Food Fortification with Vitamin D A political debate on a public health problem Food Fortification with Vitamin D A political debate on a public health problem Agnete Jürgensen, 230e10026 Sofie Gudman Valentin, 230e10003 Global Bachelor in Nutrition and Health Public Health Nutrition and Food Policy 7th semester, Bachelor Thesis Supervisor: Sanna Fisker Characters: 98.766 Date: 19th of December, 2013 2/53 Preface This bachelor thesis has been inspired by three months of internship at Danish Food and Drink Federation, where we worked with food fortification. Our working tasks included examination of the magnitude of fortified products on the Danish marked, which food categories that were fortified and a calculation of the average daily energy intake of fortified products that the average Dane consumes. Our internship gave us insight into the political aspects of foods and the interactions and disagreements between stakeholders. Our internship has therefore inspired us to go further into depth with the political aspects of food fortification and the perspectives of the different stakeholders. 3/53 Abstract Food fortification with Vitamin D – a political debate on a public health problem. Agnete Jürgensen & Sofie Gudman Valentin, Metropolitan University College, 2014 Background: The intake of vitamin D in the Danish population is lower than the Danish authorities recommend and they state that it is impossible to reach the adequate intake through the diet. The Danish authorities are looking at food fortification as an alternative source of vitamin D and as a tool to overcome the vitamin D deficiency. Aim: To gain insight into the stakeholders’ involvement, interest and motivation for a possible food fortification policy, in order to understand how the different stakeholders’ agendas can influence the government when deciding on a public health policy. Methods: Empirical material was collected by a combination of qualitative methods and a documentary method. The qualitative method consisted of one interview and three e-­‐mail correspondences, and the documentary method consisted of collecting written materials from articles, hearing statements, memorandums and a radio debate. These methods were chosen to conduct a discourse analysis examining how stakeholders’ points of view and interests are represented in various empirical materials. Results: Food fortification can be an effective tool in order to overcome a vitamin D deficiency in a population. The discourse analysis identified four main discourses, which the stakeholders use when they are talking about food fortification and vitamin D. The four main discourses are: consumer rights, health promotion, competition in economy and evidence in nutrition. The results illustrate agreements and disagreements between the stakeholders and that there are several ways to represent and talk about the food fortification and vitamin D problem within each discourse, depending on the position the stakeholder takes. Conclusion: The thesis concludes that a policy on the adoption of vitamin D fortification can be controversial and have powerful impact on food composition, food systems, food economies and public health. All of the four discourses are important when the government decides on a policy on food fortification and vitamin D. Keywords: Food fortification, stakeholders, vitamin D, policy, discourse analysis. 4/53 Table of Content Abbreviation ............................................................................................................................... 7 Figures and tables ........................................................................................................................ 7 Responsible for ............................................................................................................................ 7 1.0 Introduction and field of interest ........................................................................................... 8 1.1 Research question .................................................................................................................................................................... 9 1.2 Delimitation and justification of problem .................................................................................................................. 10 1.3 Contribution of new knowledge ..................................................................................................................................... 10 1.4 The structure of the thesis and reaching the goal ................................................................................................... 11 1.5 Definition of key concepts ................................................................................................................................................. 11 2.0 Methodology and Philosophy of Science .............................................................................. 12 3.0 Theory ................................................................................................................................. 15 3.1 Food Fortification ................................................................................................................ 15 3.1.1 What is food fortification ............................................................................................................................................... 15 3.1.2 Food Fortification Regulations in Denmark ........................................................................................................... 16 Mandatory fortification .............................................................................................................................................................. 17 Voluntary fortification ................................................................................................................................................................ 18 3.1.3 Food Regulations outside Denmark -­‐ Finland ....................................................................................................... 18 3.2 Vitamin D ............................................................................................................................. 19 3.2.1 Nutritional importance of vitamin D ......................................................................................................................... 19 3.2.2 Previous studies on vitamin D and food fortification ........................................................................................ 20 3.3 Stakeholders ........................................................................................................................ 21 3.3.1 Ethical perspective ............................................................................................................................................................ 23 4.0 Theoretical Framework ........................................................................................................ 24 4.1 Discourse analysis ................................................................................................................................................................ 24 4.2 Steps in a discourse analysis ............................................................................................................................................ 25 5.0 Method ................................................................................................................................ 26 5.1 Interview and e-­‐mail correspondences ....................................................................................................................... 27 Interview ........................................................................................................................................................................................... 27 E-­‐mail Correspondences ............................................................................................................................................................. 28 5.2 Documentary method ......................................................................................................................................................... 28 5.3 Data collection from fieldwork ........................................................................................................................................ 29 5.4 Stakeholder Presentation .................................................................................................................................................. 30 6.0 Result .................................................................................................................................. 31 7.0 Analysis ............................................................................................................................... 34 7.1 Consumer Rights ................................................................................................................................................................... 39 7.2 Health Promotion .................................................................................................................................................................. 41 7.3 Competition in Economy .................................................................................................................................................... 42 5/53 7.4 Evidence in Nutrition .......................................................................................................................................................... 44 8.0 Discussion ............................................................................................................................ 45 8.1 The Current Situation .......................................................................................................................................................... 50 8.2 Limitations and Considerations ...................................................................................................................................... 51 9.0 Conclusion ........................................................................................................................... 52 10.0 References ......................................................................................................................... 54 Appendix ................................................................................................................................... 60 Appendix 1 – Food Categories and Content of Nutrients for Mandatory and Voluntary Fortification ... 60 Appendix 2 – Different Fortification Practices in 9 EU Countries ........................................................................... 61 Appendix 3 – Interview Guide ................................................................................................................................................. 62 Appendix 4 – Statements from the radio debate P1 ...................................................................................................... 64 Appendix 5 – Calculation of the Energy Intake ................................................................................................................ 68 Appendix 6 – E-­‐mail Correspondences ............................................................................................................................... 69 Appendix 7 – Non-­‐available hearing statements ............................................................................................................ 74 Appendix 8 – Numbered Empirical material .................................................................................................................... 77 Appendix 9 – Transcription of the Minister’s Statements .......................................................................................... 82 6/53 Abbreviation DFDF: Danish Food and Drink Federation MFAF: Ministry of Food, Agriculture and Fisheries UL: Upper level Figures and tables Figure 1: Hermeneutical circle Figure 2: Policy analysis triangle Figure 3: Stakeholders Figure 4: Discourses Table 1: Stakeholders’ position towards food fortification. Table 2: Stakeholders’ position and how they talk about food fortification. Responsible for The entire thesis has been written in collaboration between Agnete Jürgensen and Sofie Gudman Valentin. 