Food Fortification in Indonesia

The paper highlights the history, policy, programs of food fortification intervention and its impact on reducing micronutrient deficiency, especially iodine deficiency disorders (IDD), iron deficiency anaemia (IDA), and vitamin A deficiency (VAD) in Indonesia. General issues in the management of food fortification, and lessons learned from the Indonesian experience are discussed in this paper.

Vitamin A Status Monitoring in Women and Children in Rural Indonesia: Serum Retinol and Retinolbinding Protein and their Correlation.

Objectives: To assess retinol binding protein (RBP) as an indicator of vitamin A status in children and women, during a pilot program fortifying cooking oil with retinyl palmitate in West Java. Methods: Surveys measured serum retinol using High-Performance Liquid Chromatography (as gold standard), and RBP using Enzyme-Linked Immunosorbent Sandwich Assay, among children 6-59 months (n=753) and 5-9 years (n=175), women 15-29 years not reportedly pregnant (n=170) and lactating mothers (n=303). C-reactive protein and α-1-acid glycoprotein were measured to adjust serum retinol for sub-clinical inflammation using established correction factors. Results: At baseline, serum retinol concentrations (μg/dL, mean and standard deviation) were 33.2±14.0, 33.0±0.91, 40.9±18.7, and 44.2±18.5 for children 6-59 months, 5-9 years, women and lactating mothers. Prevalences of vitamin A deficiency (retinol <20μg/dL) were 14.9%, 10.9%, 10.0% and 5.3%. Mean RBP concentrations (mg/kg) were 1.00±0.24, 1.01±0.22, 1.24±0.35, 1.34±0.37, respectively. Serum retinol and RBP concentrations correlated positively (Pearson's correlation coefficient r=0.54, 0.50, 0.51, and 0.48 in the four groups). In the 2nd survey a year later, retinol and RBP averages were 3.2-17.4% and 3.7-13.7% increased among groups; correlation patterns were similar. Using RBP<0.80 μmol/L as cut-off (lacking a WHO recommendation), deficiency prevalence, sensitivity and specificity of RBP were 15%, 36% and 88% in children 6-59 months. Conclusions: RBP can be an indicator of vitamin A status in child and woman populations, saving cost compared to serum retinol-based monitoring. The lesser retinol-RBP concordance compared to earlier studies suggest that precision of measurements in this study may have been less than typical.

Quality Control to Enable Successful Vitamin A Fortification of Cooking Oil in Indonesia - A Pilot Program in Two Rural Districts.

Objectives: To describe prospects of successful fortification of unbranded cooking oil with vitamin A in Indonesia through public-private cooperation, based on a pilot program in 2 districts on West Java. Methods: Collaborating with Ministries of Health, Industry and Trade, Indonesia's Food Fortification Foundation and Food & Drug Agency, and GAIN, two producers covering a large market share on West Java piloted fortification of cooking oil with 45 IU/g retinyl palmitate, the National Standard (SNI) for oil at factory-level. For quality control, vitamin A in cooking oil was measured at a factory, distributors and retailers, and from households. Household surveys measured oil consumption. Results: Oil consumption among children 12-23 and 24-59 months averaged 12.5 and 22.3 g/day, and 29 g/day in women 15-29 years, similar before and after start of fortification. Oil samples contained retinyl palmitate at averages of 43.6 IU/g at the factory (68 samples), 33.8 IU/g among distributors (2 stores, 28 samples), 33.3 IU/g at retail shops (24 shops, 64 samples) and 19.2 IU/g among households (339 households, 6376 samples). Vitamin A content in oil varied over the 12 months of the pilot. Further work should determine if variations reflect degradation of vitamin A during storage (including varying storage times of samples before measurement), or mixing of fortified oil with non-fortified oil by retailers. Conclusions: Quality control and enforcement of compliance throughout the distribution chain of cooking oil by the Government, and a mandatory fortification standard supported by all stakeholders are essential for this program to be sustained and expanded.

Fortifying Cooking Oil with Vitamin A in Two Rural Districts of Indonesia: Impact on Vitamin A Status of Mothers and Children.

Objectives: To measure impact of fortifying unbranded palm oil with retinyl palmitate on vitamin A status in poor households through two surveys, just before fortification started (four months after the twice-yearly vitamin A capsule supplementation for children 6-59 months) and a year later. Methods: 24 villages from a pilot area on West Java were randomly selected, and poor families sampled. Serum retinol (adjusted for sub-clinical infections) was analyzed in lactating mothers and their infants 6-11 months, children 12-59 months and 5-9 years and women 15-29 years, in relation to socio-economic conditions, oil consumption, and food intake. Fortified oil was sold through existing market channels. Results: Fortified oil improved vitamin A intakes, contributing an estimated 34%, 77%, 55%, 42%, 50% of Recommended Nutrient Intake (RNI) for children 12-23 months, 24-59 months, 5-9 years, lactating and non-lactating women, respectively. Serum retinol increased by 13-17% across groups (p<0.02 except in 12-23 months). Deficiency prevalence (retinol <20 mg/dL) decreased by 67%, 64%, 96%, 89%, 79%, and 89% in infants 6-11 months, children 12-23 months, 24-59 months, 5-9 years, lactating and non-lactating women (p<0.011, all groups). Households' non-food expenditures, housing conditions and capital assets also improved from baseline to endline. However, in multivariate regressions, socio-economic variables did not independently influence retinol status, whereas RNI contributions from oil positively predicted improving retinol for children 6-59 months (p=0.003) and 5-9 years (p=0.03). Conclusions: Fortification of cooking oil proved an effective way to reduce the vitamin A intake gap in underprivileged women and children in rural communities.