals and vegetables, so micronutrient deficiency is a critical issue for further improvement of health status, even though the overall nutrition status of Chinese people is continuously improving.
A household survey on the accessibility to primary health services organized by the Ministry of Health in 2000 showed that: (1) the percentage of households that could access to the nearest medical care service within 1 km was 77.5 and 67.91% in urban and rural areas, respectively; and (2) the percentage of households that could reach the nearest medical care service within 10 minutes was 72.4 and 67.4% in urban and rural areas, respectively.
Something to describe why the government can't afford to do his on it's own and needs an additional $3 from GAIN. The reasons for asking $3 million from GAIN are: (1) the current overall health expenditure (5.1% GDP) is low; and (2) the government would agree to spend funds on those internationally recognized health intervention strategies such as new vaccination (hepatitis B), tuberculosis, AIDs, etc and in contrast, nutrition intervention by food fortification is a new initiative for the government, especially the Ministry of Finance. Therefore, it is not that the Chinese government could not afford to spend an additional $3 million on flour fortification, but an international initiative is certainly needed to facilitate this new health intervention strategy. The budget planning in this proposal clearly shows that the Chinese government and industry will eventually cover all the necessary funds for fortified flour fortification.

4. Describe current national policies and programs to reduce the prevalence of micronutrient deficiencies including fortification, supplementation, nutrition education and dietary diversification, and nutrition-related public health measures, e.g. IMCI and growth promotion (including
breastfeeding/complementary feeding practices), and deworming. A guideline template is provided in Section IV. 1 page

Food fortification :
1. The National Plan of Action for Nutrition for China (issued by the State Council on December 5, 1997)
w Provision 5.10 (under Provision 5. Specific Objectives) - Increase the production of micronutrient-rich processed cereal products and nutrient-fortified food in compliance with national standards.
w Provision 23.4 (under Part IV Strategies and Measures) - To meet the demand of the consumer, food industry shall develop priority nutrient fortified foods and cereal products.
2. The National Program for Food and Nutrition Development from 2001 to
2010 (Food and Nutrition Advisory Committee, State Council, 2001)
w Provision 12 - Food industry: Speed up food fortification and focus on the fortification of staple foods, in order to improve the lack of nutrients in foods.
3. The Report Concerning the Improvement of Physique and Heath Status in Children
and Youth (by Ministry of Health, Ministry of Education, Ministry of Agriculture and State Administration of Sports to the State Council; July 14, 2000)

Item 3 Action plan - Specific measures 4. The fortification of wheat flour, soy sauce, complimentary food and staple foods in school lunch.
Currently there is no other national program on micronutrient fortification besides salt iodization, although there are a lot of food products voluntarily fortified with micronutrient by industry. The plan of wheat flour, soy sauce, complimentary food and cooking oil fortification is underway.
Dietary diversification:
Since 1998, the Chinese Nutrition Society recommended a "Dietary Guidelines for Chinese Residents" with a "Food Pagoda for Balance Diet". In order to promote the awareness of the Guidelines and the Pagoda, pamphlets and various education materials have been widely distributed in the urban areas, but rural population is limited in access to such education. In the past years, home gardening and community nutrition education have been promoted in selected rural communities but have not been effectively expanded throughout the country.
Supplementation:
The UNICEF vitamin A supplementation program was carried out in year 2000 and 2001 in limited areas in China. There is no current vitamin A supplementation programs. Iron supplementation is not widely used in women even during pregnancy. Folic acid supplementation is recommended during pregnancy check-up, but the percentage of pregnant women who take folic acid tablets is unknown.
Breastfeeding:
Breastfeeding coverage is about 80% in rural areas, but low in urban. Proper complementary feeding practice is not intensively advocated, so improper complementary feeding significantly attributed to under-5 malnutrition prevalence in the rural. The estimated Attributable Risk of the presence of vegetable, meat and milk in complementary food ranged 20-50% to stunning prevalence of under-5 in the rural households. There is no national deworming program but there is selected school program on deworming.

5. Discuss the barriers in current micronutrients programs and describe how the proposed fortification program presents an opportunity to address gaps that exist in the country's current response to micronutrient deficiencies. 1 page

The main barriers in current iron deficiency control programs are: lack of proper food vehicles to reach most consumers needed and proper iron compounds for fortification; lack of knowledge and awareness of micronutrient deficiency and its health outcomes in consumer, food industry and clinical doctors; and the lack of incentive in producing nutrient fortified food products by industry, because of not many consumer purchasing currently commercially produced fortified foods (not sustainable). The proposed flour fortification program presents an opportunity to address all these barriers and gaps. First, flour is a main staple food used by most Chinese consumers in their daily life and vast international experiences showed that flour fortification is a sustainable, economic and effective approach for nutrition intervention in a country or a region. Sufficient data have been accumulated in North America, Europe counties and other developing counties showing that there are technique, economic and market feasibility for flour fortification.
A national policy so called "withdraw agricultural land for trees and grass planting" and the policy request to compensate wheat or flour to the farmers according to the areas of land for trees and grass. This compensation gives an opportunity for the target reach apporch of fortified flour in west area in China that is a rather backward area. Intensive social marketing activities will be carried out in the program, in order to increase the awareness and knowledge of iron nutrition, health consequences of malnutrition, and the health benefits of fortified flour in all population segments. Flourmill industry, especially those big producers, has shown its enthusiasm and incentive in producing fortified flour with only reasonable increasing the product price to compensate the cost, because a nice image and enlarged market for fortified flour are what they want. This will be a major factor in determining the sustainability of the proposed program. Further more the flour fortification is a part of the government nutrition improvement program, not just a new commercial product marketed by industry itself. In addition, the program will also present an opportunity to upgrade the flourmill industry in China, because the producers who would like to participate in this program shall meet all the requirements, including the implementation of GMP and HACCP, etc.

B. Strategic Approach to Food Fortification: Program Rationale, Goals & Objectives

1.                   In the form below specify the proposed vehicles, micronutrients and levels

Table 3.1 proposed fortification vehicles

2.                   Define the rationale for selecting the proposed food vehicles including: food

consumption and purchasing patterns (with emphasis on at-risk groups); capacity of industry to cost effectively produce and distribute quality assured fortified vehicles; coverage of large scale and formal food production sector coverage versus small scale and informal sector; trade environment including import and export of the proposed foods; existing regulations and legislation; capacity of relevant government institutions and other relevant factors. A worksheet in Section IV may assist in this analysis. 2 pages

2. 1 Consumption statistics for wheat flour

Wheat production in China accounts for about one fifth of global production. Most wheat produced in China is consumed domestically as a staple food (see table 3.2). Wheat production accounts for one quarter of the total grain production in China and is listed as the second main grain compared with the rice in terms of production and planted areas. People living in the north and western regions of China consume wheat flour as a their major staple while people in south part of China consume rice as their major staple.      

Table 3.2  Global and Chinese wheat production and consumption, 1999 and 2000.

Coverage and amounts of wheat flour in terms of consumption varies in different areas of the country and according to the different income levels (see table 3.2).  

Table3.3  Wheat flour consumption by income levels (g/reference man/day) in China