7/53 1.0 Introduction and field of interest Today the availability and access to adequate energy is increasing globally, but individuals who are food secure still lack essential micronutrients that are important for human health. This is called the “hidden hunger” (Rajendram, R. et al. 2013) and it has been estimated that micronutrient deficiencies account for 7,3% of the global burden of disease (Allen, L. et al. 2006). Especially vitamin D deficiency is a public health concern and it is the most common medical condition in the world (Holick, M. 2010). Globally 1 billion people suffer from vitamin D deficiency or insufficiency, and it is now described as a pandemic (Lawrence, M. 2013). One reason for vitamin D deficiency is lower exposure to direct sunlight, which is the primary source of vitamin D (Lawrence, M. 2013) and, furthermore, there is a limited number of natural sources of vitamin D. Therefore, it can be very difficult for any diet to fulfill the requirements from the Nordic Nutrition Recommendation at 10 µg a day (Black, L. et al. 2012). The intake of vitamin D in the Danish population is lower than the recommended (DTU Fødevareinstituttet 2010), and studies show that it is a problem for the majority of the Danish population (Lamberg-­‐Allert, C. 2013). A Danish food study collected from 2003 – 2008 shows that the average intake for adults age 18 to 75 years old is 3,4 µg/d (DTU Fødevareinstituttet 2010). During the winter season it is estimated that up to 40% of the Danish population has an insufficient vitamin D intake and it is estimated that up to 10 % suffers from severe vitamin D deficiency (Haslund, Elisabeth 2013). Globally there have been different public health strategies to tackle vitamin D deficiencies; nutrition education, vitamin D supplementation, promotion of sunlight exposure, maintaining status quo and food fortification with vitamin D (Lawrence, M. 2013). The field of interest in the thesis will be food fortification. The reason for this is that food fortification has proven to be an effective tool to tackle nutritional deficiencies. It is in studies described as a preventive strategy that reach the entire population (Madsen, K. 2013), because it does not require complex change of behavior and may enable the consumers to maintain their traditional dietary patterns (Rajendram, R. et al. 2013). Several studies show (Lamberg-­‐Allert, C. 2013) a positive effect of fortifying foods with vitamin D. It is however important to bear in mind that fortification cannot solve all micronutrient problems, but may 8/53 be a valuable and efficient way to addressing these in an effective, safe and sustainable way (Rajendram, R. et al. 2013). Food fortification is a topic within the food system that is very controversial, because policymakers must deal with conflicting conceptions, vested interests, and technical challenges. These challenges may arise due to different views among stakeholders regarding the cause of the policy problem, the type of food fortification, and whether food fortification is the right solution at all. Vested interests emerge when stakeholders have different motivations for either supporting or opposing food fortification, and some may have either a public health interest or commercial interests (Lawrence, M. 2013). The aim of the thesis is to gain insight into the stakeholders’ involvement, interest and motivation for a possible food fortification policy. This will help to understand different stakeholders’ agendas and how these can influence the government when deciding on a public health policy on vitamin D fortification. An examination of the discourses in the media, written documents and interviews is conducted to evaluate the various viewpoints of the vitamin D fortification problem. The aim of the thesis is therefore not to conclude which opinions and solutions that are the most right or wrong, but to present the most essential opinions and viewpoints and bring forward suggestions that need to be considered by the government before deciding on a policy on vitamin D fortification. 1.1 Research question On the basis of the research problem presented in the introductory section the following research question has been formulated: How can food fortification be used as a tool in the prevention of vitamin D deficiency in the Danish population? Which points of view and interests from stakeholders do the government need to consider when deciding on a public health policy on vitamin D fortification? 9/53 1.2 Delimitation and justification of problem In this thesis we have formulated the research question with a perspective on food fortification and vitamin D. We have chosen the perspective on food fortification on the basis of our work experience during our internship, where we got familiar with different stakeholders’ views on food fortification. We have only included stakeholders from the private and public sector, who we got aware of during our internship. The consumers have been left out even though they could have been very relevant to include. The focus on vitamin D has been chosen, because it is a current political topic and highly relevant due to a low intake of vitamin D among the Danish population. We find the link between food fortification and vitamin D interesting to work with, due to the fact that it is difficult to reach the recommended intake of vitamin D through the diet. Therefore it is interesting to look at an alternative method to increase the vitamin D intake among the Danish population by fortifying foods. However, when we take this view we leave out other alternative methods that can increase the vitamin D intake. The thesis takes a political perspective on the public health problem, due to the focus on stakeholders’ viewpoints. Therefore the thesis does not go into depth with vitamin D and the risks associated with a deficiency, thus leaving out the natural science perspective. Overall, we believe that this thesis and the perspective chosen is relevant for us and our specialisation Public Health Nutrition and Food Policy, as it clearly illustrates that external factors such as policies and the environment, e.g. the supply of food products in the supermarkets can affect the health of the individual and the society. Therefore, we believe that it is very interesting to look into a food policy that can contribute to better public health. 1.3 Contribution of new knowledge This thesis will contribute with perspectives on stakeholders’ position towards a vitamin D fortification policy in Denmark. It will clarify different aspects in relation to understanding the interest of the stakeholders and what underlies their representation of the problem. 10/53 Therefore the thesis will contribute to an investigation into stakeholders’ interests, commitment and viewpoints to the public health problem, which is important for a food fortification approach to emerge as an option for a policy in Denmark. The insights from the thesis can be used to identify advantages, disadvantages and opportunities for strengthening the government’s decision-­‐making for a vitamin D food fortification policy that can help protect and promote public health. 1.4 The structure of the thesis and reaching the goal In order to reach the goal of answering the research question the thesis is structured as follows. First the thesis provides the reader with all necessary background information on vitamin D and food fortification to understand the underlying problem, as well as technicalities of food fortification. The structure will then give a better understanding of the analysis and the discussion, as well as the opinions and viewpoint of the stakeholders. The theory section will address the first question of the research question, and the analysis and discussion will mainly address the second question of the research question. Thereby the structure of the thesis will move on all taxonomic levels along with answering the research question, which will make it possible for us to complete the thesis. 1.5 Definition of key concepts The key concepts are used throughout the entire thesis and will be referred to as defined in the following: Stakeholder: The term “stakeholder” is used to represent individuals, organizations or state and their actions that affect a policy (Buse, K. et al, 2011). Food fortification: The addition of one or more essential nutrient to a food (Allen, L. et al. 2006) In this thesis “food fortification” will be used and covers the Danish word “enrichment” (berigelse). Mandatory fortification: The government obliges food producers to fortify particular foods or food categories with a specific nutrient (Allen, L. et al. 2006). Voluntary fortification: Food producers can freely choose to fortify foods in response to the regulations (Allen, L. et al. 2006). 11/53 Discourse: The word discourse means “speech” or a “coherent pattern of speech”, and is a specific language that is used to talk about a specific subject (Vallgårda & Koch, 2011). 2.0 Methodology and Philosophy of Science To understand the perspectives on food fortification we have chosen to use a constructivist method that fall within a paradigm to see how the stakeholders have constructed their view on fortification. First we will describe how we use constructivism and how it is linked with discourses. Then we will argue why we have chosen a qualitative method and how the methodology is linked with our methods. At the end of the methodology section we introduce the reader to the thesis’ application of hermeneutics. Constructivists do not believe that there is one truth about reality. The phrase reality will be referring to an element of reality that focuses on food fortification. Reality cannot be clearly defined, but it can be understood as an interpretation that is constructed by humans’ different perceptions of their reality. Each person is not born with a specific realm of understanding. Instead understanding is constructed by parameters such as culture, surroundings and organization etc. that the person is a part of (Nygaard, C. 2011). From a social constructivist perspective our perceived reality is created through the various ways we speak about reality, through discourses. Thus, the reality is a part of how each stakeholder forms opinions. Therefore, a discourse analysis will be the main framework for the thesis, since we wish to gain an understanding of how the stakeholders perceive and construct their reality on food fortification and thereby how their perspectives and actions are shaped (Nygaard, C. 2011). A discourse analysis will be further explained in the theoretical framework and will be applied throughout the analysis. The discourse theoretical base in the constructivism will underlie the two chosen methods. To answer our research question we will conduct qualitative interviews through face-­‐to-­‐face interaction and e-­‐mail correspondences and use a documentary method that will give us insight into the stakeholders’ views on food fortification. A documentary method is based on 12/53 written materials that are not produced by us; it is therefore outside sources (Nygaard, C. 2011). Our qualitative method of receiving interview and e-­‐mail responses will give us insight into the stakeholders’ opinions, because we can ask direct questions and follow-­‐up questions and thereby get elaborated responses, which will give us an in-­‐depth understanding of how each stakeholder perceives reality, argue, explain and justify their actions and how this is materialises their opinions towards food fortification. Furthermore, we believe that the qualitative method will exemplify the problems arising when planning a public health policy and that constructivism will represent the different stakeholders’ opinions of food fortification. Additionally, the method can also explain the complexity of planning a food fortification policy, because we are in contact and speak with different stakeholders and thereby we get familiar with different viewpoints on the vitamin D and food fortification problem. These methods illustrate that there might be no correct and definite answers for the government when deciding on a public health policy on vitamin D fortification, and therefore planning this policy can be quite complex. Using only a quantitative method would not generate the same in-­‐depth insight as the qualitative approach applied in this thesis. A quantitative method could for instance only clarify how many stakeholders are for or against fortification, but it cannot tell us how and why (Nygaard, C. 2011). Therefore, it would not give us the in-­‐depth insight that is essential to answering the research question. Our second method will be a documentary method, which will heighten the quality of the qualitative method, which is gained by interviews and e-­‐mail correspondences. We find this method necessary, because there is a risk that not all of the stakeholders will do interviews. Therefore this documentary method is relevant to use to clarify the opinions by documenting the different stakeholders’ approaches to food fortification (Nygaard, C. 2011). The sources will be statements from articles, hearing statements, statements from the stakeholders’ webpages, memorandums and a radio debate on food fortification. These sources will substantiate the interviews and e-­‐mail correspondences, so that the analysis and discussion will not only be based on oral and written comments from the stakeholders, but also on other sources. We expect that this method will clarify how they speak about vitamin D and food fortification, not only in interviews and e-­‐mail correspondences, but also in public. 13/53 This method is relevant in relation to the discourse analysis as it gives a deeper and broader insight into how the stakeholders speak about a certain subject. The use of both interviews and e-­‐mail correspondences in conjunction with the documentary method will therefore result in a deeper basis of interpretation. The philosophy of hermeneutics will be applied, both to the background of the assignment as well as to the understanding of the chosen methods. Hermeneutics is dealing with the important concepts of pre-­‐understanding and understanding. The pre-­‐understanding on the subject food fortification has been the basis for the formulation of our research question and the basis for the chosen method. One example is the formulation of the interview guide, which demand pre-­‐understanding on the subject and the stakeholders in order to formulate the questions (Vallgårda, S & Koch, L, 2011). During the process of working with the thesis our pre-­‐understanding will develop and lead to further understanding to answer our research question. The concepts are inseparable and this is illustrated in Heidegger & Gadamer hermeneutical circle (Vallgårda, S & Koch, L, 2011, p. 160). The figure illustrates our overall approach to the thesis, but will not be used directly in the analysis. Figure 1: Hermeneutical circle Pre-­‐
