**4. Integration of fortification and biofortification**

Chemical food fortification has been used to combat micronutrient deficiencies for 100 years in high-income countries and there are good data on positive impact. Conversely, there are few data, except for iodine fortification, concerning largescale food fortification (LSFF) with vitamin A, iodine, iron and folic acid in lowand middle-income countries (LMIC), but what data there are is positive [19].

LSFF, with chemicals, is especially useful in LMIC where micronutrient deficiency is evidenced at a population level, and where rapid urbanization is accompanied by increased household purchasing power, leading to reliance on centrally processed foods [19]. One of the complex of issues in such settings, however, is to ensure that chemical fortification of different processed foods does not result in excessive intake, resulting in delivery of a tolerable upper intake level for the population (which is acceptable) and not toxicity (which is unacceptable) [19].

The Golden Rice project has been designed from its initiation principally to assist resource-poor growers and communities who do not rely on processed foods, but largely grow their own. And that remains the objective. Regarding toxicity, Golden Rice provides beta-carotene a non-toxic source of vitamin A, and not vitamin A itself (which is toxic when consumed in excess.)

A 1992 UN Conference on Nutrition confirmed that for VAD alleviation, locally available food-based strategies are the first priority, with vitamin A capsules only an interim measure [43]. However, the bioavailability of beta-carotene from commonly available fruits and vegetables is very low. Even when they are available, a young child between ages 1 year and 3 would need to eat eight servings of dark green leafy vegetables per day in order to meet the Recommended Dietary Allowance for vitamin A. This results in "the virtual impossibility for most poor, young children to meet their vitamin A requirements through vegetable and fruit intake alone" [21]. The low bioavailability of vitamin A from plant foods explains, in part, the presence of vitamin A deficiency among children living amid ample supplies of dark green leafy vegetables and other plant sources of vitamin A [21]. Conversely, a recent study has estimated that substituting Golden Rice for white rice could provide 57–99% and 89–113% of the recommended vitamin A requirement for preschool children in the Philippines and Bangladesh, respectively [5]. Such a boost to dietary beta-carotene could do much to combat VAD and is highly sustainable.

A perfect food fortificant has been described [21] as one which exhibits the following characteristics:


Golden Rice, being consumed as a staple food, matches the requirements perfectly, except for the color imparted by the beta-carotene content.

However, the golden color imparts advantages. Golden Rice is easily recognizable, so consumers—even illiterate consumers—can exercise choice. And the color is also advantageous for government programs: Each grain is naturally labeled, so "passing off"2 as biofortified rice is not possible. With the golden color as a marker, Golden Rice can also be used—after the traits are introgressed (e.g., bred together into one variety) as a carrier for invisible micronutrient traits of rice, such as high zinc, high iron and high folate (the natural form of the folic acid used for chemical food fortification.)

Multifunctional cooperation, including between different government departments not used to working together, will be beneficial for effective use of Golden Rice [44]. (This is also the case for LSFF with chemicals [19].)

Within this requirement for multifunctional cooperation, there is clearly a role for synergistic reinforcement of what may be termed urban and rural improvement of staple foods with additional micronutrients. Social marketing research has determined that consumers of rice growing communities are interested to try Golden Rice if they can afford it and if it is good for their family's health [45], both being applicable to Golden Rice. However, although a small cultural change,

<sup>2</sup> Rice is fortified with chemicals by mixing rice powder with chemical fortificants, extruding and drying the result to resemble rice grains, and mixing the result in required proportion with polished white rice. If fortification is done badly, children may pick out and discard the fortified pellets, if done well unfortified white rice can be "passed off" as fortified rice by unscrupulous people.

#### *Golden Rice, VAD, Covid and Public Health: Saving Lives and Money DOI: http://dx.doi.org/10.5772/intechopen.101535*

changing from eating white rice to Golden Rice, even partially, is significant and will benefit from encouragement. There is an additional challenge to be overcome. The agronomic characteristics, such as yield, pest resistance and days to maturation, of any variety of Golden Rice are determined by the isogenic variety the beta-carotene-generating genetics have been bred into. So, there is little, except consumer demand, to encourage a grower to plant Golden Rice seed, rather than the isogenic variety. Demand may arise from the local community, if they know of the potential health benefits.

Another, more concrete demand generation, requiring cooperation between sectors, is for Government departments responsible for providing biofortified rice to urban populations to establish and communicate a buying price for Golden Rice sufficient to encourage growers to grow Golden Rice.

Another attractive program of demand generation is for school feeding programs to specify that Golden Rice must be used: simultaneously creating demand so that growers grow Golden Rice, children benefit from it nutritionally and learn about it, and inform their parents of it, generating demand also at home.

Such programs can assist Golden Rice's adoption in rural areas, as well as in urban areas, and save money compared with alternatives, at the same time as transferring wealth to growers for productive work. Such programs require cooperation between agriculture, education, women and children's affairs and public health functions of government with their own accountabilities, and should not be held back by narrow, unsubstantiated technology suspicions, which have been disproved [46–48] or for any other reason: the available health, welfare and economic benefits are too great.

Large-scale food fortification against VAD could protect nearly three million children annually by only a minimal 0.5% reduction in VAD prevalence, in a little over a year, "an effect that, importantly, would plausibly be compounded with increasing program maturity, and better intervention coverage and reach" [19].

Vitamin A capsules are only recommended for children of 6 months and older [49], and very young children do not consume solid food. These children are the most vulnerable to vitamin A deficiency: Neonate deaths in 2011 accounted for 43 percent (increased from 36 percent in 1990) of all deaths among under 5-year-olds [50]. Can a good source of vitamin A, such as Golden Rice, when part of the staple diet, improve the mother's vitamin A status, benefiting her health, and simultaneously *via* the placenta and breast milk increase the baby's resistance to disease, and reduce neonate and child mortality? [14].

For the first time since the UN's International Conference on Nutrition three decades ago [43], there is a beta-carotene-rich staple food—Golden Rice—with excellent bioavailability [51], and at no greater cost than white rice, capable of delivering a significant improvement, 57–99% and 89–113% of the recommended vitamin A requirement for preschool children in the Philippines and Bangladesh, respectively, when substituted for white rice [5]. Even partial substitution, for example, through school lunches, would contribute positively to health outcomes, especially for children from more disadvantaged households.