understanding Understanding Hermeneutics will be applied to our chosen methods by interpreting texts and interviews and thereby to understand the stakeholders’ reality on food fortification. Hermeneutics focus on how we can gain understanding by interpretation, and this can be carried on in the discourse analysis where each stakeholder’s reality on food fortification will 14/53 be examined. We will apply hermeneutics by moving from examining single interviews and texts to examining all interviews and thereby to understand the food fortification problem as a whole. Therefore the philosophy of hermeneutics is essential for answering the research question (Vallgårda, S & Koch, L, 2011). 3.0 Theory The theory section is divided up into three parts: food fortification, vitamin D and stakeholders, and aim to explain technicalities, backgrounds and relevant perspectives to develop a further understanding of food fortification and the vitamin D problem in Denmark. This section will also be the basis for answering the first part of the research question: How can food fortification be used as a tool in the prevention of vitamin D deficiency in the Danish population? The part on food fortification will include information on what food fortification basically is and how the national and international regulations are framed, especially with a focus on mandatory and voluntary fortification. Further, a small part on a fieldwork examining the amount of daily energy an individual gets from fortified products will be presented. The second part on vitamin D includes information on its nutritional importance, why and how it is essential for body function and sources of vitamin D. Furthermore previous results from studies on vitamin D fortified foods will be presented. The last part on stakeholders will include information on stakeholders in general, interactions and interest and a presentation of a policy triangle. Furthermore an ethical perspective will be presented illustrating different viewpoints of stakeholders. 3.1 Food Fortification 3.1.1 What is food fortification The Codex General Principles for the Addition of Essential Nutrients to Foods defines food fortification as, “the addition of one or more essential nutrients to a food whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated 15/53 deficiency of one or more nutrients in the population or specific population groups” (Codex Alimentarius, 1987, p. 2). Food fortification is therefore understood as a way to add nutrients to foods and give them qualities, which are not naturally present in the product (FVST, 2013). Food fortification is used as a tool to prevent a micronutrient deficiency and thereby provide a health benefit. Several parameters such as; the level of fortification, the bioavailability of the micronutrients and the amount of fortified foods consumed determine whether food fortification has an impact on public health. The term “enrichment” is used as a synonym for food fortification and gives the term a more positive description (Allen, L et al. 2006). 3.1.2 Food Fortification Regulations in Denmark Before 2003 the Danish regulation was administrated by the principle that food producers were only allowed to add nutrients to food products if the fortification could remedy or prevent nutritional deficiencies seen in a large part of the population, as seen with iodine in salt. However, the Danish practice got an EU-­‐sentence in 2003, because the it contravened EU regulations, since products legally produced and sold in other member states could not be marketed in Denmark (Virksomhedsforum, 2013). The EU-­‐regulation dictates free movement of goods in the EU, unless the products have a risk for the public health (EU Regulation 1925/2006). Today both EU and Danish regulations are applicable to food fortification in Denmark, and in the absence of a specific rule, for instance regarding how much vitamin and mineral that can be added to a product, national rules may be applied (EU Regulation 1925/2006). Denmark is following the Regulation no. 1925/2006 on the addition of vitamins and minerals and of certain other substances to foods (EU Regulation 1925/2006), and can no longer decline a food product to be fortified, even though there is no nutritional reason for the fortification. Today the Danish authority examines each application and assesses the health risks associated with fortification of a specific product. This risk assessment is based on the Danish Model, which will be explained later. The Food department will undertake the risk assessment and report whether the products are accepted or declined for marketing in Denmark. In many other countries in the EU the risk assessment is not conducted (1. Fødevarestyrelsen, 2013). 16/53 The Danish Model is a practice, which is only used in Denmark and it is developed by the Technical University of Denmark’s (DTU) Food Department. The model compares the theoretical intake of nutrients a person can intake with the upper level intake of the same nutrients for a longer period of time. Further, the permission of a product is determined by the content of nutrients pr. energy unit. The theoretical intake is based on: o The most vulnerable group in Denmark (children 1-­‐3 years old). o The 5 % of the vulnerable group with the highest intake of nutrients from the diet. o That they daily take a multivitamin pill. o That they daily get 25% of their energy intake from fortified products. (Peetz-­‐Schou, M., 2012). These reservations make it difficult to get fortified products approved for the Danish marked as the reservations are very strict. Apart from the regulation no. 1925/2006, the Danish government has a consolidation act on addition of nutrients to foods1 with Danish rules for the amount of added nutrients to foods and rules for mandatory and voluntary fortification. Mandatory fortification Mandatory fortification is determined by the government and obliges food producers to fortify particular foods or food categories with a specific nutrient (Allen, et al. 2006). Its intention is to deliberately expose all individuals in a population to the nutrient, if the individual consumes the fortified food, in order to increase the intake of a nutrient and avoid a deficiency in the population (Lawrence, M, 2013). As mentioned, iodine is an example of a mandatory fortification policy in Denmark, where salt for household use and salt in bread and baked goods are with added iodine (1. Fødevarestyrelsen, 2013). 1 BEK nr 1104 af 26/11/2012 17/53 Voluntary fortification Voluntary fortification is determined by the food producers to freely choose to fortify foods in response to the regulations (Allen, L. et al, 2006). There are two branches of voluntary fortification: general and individual. General fortification means that the food producers are always allowed to add a specific nutrient to a food product. The food producers can for example add vitamin C to fruit juices in order to restore nutrients lost during manufacturing (Molander, E, 2012). The food categories that are allowed to be general fortified are listed in the regulation. Individual fortification is when food producers apply to add a nutrient to a product. This is for example when producers want to add nutrients to energy drinks or other drinks. Here the Danish authority has to examine each application and assess the health risks associated with fortification of a product (Molander, E, 2012). Throughout in the thesis voluntary fortification will be used and will primarily refer to the individual fortification. See appendix 1 for a table showing food categories and content of nutrient for mandatory and voluntary fortification, respectively. 3.1.3 Food Regulations outside Denmark -­‐ Finland The food fortification regulation in Denmark is different from other countries. Several other EU member states are more welcoming towards food fortification, and fortified products are widely distributed in the supermarkets. Both mandatory and voluntary fortification is applied and the member states are not as strict as Denmark when controlling fortified products. See appendix 2 for a table illustrating the different fortification practices in nine EU countries. Finland will be highlighted as an example of a voluntary fortification practice to address the issue of vitamin D deficiency, because Finland has experienced a low vitamin D status in all age groups (Lamberg-­‐Allardt et al. 2013). Therefore the Finnish authorities have introduced a fortification scheme to broaden vitamin D in the population. 18/53 Finland has a voluntary milk fortification policy with vitamin D, but since it is a common practice and there is consensus between the ministry and the industry, the fortification practice is called a semi-­‐mandatory practice (Flynn, A et al, 2009). Finland fortifies milk with 1 µg vitamin D3/100 g., and several studies have evaluated the effect of the fortification practice with many countries using Finland as an example when discussing their own fortification policies on vitamin D (Lamberg-­‐Allardt et al. 2013). One study examined the intake of vitamin D from the diet in Spain and the diet in Finland, ranging from 3.1 µg/d for women and 2.4 µg/d for men in Spain, and 17.3 µg/d for men and 10.5 µg/d for women in Finland. Finland’s higher level of vitamin D was associated with the fortification of milk (Flynn, A et al, 2009). A literature review evaluating the effect of the vitamin D fortification in a larger population concluded that for those using fluid milk products the impact on intake and vitamin D status was significant (Lamberg-­‐Allardt et al. 2013). 3.2 Vitamin D 3.2.1 Nutritional importance of vitamin D Vitamins are essential elements needed in small amounts in the diet. They cannot be synthesized in the body or synthesized in the right quantities, and therefore the body needs to get it from other sources e.g. dietary sources. When a vitamin intake is insufficient, a deficiency develops which can be followed by a decline in health. This is applicable for Vitamin D, which is a fat-­‐ soluble vitamin that is absorbed along with dietary fat in the small intestine (Byrd – Bredbenner 2009). Research shows that vitamin D has an effect on muscle function and bone health. Vitamin D deficiency can lead to decreased muscle function and muscle strength, and an increased risk for fractures due to reduced bone strength (DTU Fødevareinstitut 2010). Vitamin D has hormone like functions and promotes the absorption of calcium from foods so that it is available for body cells and the bones. Therefore, if the bones are not supplied with calcium, a person could have severe health consequences (Byrd – Bredbenner 2009). 19/53 Further, research has shown a connection between the recommended level of vitamin D and asthma, cardiovascular diseases, diabetes type 1, diabetes type 2, multiple sclerosis, respiratory infections, influenza and tuberculosis. Thus, the evidence has not been sufficient enough to conclude a real connection (DTU Fødevareinstitut 2010). An upper level (UL) for vitamin D intake has been set at 100µg/d due to serious consequences from toxicity (NNR 2012, 2013). A high intake of vitamin D can cause over-­‐absorption of calcium and hypercalcemia, which can lead to deposits of calcium in the kidneys, heart and lungs. Further it can lead to bone demineralization, weakness and joint pain (Byrd – Bredbenner 2009). Sun irradiation is the most important source of vitamin D for humans and covers up to 90 % of the need for vitamin D. Only 10-­‐20 % is obtained from the diet, where especially fatty fish is a good source. The Danish dietary guidelines recommend eating 200-­‐300 g. of fish each week, but this amount is still not enough to get the recommended intake of vitamin D. In Denmark it is only possible to create vitamin D from the sun during the summer months (April to October) since the sun irradiation is only strong enough in that period. Furthermore people wear more clothes during the winter and thereby the body and skin is covered, making it very difficult to obtain sun irradiation and thereby vitamin D (DTU Fødevareinstitut 2010). 3.2.2 Previous studies on vitamin D and food fortification Several studies have examined vitamin D deficiency and the effects of vitamin D fortified food on humans. This section will be based on previous literature reviews from PubMed, since it is not within the scope of this thesis to conduct a systematic literature review. One systematic literature review conducted by Lamberg-­‐Allardt and colleagues for the new Nordic Nutrition Recommendation examined 35 studies in total. Three of these studies concluded that the vitamin D status in native Danes is a problem, but especially also for the Pakistanis in Denmark. The Danish studies were conducted from August to February and from January to November and have therefore accounted for variation in seasons. The review concludes, based on 15 studies, that fortifying foods with vitamin D do increase the concentration of vitamin D. This result was very consistent in all interventions (Lamberg-­‐
Allardt et. al, 2013). 20/53 Another systematic review by Black and colleagues on the efficacy of vitamin D food fortification included 16 studies in their review. The inclusion criteria for the studies to be accepted were that they should be conducted in adult populations, and that the studies had accounted for seasons. Seven studies were conducted at latitude above 40° and four studies were conducted for one year or longer. This review also concludes that food fortified with vitamin D will increase the concentration (Black, L et al., 2012). One Danish randomized controlled trial will be highlighted since it investigates if it is possible to maintain a recommended vitamin D status during a 6 month winter period, by eating fortified milk and bread. Scientists from DTU Food have conducted the study among 201 families in Denmark from September and six months onwards. The study showed that 66% of the participants in the fortification group were able to reach the vitamin D intake goal of 7,5 μg/d. compared to only 2% from the control group. It also showed that none of the participants reached the UL intake of vitamin D. The intake goal on 7,5 μg/d. is based on the 4th edition of the NNR. The 5th edition of the NNR recommends an intake on 10 μg/d. (Black, L. et al. 2012). The study concluded that fortified milk and bread can be a help to maintain a daily vitamin D intake of 7,5 μg. (Madsen, K.H 2013). Though the studies are more or less consistent in the results, they should be interpreted with caution due to large heterogeneity between the studies. This means that the studies are different in design, study population, fortification amount and the food vehicle used, however they still indicate that vitamin D fortification is effective. 3.3 Stakeholders Food is very much a political topic and is influenced by battles among different stakeholders with different values, beliefs and interest. Different interests arise because of different motivations for either supporting or opposing activates relating to food fortification. The interests range from protecting public health to promoting consumer and food industry interests. Therefore, these conflicting interests give rise to challenges because policy makers 21/53 need to consider all of the aspects within food fortification e.g. science, cost, culture, politics, resource allocation, prejudice relating to fortification, technical issues, commercial interests and trade (Lawrence, M. 2013). To get an understanding of the policy process it is necessary to focus attention to the stakeholders, as Walt comments: “ since processes do not have a life of their own, but are dependent on stakeholders to give them expressions, analysis of the policy process is interwoven with an exploration of which stakeholders are involved, and how far each may be exerting influence on policy” (Walt, G. 1994). The stakeholders in a food fortification policy primarily include a government department, statutory agencies, experts, private sectors and non-­‐governmental stakeholders with interests that especially are affected by a food fortification policy. The policy triangle will be used as an example to understand the influencing element in a policy process. The triangle below focuses on “content”, “context”, “process” and “stakeholders” and illustrates that stakeholders are influenced by the context in which they work, and that context is affected by the process of the policy-­‐making. However, also the process is affected by the stakeholders due to their position in regard to power, their values and their expectations. Therefore, the elements influence each other, and content reflects all the dimensions in the triangle. Nevertheless, stakeholders have a central position in the middle of the triangle indicating their power to interact and influence a policy (Buse, K. et al, 2011). Figure 2: Policy analysis triangle 22/53 Therefore, it is essential to get an understanding of the stakeholders and how they interact and are influenced by the processes and the context. 3.3.1 Ethical perspective To gain further understanding on the different stakeholders it is relevant and interesting to look at the ethical perspectives reflecting their different viewpoints and interests towards the vitamin D deficiency problem and food fortification. The two ethical perspectives that can be applied when working with public health policy interventions are conflicting between individualism and collectivism. Individualism is the individual’s ability to control their own life and decide for themselves. Collectivism is the needs of the public as a whole. The two ethical perspectives are the theory of utilitarianism and the theory of non-­‐consequentialist (Lawrence, M. 2013). The role and the responsibility of the government is to protect public health and undertake certain interventions, for instance deciding whether mandatory or voluntary food regulation shall be applied (Childress, J.F. et al, 2002). The theory of utilitarianism strives to achieve the maximum benefit for public health and to achieve “the greatest good for the greatest number”. This means that the end justifies the mean, and focuses on the outcome rather than the process (Lawrence, M. 2013). The utilitarian theory can be applied to understand mandatory food fortification. Contracting the theory of utilitarianism are the theories of non-­‐consequentialist. These theories focus on the process rather than the outcome. A viewpoint against mandatory food fortification is liberalism, which classifies such interventions as being paternalistic, meaning that the action of the government restricts the individual’s freedom and choice (Lawrence, M. 2013). Therefore utilitarianism believes that protecting or promoting public health always has priority over privacy, while the theories of non-­‐consequentialist believe that individual liberty always has priority over protecting or promoting public health. These ethical perspectives can provide insights for discussing ethical conflicts and analyzing the consequences for a food fortification policy intervention, and help identifying the arguments between individual interests and the common good. 23/53 4.0 Theoretical Framework The stakeholders’ responses to food fortification as a tool to solve the vitamin D deficiency have impact on the policy implementation, because the different opinions and viewpoints can influence how the policy is developed and implemented. Therefore a discourse analyses is very relevant to apply, because it examines different opinions. It will be the theoretical framework used in the analysis and in the discussion. 4.1 Discourse analysis The discourse analysis examines how the problem concerning vitamin D deficiency in Denmark and fortification is represented by the stakeholders in the media, hearing statements, interviews and in e-­‐mail correspondences, and provides a helpful framework to guide the government when deciding on a policy. How policies are developed is an unavoidable result from stakeholder interaction, since they are all contributing to how vitamin D deficiency and fortification are framed as problems (Begley & Coveney, 2010). The purpose of the thesis is to conduct an analysis of stakeholders’ representations of vitamin D fortification by examining the underlying discourses in the chosen methods to answer the second part of the research question: Which points of view and interests from stakeholders do the government need to consider when deciding on a public health policy on vitamin D fortification? When using the phrases ”points of view” and ”interests” it is ideal to conduct a discourse analysis, because the fundamental part of the analysis is to focus on how the stakeholders’ reality are discursively constructed. Thereby, when analysing different discourses on the vitamin D deficiency and fortification problem we examine what underlies the stakeholders’ point of views and interests. In continuation hereof the discourse analysis observes the stakeholders that observe their reality and therefore the aim of the analysis is not to conclude which of the realities that is true, but rather to understand why the stakeholders’ think of their reality as true (Vallgårda & Koch, 2011). 24/53 4.2 Steps in a discourse analysis When conducting a discourse analysis in this thesis it is important to pay attention to language, concepts and contexts that are used to frame the vitamin D deficiency and fortification problem. According to Foucault every discourse is recognized in the way it establish certain elements in relation to each other. The elements are: objects, subject positions, concepts and strategies. These elements are important to have in mind when analysing our material in order to create patterns of correlation between a number of statements to identify discourses. In the following the elements will be explained briefly. It is important to bear in mind that there is not a clear formula on how to conduct a discourse analysis and furthermore the elements are not necessarily to be followed step-­‐by-­‐step but are helpful when analysing the material (Vallgårda & Koch, 2011). •
Objects: How is food fortification talked about in the various discourses? E.g. food fortification as being a problem or a solution. •
Subject positions: Which stakeholders speak about food fortification, which positions do they take, which authority do they draw on and who do they talk to? Subject positions can for instance be the consumers or the industry. •
Concepts: How do they talk about it, what type of vocabulary and categories are used? E.g. the concept of food fortification. •
Strategies: Why are the concepts evoked as they are? The objects, the subject positions and concepts that are present in a discourse create all together a discursive strategy and therefore there is no schematic structure in the analysis but the elements are closely connected and should be seen interlinked. (Vallgårda & Koch, 2011). In a discourse analysis you will often identify several different discourses because all of the stakeholders have a different perspective and are likely to see the same policy problem in different ways. Therefore the discourses illustrate their opposing interests and viewpoints. These opposing interests and viewpoints are fighting to be the dominant discourse. The dominant discourse is determined by what most stakeholders think about the subject at a 25/53 certain time. The dominant discourse is relevant to include in the analysis and discussion to make sense of the opposing debate on vitamin D deficiency and food fortification (Vallgårda & Koch, 2011). A study on the discourses used in media and health journals on folate fortification has been used as inspiration for the analysis and especially the discussion (Begley & Coveney, 2010). Inspired by the study the discussion will be applied to the analytical framework by Bacchi who asks questions that highlight how the vitamin D deficiency and food fortification issue is positioned as problematic. In the discussion the following questions will be asked from the book “What’s the problem represented to be?” by Bacchi (Bacchi, C. 2009): •
What is the problem represented to be in a vitamin D fortification policy? •
What is left unproblematic in this problem representation? Where are the silences? Can the problem be thought about differently? •
What effects are produced? What is likely to change and what is likely to stay the same? Who is likely to benefit? Who is likely to be harmed? The questions will be the basis for the discussion and pave the way for new questions, issues and perspectives to discuss. 5.0 Method To answer the research question two methods have been applied: a qualitative method and a documentary method. The purpose of the thesis is to examine the stakeholders’ points of view and interests by assessing their statements on the vitamin D problem and food fortification in various empirical materials. Therefore, the methods have been identified as being the most suitable, available and optimal for conducting a discourse analysis, because they provide us with insight and information on the opinions of the stakeholders. 26/53 All the applied methods are used on equal terms and therefore there will not be a primary or secondary method, because both methods are important for the analysis. A previous fieldwork from our internship is included in the method section, however it will not be seen on equal terms with the qualitative and documentary method, but as an extra method to illustrate a certain point. In order to understand the influencing factors in regard to a policy on food fortification, it is for this thesis necessary to identify relevant and influential stakeholders who have an interest. Therefore there will be a presentation of the chosen stakeholders in the end of the method section. 5.1 Interview and e-­‐mail correspondences Eight stakeholders2 have been contacted regarding a face-­‐to-­‐face interview, four of which responded and only one agreed to do an interview. The three remaining agreed to answer through e-­‐mail. The eight stakeholders have been chosen because they represent different sectors, and have been active in the debate on food fortification. In the following the empirical materials will be explained in details. Interview An interview guide has been constructed consisting of 25 questions relating to vitamin D and food fortification. The questions in the interview guide have been formulated clearly and open-­‐ended in order to get in-­‐depth, comprehensive and useful answers. The questions were formulated quite specifically, so that each question consisted of one question only. The rationale behind this is that the interviewee does not have to relate to various questions at once. The number of questions in the interview guide illustrates that there are many specific questions. The thought behind the questions is that the clearer the questions are, the clearer the answers will be and therefore the assumption is that the interview will not be longer than 30 minutes. Some of the questions are essential to get an answer to, because they are leading factors for the analysis. Other questions are asked to substantiate further answers from the interviewee and to get supportive answers that can be used in the analysis. 2 DFDF, MFAF, Arla Foods, DTU Food, Cancer Society, Consumer Council, Schulstad and Unilever. 27/53 One example of a question from the interview guide is: “What is X’s opinion towards voluntary food fortification?” Here is it not possible for the interviewee to answer yes or no, but the interviewee is obliged to elaborate and form an opinion. See appendix 3 for the full interview guide. The purpose of the interview is to get insight into the opinions of the stakeholders and to further elaborate on the problem in addition to what has been expressed in the public. E-­‐mail Correspondences In order to collect interviews by e-­‐mail correspondences, the full interview guide is edited and a number of questions are selected. The selected questions are the ones we find most relevant, meaning that the questions are essential to get a reply to, because the replies are needed in the analysis. Furthermore the questions are relevant, because elaborated answers to the question cannot be found elsewhere. The questions are taken directly from the interview guide and therefore the considerations behind the questions used in the e-­‐mail correspondences are the same as the consideration with the interview. 5.2 Documentary method The documentary method is applied by collecting written materials from different sources. All articles are found on the website Infomedia, which is a site giving access to all published articles in Denmark. The search criteria include articles published within the last 12 months in all Danish media. The period of 12 months is chosen to get the most up-­‐to-­‐date articles and to limit the number of articles. This will give us the best insight in the current points of view of the stakeholders. The documentary method also includes hearing statements and memorandums from the stakeholders. This material will give a formal insight into the opinions of the stakeholders and how they express themselves when responding to policy suggestions. Therefore this method is also very relevant to the analysis, because the stakeholders might express themselves differently compared to in the media. 28/53 The search for hearing statements and memorandums is not systematically conducted, since we were given access to them during our internship at Danish Food and Drink Federation by a student worker. In addition to those documents, a Google search for hearing statements is conducted. A radio debate is also included in the documentary method. This debate is included, because two stakeholders clearly express their opinions and discuss them up against each other. The radio debate is named “The Word is Yours – Should we add vitamins to foods?” and was broadcasted the 15th of June 2013. The duration of the debate is 53 minute and DFDF and Consumer Council were represented. Statements from the Consumer Council and DFDF have been transcribed. See appendix 4 for the transcription of their statements from the radio debate. 5.3 Data collection from fieldwork During our internship at Danish Food and Drink Federation a fieldwork on fortified products was conducted. We have chosen to present the fieldwork in the thesis, because it will be used as background material and since the data contradicts one of MFAF’s reservations, namely that 25% of the daily energy comes from fortified products. Since it is not one of our main methods, but a fieldwork we have conducted previous to the thesis, we will not go into depth with the method. Therefore the fieldwork will only be shortly described. We were asked to examine how much daily energy an average Danish person gets from fortified products since the amount varies a lot depending on whom you ask. In relation to this we wanted to know the magnitude of fortified products on the Danish marked. We visited six different supermarkets and convenience stores that represent the major retailers in Denmark. Here we looked at the number of products on the shelves and registered the product details and code number of the fortified products. In order to calculate how much daily energy an average Dane gets from fortified products, we used a food study on average intake from 2003-­‐2008. See appendix 5 for calculations of the energy intake. 29/53 5.4 Stakeholder Presentation The stakeholders have been chosen because they are all visible in the debate on vitamin D fortification and represent different sectors with different opinions on how to solve the vitamin D deficiency by means of food fortification. Five stakeholders have been identified: Figure 3: Stakeholders Short presentation of the stakeholders: •
DFDF is an industry association, which represents 227 food producers and has an annual turnover of 135 billion DKK. This gives them power of penetration in the political debate (Danish Food and Drink Federation, 2009). •
Cancer Society is one of Denmark’s largest member organizations with 466.215 members (Cancer, 2012) •
MFAF is responsible for regulations on the food area and the closest instant to the Minister of Food, compared to the other stakeholders (Fødevarestyrelsen, 2013). •
Arla Foods is a global dairy concern. Arla Foods has an annual turnover on 63.1 billion DKK (Arla, 2013). •
The Consumer Council is an independent membership organization with 73.000 members and 30 member organizations. The purpose of the organization is to defend the rights of the consumers and give them power in the market (Forbrugerrådet, n.a) 30/53 •
DTU Food is responsible for conducting research and to provide new knowledge based evidence. They are working in collaboration with MFAF (DTU Fødevarerinstituttet, 2013) 6.0 Result The following presents the results from the methods, results from the interview and the documentary method, as well as the result from the fieldwork. All the statements, opinions and viewpoints we obtain from these methods will be presented in the discourse analysis. We succeeded in getting one interview with senior consultant Mette Peetz-­‐Schou from DFDF. The interview guide was sent to Mette Peetz-­‐Schou in advance as request by her. The interview was conducted in Danish on the 11th of October 2013 and was recorded with an IPhone with the permission of Mette Peetz-­‐Schou. The duration of the interview was 41 minutes, and it was carried out by one interviewer asking the questions and another interviewer focusing on asking follow-­‐up questions. The entire interview has been transcribed and sent to Mette Peetz-­‐Schou for approval. In order to conduct the interview certain terms were set up. All quotations in the analysis has to be accepted by Mette Peetz-­‐Schou, and we are not allowed to put the transcription of the interview in appendix, since it should not be available for the public. Therefore, there have been some legal procedures and reservations to take into account in relation to the interview. Fortunately, Mette Peetz-­‐Schou accepted all of the quotations. If she had not accepted the quotations it would have forced us to change the analysis. E-­‐mail correspondences have been conducted with Hanne Hansen from MFAF, Inge Tetens from DTU Food and Anja Møller from Cancer Society. They all said no to a face-­‐to-­‐face interview due to lack of time, but agreed to answer some questions by e-­‐mail. MFAF would only answer a few questions, and we received answers to the four questions we sent to her. The Cancer Society did not have any requirement to the number of questions and responded 31/53 to 17 questions. DTU did not answer any questions directly and stated that all their opinions are based on scientific evidence, available in a scientific published report, which was attached. The answers we received from all the stakeholders were sufficient and therefore we did not ask any follow-­‐up questions. They were informed about the purpose of the interview and how we were going to use it. Three of the stakeholders, Arla Foods, Schulstad and Consumer Council, did not respond to our e-­‐mail, and Unilever responded that they did not have resources to help us. In total we received one interview and three e-­‐mail correspondences, which will be used in the discourse analysis. See appendix 6 for e-­‐mail correspondences. A part of the documentary method was a search for articles. This search was conducted on the 30th of October 2013. The following search terms were used: “fortification foods” and “fortified foods”. Only two search terms were used focusing on food fortification, because the articles provided sufficient information on the stakeholders’ points of view according to food fortification as well as vitamin D. Therefore we did not use any search terms on vitamin D. The first search resulted in 42 articles, and the second search resulted in 64 articles. All articles were examined, but we found that some of the articles were the same in the searches and furthermore some articles were not related to food fortification. 39 articles were identified as relevant due to the focus on food fortification and vitamin D. All articles were read and examined for statements from the chosen stakeholders presented in the stakeholder presentation in the method section. Based on the inclusion criteria that the articles should contain at least one statement from a stakeholder, 18 articles remained and they have been used in the analysis supporting the qualitative method. Another part of the documentary method is the search for hearing statements and memorandums. As mentioned in the method section a student worker did the search and found four hearing statements with statements from DFDF and Consumer Council and two memorandums with statements from MFAF. We have tried to conduct the same search, however two3 of the four hearing statements are not accessible to the public. The other two 3 Høringssvar J-­‐nr.: 2012-­‐20-­‐221-­‐01241, 2012 Høringssvar J-­‐nr.:2012-­‐27-­‐221-­‐01289, 2012 32/53 hearing statements that are accessible4 can be found when conducting a Google search on the case citation. The two5 memorandums can also be found when conducting a Google search. In the Google search we conducted ourselves, the following search term is used for all of the stakeholders: “Hearing statement fortification Consumer Council”. Two6 hearing statements were identified from Cancer Society and Consumer Council. In total two memorandums and six hearing statements have been included in the analysis. In relation to the documentary method it is important to highlight that it can be difficult to repeat the search by other researches, due to the fact that some of the hearing statements used are not available online, and that we cannot document the search for the other hearing statements and memorandums. This can affect the credibility of the empirical data and the analysis. See appendix 7 for the non-­‐available hearing statements. Even though we did not receive any response from Arla Foods and the Consumer Council they have been chosen as main stakeholders in the analysis, because the documentary method has shown that they participate with their points of view and opinion in the public. Therefore, we have assessed that there have been sufficient and relevant statements from them, which can be very useful and relevant in the analysis. The result from the fieldwork during the internship is that we found that there are few fortified products, and that it is mainly vitamin waters and energy drinks that are fortified. We found that only few margarines -­‐and butter products and few cereal products are using their possibility to use the general permissions and that only few products that have received a voluntary permission use it. Based on our fieldwork and the food study in Denmark we have found that the average Dane gets 1.35 % of their daily energy from fortified products. 4 Grundnotat til Folketingets Europaudvalg. J.nr.: 2003-­‐4113-­‐0049, 2003 Høringssvar J-­‐nr.: 2012-­‐20-­‐2301-­‐ 00917, 2012 5 Grundnotat til Folketingets Europaudvalg. J.nr.: 2003-­‐4113-­‐0049, 2003 Grundnotat til folketingets europaudvalg. Sagsnr.: 2011-­‐20-­‐221-­‐010696, 2011 6 Høringssvar J.nr.: 2009-­‐20-­‐24-­‐00175, 2011 Høringssvar J-­‐nr.:2011-­‐20-­‐269-­‐00077, 2012 33/53 7.0 Analysis The purpose of the discourse analysis is to present the results from the methods applied to answer the research question. The analysis will especially focus on answering the second part of the research question, by analysing the stakeholders’ points of view and interests. Therefore, the analysis will form a basis for the interpretation of the different points of view, as well as an assessment of the stakeholders’ interests and an assessment of the strongest discourses. Furthermore the results from the analysis will form a basis for our discussion. All materials have been analysed according to the discourse analysis explained in the theoretical framework by using the four elements; objects, subject positions, concepts and strategies. The elements are not followed step-­‐by-­‐step, but have been used interlinked in the analysis. Therefore they will not be presented slavishly, but form a whole for the analysis that identifies the discourses. The references to our empirical material are numbered and superscripted. See appendix 8 for the numbered empirical material. In order to know how the stakeholders are positioned and respond to the concept of food fortification and the vitamin D problem, their choice of words have been identified in all of the selected sources. The stakeholders’ use of words will be further elaborated and analysed in the “discourse” section. We have chosen to look at all types of fortification because the analysis showed that one stakeholder may have different opinions towards food fortification in general and in relation to either mandatory or voluntary fortification. In general there is the same attitude towards the vitamin D problem as being a problem among four of the stakeholders. DFDF and MFAF both word the problem as a “public health problem”8,18, DTU Food words the problem as “low vitamin D status”29 and the Consumer Council words it as a “concrete problem”7. However the Cancer Society has another attitude towards the problem and words it as “not technical substantiated”26. Arla Food remains passive towards the problem and has no statements in relation to the vitamin D deficiency, but states that they are “willing to take responsibility and contribute with solutions”18. 34/53 The attitude towards food fortification in general is mixed. DFDF is overall positive and uses the following words: “long term solution”31, “development and innovation”31, “health promoting”31 and “contribute to health”15. The Consumer Council is more negative and uses the words “blurs the health effect of the product”10, “skeptical”10 and a “bad idea”7. The Cancer Society agree with the Consumer Council and uses the words “skeptical”26, “incoherent evidence”26, “no benefits” 26 and “not technical substantiated”26. MFAF is more neutral towards fortification and uses the words “perhaps the only solution”17, “need political endorsement”13 and “complex”9. DTU Food is positive and uses the words “makes a difference”29 and “recommendable”29. Arla words it as being “interesting”14. The general attitude towards mandatory fortification is also mixed and especially DFDF and Arla are against. DFDF uses the words “restrictive”5, “prevent trade”31, “business disadvantages”31 and “mass-­‐medication”31. Arla states that it is “against a command”18. Though the Cancer Society and the Consumer Council are negative towards food fortification overall, they are more positive towards a mandatory fortification practice. The Consumer Council uses words such as “reach all target groups”2 and “avoid an active choice”17, and the Cancer Society uses words such as a “treatment”28 and “secures a minimum intake”28. DTU Food words mandatory fortification as “positive effect”29, “appropriate”29, “targeted”29, “health related profit”29, “prevent deficiency”29, “makes a difference”29 and “avoid additional choices”29. MFAF uses the words a “good idea”13 and “compulsive fortification”13. Three of the stakeholders do not speak about voluntary fortification, namely DTU Food, MFAF and Arla. DFDF uses the words “individuals own choice”15, “provide options”31, “market benefits of products”31, “the best solution”31 and “active choice for the consumer”15 about voluntary fortification. The Consumer Council and the Cancer Society have a more negative attitude towards voluntary fortification. The Consumer Council uses the words “deceptive”1, “blurs the health effect”10, “food producers will add cost to the products”7, “cannot solve the problem”22, “unnecessary sales promotion”22, “no health benefits”22 and a “bad idea”7. The Cancer Society uses the words “no benefits”26, “deceptive”26, “unnecessary sales promotion”28, “negative consequences”28 and “increased value for food producers”28. The choice of words clearly illustrates which attitudes the stakeholder has and that the attitudes vary among the stakeholders and span from positive to negative. The attitudes of the stakeholders are presented in the table below. 35/53 Table 1: Stakeholders position towards food fortification. Stakeholder MFAF DTU Food The Consumer Council The Cancer Society DFDF Arla Foods Position towards food fortification Neutral Positive Position towards mandatory fortification Positive Positive Position towards voluntary fortification Negative Negative Negative Positive Negative Negative Positive Negative Positive Positive Negative Negative Positive Positive Table 2 below illustrates the stakeholders and their positions in the debate on vitamin D deficiency and food fortification. The way they are positioned also reflects how they talk about food fortification, mandatory fortification and voluntary fortification. The statements presented in the columns “How they talk about” are our interpretations and sum-­‐ups of the wording on how the stakeholders talk about fortification. 36/53 Table 2: Stakeholders position and how they talk about food fortification. *The Cancer Society is positioned in the same way as the Consumer Council, since they both take a consumer perspective. The table identifies how each stakeholder sees fortification in relation to the vitamin D problem. The stakeholders positioned as consumers see food fortification as a problem that will not solve the vitamin D problem, whereas the others see it as a solution – either to apply mandatory or voluntary fortification. The table illustrates contradictions on how to talk about the different types of fortification. There is a clash in talking about it as being a matter of solving the problem by the use of compulsion vs. maintaining ones own free will. Another clash is seen on fortification as being health promoting for the consumer vs. sales promoting for the industry. A third major clash is whether there is sufficient evidence for implementing a policy vs. unsubstantiated evidence. The clashes illustrate that the stakeholders use different objects to talk about food fortification and to address the problem, which demonstrates the complexity when deciding on a public health policy. In relation to the concept food fortification there are disagreements on the term. The Consumer council believes that the wording enrichment (“berigelse”), which it is called in 37/53 Danish, is way too positive and suggests using the term “addition” (Grundnotat til Folketingets Europaudvalg 2003). However in the ongoing debate food fortification/enrichment is the most used term and thereby interpreted as the strongest. The presentation of the words that the stakeholders use for food fortification and the vitamin D problem can also identify similarities in how they talk about it. A strong similarity is for example seen in how they talk about the vitamin D problem as being a public health problem. Discourses are formed on both similarities and differences, and often stakeholders are drawing on more than one discourse; both discourses they agree and disagree on, and a discourse only one stakeholder has constructed. On the basis of the analysis and interpretation of how the stakeholders talk about food fortification, the following discourses have been formulated; Figure 4: Discourses These four discourses have been identified being the strongest ones, since the majority of the stakeholders’ viewpoints are framed in the four discourses. The four discourses will be presented in detail in the following sections. 38/53 7.1 Consumer Rights Consumer rights are the first of the four discourses. For the purpose of this analysis consumer rights are referred to as the right to basic needs, safety, to be informed and the right to choose (Consumers International N.A). This quotation from Consumers International states the following about the consumer: “They are the largest economic group, affecting and affected by almost every public and private economic decision. Yet they are the only important group whose views are often not heard” (Consumers International N.A). In the consumer rights discourse the stakeholders express their views on the consumers’ rights seen from the stakeholders’ own perspective. This discourse is divided into two dominate viewpoints; one where the consumers have the right to choose themselves and another where the state has the right to choose over the consumers. DFDF advocates for the first viewpoint and states: “We believe that it ought to be up to the individual to choose how they want to cover themselves…. When it comes to vitamins or minerals, we will not sit in judgment on how people choose to meet their needs for vitamins and minerals”15. This statement illustrates that DFDF is against a mandatory fortification policy where all individuals are exposed to vitamin D and are not capable of deciding if they want vitamin D or not. Contrary to DFDF, DTU Food advocates for the second viewpoint. DTU Food states: “An essential requisite for fortification to have an effect, is that it covers all products in one or several food groups so that it doesn’t require a deliberate choice from the consumers to get fortified products”29. Thereby they recommend that it is best for the consumer if they do not have a choice themselves and that everyone gets exposed to vitamin D fortified products. Other stakeholders’ that advocate for the second viewpoint are MFAF, the Cancer Society and the Consumer Council. They all agree that a fortification policy needs to be mandatory so that everyone in the population is targeted17,28,17. An argument, which DFDF uses against mandatory fortification in this discourse is: “Many people don’t know that they are compulsory fortified with iodine because they have never been made aware that they have an insufficient intake. Is it then okay to mandatory fortify? We don’t think so. We believe that they need to be made aware of and reflect on it and act on the market. The obligation to provide the information we see as an ethical information too”31. DFDF sees 39/53 mandatory fortification as a way to neglect the consumers’ right to information. It is a way to solve the vitamin D problem without telling anyone about it. Here the consumer is stripped off to choose, thereby giving information low or no relevance according to DFDF (Peetz-­‐Schou, M). When focusing on the consumers’ right to basic needs, it is essential to focus on the consumers’ right to a recommended intake of vitamin D. An argument against voluntary fortification is that it will not cover all the consumers’ basic needs, but only the ones that take an active choice to buy the fortified products. The Consumer Council states: “With voluntary fortification it will only be the consumers who active choose and possibly pay more for a fortified product. The Consumer Council would like to question if these consumers actually are the ones who need it”22. Thereby the Consumer Council expresses that the ones buying the fortified products are the ones who already have their basic needs covered. This is a point of view that DTU Food agrees with and states in continuation here of: “With a targeted and comprehensive fortification the prevalence of severe vitamin D deficiency will be near zero and such a fortification is the only way to reach the entire population” 29. In this statement DTU Food refers to mandatory fortification as a tool raising the level at the bottom. Thereby, less people will suffer from severe vitamin D deficiency and more will get their basic need fulfilled since mandatory fortification will lift the vitamin D level for the majority of the population (DTU Fødevareinstitut, 2010). When focusing on the consumers right to safety it is understood as the risk of reaching the UL for vitamin D intake. This aspect is something that the Cancer Society is concerned with and states: “A treatment of a whole population where the majority does not gain any benefit of the treatment. There is a risk for negative effects of high intakes among people.” 28. This illustrates that targeting the entire population may have some disadvantages from the perspective of the Cancer Society. However, DTU Food clarifies with the following: “UL is set with a safety margin, so an intake close to the UL for a longer period of time will not be harmful to anyone.” 29. The discourse of consumer rights has identified opposing viewpoints among the stakeholders. The dominant viewpoint of the discourse has been identified to be the utilitarian approach, where the state has the right to choose over the individual. 40/53 7.2 Health Promotion Health promotion is the second of the four discourses. Health promotion is referred to as WHO’s definition: “The process of enabling people to increase control over, and to improve their health” (WHO, 2009). In this discourse the stakeholders express their views on fortification as health promoting. Also, in this discourse there are dominant viewpoints on fortification in health promotion. Some of the stakeholders see fortification more as a sales promotion, some see it as being deceptive and others see it as being health promoting. DFDF advocates fortification as being health promoting and states: “DFDF has for a long time said that health promoting food products as for example foods with added vitamins and minerals can contribute to the health of the Danes” 8. Arla Foods shares this point of view and states: “We would like to take our part of the responsibility and contribute to find solutions to the problem” 18. Thereby Arla Foods expresses that they by means of their products will help to diminish the vitamin D problem, and therefore contribute to the health of the Danes. MFAF agrees that fortification can be seen as health promoting and describes it as an addition that is a determinant of health more than an addition of vitamins (Haslund, E. 2013). Thereby, MFAF says that if you buy a fortified product you will not only get vitamins, but also gain health benefits. The Cancer Society and the Consumer Council strongly disagree on this viewpoint, and the Consumer Council believes that there are no extra health benefits of fortified products (Høringssvar J.nr.: 2009-­‐20-­‐24-­‐00175, 2011). They further state: “We see a risk that someone will be deceived to believe that a product is healthier when there is added extra vitamins” 1. Thus the Consumer Council does not see fortified products as being health promoting, but instead as something that misleads the consumer to believe that the product is healthier. A contrary argument to the deceptiveness of fortification is from DFDF that states: “There, I think we should be careful not to perceive people to be less intelligent than they really are…it is a shame that it is a question of whether someone it trying to cheat someone” 31, 27. DFDF believes that the consumers themselves are capable of evaluating whether a product is healthy or not, and does not see it as deceptive, but rather as an option for the consumer to get vitamins in a way that suits them best. Therefore, they are not trying to cheat anyone, but to give the consumers alternatives to choose how they want to cover their needs (Peetz-­‐Schou, M). 41/53 The third dominant viewpoint is the Consumer Council and the Cancer Society disagreeing on the statements relating to food fortification as being health promoting. Instead, they see fortification as a sales promotion giving the food producers the opportunity to raise the price of the products and get profit. The Cancer Society states: “Voluntary fortification is pure promotion and a possibility for the food producers to add more value to their products” 28. Here the Cancer Society expresses that the food producers are only interested in profit and not health. The Consumer Council strongly agrees that the producers only want to increase the value of their products, in the sense of profit. This statement does DFDF respond to in the following way: “Of course food producers promote the benefits of their products, and we know that there are a lot of evidence that voluntary fortification can be an excellent supplement to those who lack vitamin and minerals the most. So in virtue of that it is not only promotion, but products that contribute positively… Products that some people can choose if they would like to get more vitamins and minerals” 31. DFDF agrees that they want to promote their products, but explains that added value not necessarily only is related to more profit, but that adding value to a product can also be understood as adding value to health. The three dominant viewpoints have been presented and analysed, and in the debate all three viewpoints are equally presented and not one viewpoint is trumping another. This again illustrates that there are agreements and disagreements on how to talk about fortification in different discourses. 7.3 Competition in Economy Competition in economy is the third of the discourses and is primarily constructed by DFDF. From the perspective of DFDF this discourse is referring to the concepts of competition and entry barriers to a market that can affect the economy of the industry. An entry barrier is understood as anything that obstructs entry and reduces or limits the competition (OECD, 2007). DFDF believes that the Danish regulation is very obstructive and affects the competition and economy. DFDF state: “We believe that the Danish Fortification Model is way too restrictive. The assumptions that are the basis for whether you (RE: authorities) allow foods to be fortified in Denmark is precautionary principle multiplied by 20 – at least!” 31. Here DFDF indicates that the 42/53 authorities take all possible reservations, which hinders the industry to act on the national and international market. One assumption is that 25% of Danes’ energy intake comes from fortified products. The purpose of this assumption is to control the amount of fortified products in Denmark. This is something DFDF strongly opposes to and states: “We know for a fact that it is maybe only 1%”31. Thereby, DFDF expresses that they do not agree and that the Danish Model is stricter and not in agreement with the magnitude of fortified products on the shelves, because there are few fortified products on the Danish market. DFDF is convinced that the Danish Model is an obstacle to trade and export and states: “Why do we intentionally prevent ourselves from tagging into growing market globally. There we know they are more positive towards fortified products. We should not limit ourselves because we up here in our small country believes that fortification is a bad idea” 31. DFDF expresses that the Danish regulation has an impact on the food producers’ competitiveness outside Denmark, and that the regulation functions as a barrier to trade. One example where DFDF illustrates this is: “The Danish food producers need to make a double production if they would like to export… They will get a hard time, because they can’t produce under the same circumstances as their competitors abroad. In this way we are losing jobs in Denmark, and that provides challenges to Denmark” 31. This statement refers to a mandatory fortification practice. Since the fortified products have to be produced in Denmark, the food producers have higher production expenses, because they have to produce both for the Danish market and the market outside Denmark. This means that it is difficult for them to compete with other food producers that are not under the same regulation (Peetz-­‐ Schou, M). DFDF expresses a wish for a more growth-­‐oriented administration that does not restrict the trades and industries as the current does (Peetz-­‐ Schou, M). Despite the EU sentence against Denmark in 2003 that forced Denmark to change its regulation practice, DFDF still believes that the Danish model is contrary to the EU regulations and that the current model have maintained the politics as before the EU sentence (Høringssvar J-­‐nr.: 2012-­‐20-­‐2301-­‐ 00917, 2012). To this MFAF is of another persuasion and states: “The Danish model is a useful tool” 30. This discourse is only presented by DFDF and is a strong viewpoint for them to make use of when discussing food fortification. This discourse shows that the industry has another approach to food fortification compared to the other stakeholders who do not touch on this discourse. 43/53 7.4 Evidence in Nutrition Evidence in nutrition is the fourth discourse and refers to evidence in relation to food fortification and vitamin D. Evidence based nutrition is understood as research on cause and effect relationships and about how nutrients affect health (Shao, A. 2009). In this discourse there are two focuses; vitamin D and food fortification. Within both of the focuses there are opposing viewpoints on whether there is evidence or not for the vitamin D deficiency in the Danish population, and whether there is evidence on the effect of food fortification. The first focus is on the vitamin D deficiency. DTU Food concludes that the intake of vitamin D in the Danish population is lower than recommended, but that the data for the vitamin D status is not representative (DTU Fødevareinstitut, 2010). DFDF is confident that the intake is lower than recommended and states the following: “If this (i.e. the current intake) doesn’t indicate a deficiency then there is something wrong with the way we establish the scientific foundation (i.e. relating to how we assess nutrient sufficiency)” 31. This illustrates that DFDF believes that there is evidence for a deficiency based on the low average intake. The Cancer Society, on the other hand, does not believe that there is sufficient evidence for a deficiency and states: “First step must be to cover the magnitude of a deficiency problem. A deficiency is a situation where too little of a vitamin results in illness. How many that suffers from illness, as a consequence of their vitamin D status is unknown. Insufficiency and deficiency are not the same” 28. Therefore, they believe that the vitamin D intake possibly is insufficient and that there is a need for more evidence in order to conclude the vitamin D status. The Consumer Council stands idly and do not comment on the evidence. MFAF says that the Danes’ intake of vitamin D is too low (Heidemann, H. 2013), and furthermore that it is not possible for the Danes to get enough vitamin D through the diet (Haslund, E. 2013). Therefore MFAF sees a need for other alternatives and sources of vitamin D, as for example products fortified with vitamin D, which they recommend the Danes to consume (Heidemann, H. 2013). DTU Food has completed a research project to clarify the effect of food fortification. DTU Food concluded that families could maintain their vitamin D level throughout the winter if they consume fortified milk and bread (DTU Fødevareinstitut, 2010). DFDF supports that food fortification could remedy the vitamin D problem and states that there are studies showing the effect (Peetz – Schou, M.). The Consumer Council does not support this viewpoint and says 44/53 that the current evidence for the effect of food fortification is not sufficient (Høringssvar J.nr.: 2009-­‐20-­‐24-­‐00175, 2011). In both of the focuses in the discourse the dominant viewpoint is that the evidence on the vitamin D problem and the effect of food fortification is sufficient, though some stakeholders disagree with this viewpoint. This illustrates the complexity of deciding on a policy when stakeholders disagree on the essential question – whether there is a vitamin D problem or not. The discourse analysis has shown that there are several ways to talk about vitamin D and food fortification, and that the main opinions and viewpoints of the stakeholders are represented in the four discourses. Furthermore, the analysis shows the disagreements between the stakeholders and how the problem should be addressed according to them. 8.0 Discussion The discussion will be based on the three questions by Bacchi presented in the theoretical framework. Furthermore, we will discuss the current situation of the policy on vitamin D and food fortification, as well as the limitations and considerations of our methods. What is the problem represented to be? In the context of a policy, a problem is often dealt with along side an understanding that the problem needs to be fixed. Each stakeholder has different suggestions as to how the problem needs to be fixed, but behind these suggestions there are implicit problem representations. It needs to be understood that how a stakeholder feels about a policy problem determines what they suggest doing about it. Therefore we believe that what the stakeholders propose as a policy intervention reveals how the problem is being thought of. This is for example illustrated when DFDF proposes the policy that the vitamin D problem should be fixed by a voluntary fortification policy. They propose this solution, because such a policy will have a positive influence on the industry in relation to competition, trade, innovation and economy, and further that it will benefit the consumer as seen from their perspective. Therefore, from 45/53 DFDF’s perspective the problem is represented to be a matter of economic development and consumer rights. Thus, it is not only a question of whether DFDF wants a voluntary fortification or not, but also what the underlying factors and representations are. The discourses have been identified on the basis of how the problem is represented from the perspective of the different stakeholders. The discourse analysis has shown that there is more than one problem represented within the discourses and within the stakeholders’ viewpoints. All discourses are powerful in the debate, however one discourse is more dominant in representing the problem. This is the discourse on consumer rights. All the stakeholders talk about this discourse by discussing the rights of the consumer, and furthermore the discussion has high priority in the debate. This debate focuses on a public health policy targeting the Danish population, thereby the consumers, and discusses how a food fortification policy with vitamin D will affect the consumers. The discourse on consumer rights touch upon two ethical perspectives. These ethical perspectives emerge when deciding on a public health policy intervention and arise from the analysis based on the stakeholders’ viewpoints. It is the conflict between acting for the common good and acting for the rights of the individual. Further it is a conflict of whether it is the process towards decreasing the vitamin D deficiency in Denmark that is the most important focus or whether it is an adequate vitamin D intake that is in focus, no matter how it is reached. The process is in line with giving the consumers a choice and information, whereas an increased vitamin D intake, which is the goal, does not consider the process towards an increased intake. The debate on ethics is very value-­‐laden and varies among the different stakeholders who have competing views regarding how to tackle the policy problem. Some of the stakeholders view it as being unethical not to introduce food fortification, because it has proven to have an effect. Other stakeholders view it as unethical to introduce food fortification, because it is associated with risk since it will increase the vitamin D intake for everyone in the society who consumes the fortified product. Some of the stakeholders argue that it would be more effective to manage public health deficiencies by using more consumer information and less regulation, because excessive use of regulation and paternalistic interventions can result in overprotection of the citizens and 46/53 thereby create a so-­‐called “nanny” state. Therefore, the stakeholders that advocate this viewpoint argue that a “nanny” state removes the free choice of the individual. Contrarily, other stakeholders argue that the consumers’ ability to have freedom of choice would not combat the problem, and instead argue in favour the utilitarian approach. The utilitarian approach focuses on equality and social justice where everybody in the society is to be reached with the benefits of vitamin D, and not only the ones who actively choose to increase their vitamin D intake. The way ethics is constructed, interpreted and applied by the stakeholders is very political and is influenced by their dominant political agendas and how they relate to vitamin D and food fortification. We believe that when the government is deciding on a public health policy on vitamin D fortification it is important not only to consider the stakeholders’ proposal for a solution, but to look at how they represent the problem, because this will often illustrate and indicate other very important views. What is left unproblematic in this problem representation? Where are the silences? Can the problem be thought about differently? The government needs to consider several viewpoints and interests when deciding on a policy, which makes it difficult to find a solution to the problem. This is demonstrated in the discourse analysis where there is not one viewpoint that all the stakeholders agree upon; therefore, we assess that nothing is left unproblematic in the problem representation. An aspect we believe that has been left problematic in the debate is the silence on consumer acceptance of fortified products. We believe that consumer acceptance is an important factor for a food fortification policy to be successful, because it will ultimately depend on whether the consumers accept and buy the fortified product or not. This perspective has on the whole not been represented in the applied empirical material, but we think that it is very essential, because the Danish consumers are skeptic towards fortified products. This is clarified in a consumer survey conducted by COOP in 2013 where 58% answered that they do not think that vitamin D should be added to any foods (COOP, 2013). 47/53 Therefore this aspect is also important for the government to consider when deciding on a policy on vitamin D fortification, because it is a policy targeting the consumers. In relation to the consumer it is important to discuss if the consumers can be deceived. Some stakeholders believe that food fortification is manipulation, and something that changes the properties of the basic food. Therefore, fortification can lead to blurry lines between what is healthy and what is unhealthy, and this is also a concern to consider, since it can lead to further complications and confusion on healthy eating messages to the consumers. Therefore, we believe that it is important to assess if the consumer can be deceived, or if they are able to identify what the products actual contains. Food fortification has been constructed as the only solution to the vitamin D problem, and on the basis of scientific evidence and experiences from other countries we believe that food fortification can be effective. However, we believe that before deciding on a vitamin D fortification policy, it is relevant to consider if the solution could be thought about differently. All stakeholders are mainly focusing on food fortification and do not propose any other concrete solutions. One alternative solution could be promotion of sunlight exposure, since this policy solution is directly linked to the cause of the policy problem; lack of sunlight exposure. Though this solution is associated with public health benefits, it is also associated with health risks and disadvantages, including increased of risk of skin cancer and lack of sunlight in the winter months. Another solution could be vitamin D supplementation, which is quite effective because it gives the precise dose of vitamin D needed, though there are individual differences regarding the need for vitamin D. However, for this solution to be effective a person must be aware of the need to take a supplement. This solution maintains the free choice of the consumer. A third solution is nutrition education where the awareness and skills relating to the nutritional effects and benefits of vitamin D are raised. Though this solution cannot provide the adequate intake of vitamin D, it should be seen as a complementary option to the policy that the government decides upon. Therefore, we believe that it is very important that a possible vitamin D fortification policy also includes nutrition education to inform and create awareness of vitamin D and fortified vitamin D products. 48/53 What effects are produced? What is likely to change and what is likely to stay the same? Who is likely to benefit? Who is likely to be harmed? When the government needs to decide on a policy and relate to different opinions and view points from the stakeholders they need to assess what effects that are produced on the basis of the opinions and view points. This is necessary because different problem representations can have detrimental effect for different stakeholders. This consideration is very important because it can illustrate a need for the policy to be rethought, which can lead to a new way of perceiving the policy. The effects can be clarified by considering what is likely to change and what is likely to stay the same, and who will benefit and who will be harmed. In relation to the strongest problem representation; consumer rights, a mandatory fortification policy is likely to change the average vitamin D intake to a higher level among the entire population. However, what is likely to stay the same is the inequality in nutritional knowledge and awareness of what healthy eating is. This means that some people will still have more knowledge compared to others and the ones with more knowledge will still have better conditions for overall health. By implementing a mandatory fortification policy, the aim is that every consumer will benefit, however there are certain stakeholders that will be harmed. Especially the industry will be harmed, because it complicates production and trade and hinder innovation, which has an influence on the overall economy. Further, a consideration is that it will affect the dietary supplement industry, which produces vitamin D supplements, because it is assumed that their sale will decrease since the consumers are exposed to mandatory fortified vitamin D products and, therefore, will not purchase vitamin D supplement in the same amount as before. By implementing a voluntary fortification policy there is a risk that the average intake of vitamin D will not change much, because the consumers need to choose the fortified products themselves. However, what will change is the supply of fortified products, which will increase because the industry is allowed to fortify products with vitamin D. There is a possibility that the increased supply will heighten the awareness of the product and the nutritional benefits of vitamin D, since the food producers are allowed to use nutrition and health claims on the products. The food producers can for example use the health claim “Added vitamin D strengthen bones and teeth” to milk fortified with vitamin D (COOP, 2013). In a mandatory fortification policy the food producers are not allowed to use nutrition and health claims on 49/53 the products, because it is not legal to enhance nutritional benefits of a product that is the same as other products within the same food category (EU Regulation nr.1169/2011). Therefore, there is a possibility that a voluntary fortification policy can benefit and contribute to increased nutritional knowledge for the consumer. Contrary to the mandatory fortification policy where the industry is harmed, a voluntary fortification policy will benefit the industry in all aspects of the economy. Therefore, the government needs to consider the advantages and disadvantages of the effects of the problem representation, and they need to consider the long-­‐term impact of the policy for the different stakeholders when deciding on a policy. 8.1 The Current Situation The current situation is that the former Danish Minister for Food, Karen Hækkerup, is positive towards a mandatory fortification policy with vitamin D. This position is illustrated in the media and in a speech she delivered on the 26th of November 2013 in The House of the Confederation of Danish Industry where she indicated that there are certain groups in the society that do not read or have an interest in vitamin D. She thinks that it is important to have a focus on the ones that cannot help themselves, and the ones that do not prioritise to take a vitamin pill. What we found interesting is that the Minister normally has a very high focus on growth and work places, but when it comes to public health problems the Minister has a higher focus on health, and therefore opposes the proposal from the industry and supports a mandatory fortification policy. See appendix 9 for the transcription of the Minister’s statements on vitamin D from the speech. There is not yet a final decision on the vitamin D problem in Denmark, but as of now it takes the direction of a mandatory fortification policy. However, the new Minister for Food, Dan Jørgensen’s, position towards the vitamin D fortification is unknown and therefore the current situation might be different in the near future. 50/53 8.2 Limitations and Considerations There are certain limitations to our methods and how the collection of empirical data has been carried out. A limitation from the qualitative method is that we were only able to conduct one face-­‐to-­‐face interview, and therefore we are aware of the fact that we might lack some of the benefits of interviewing, when not all of the stakeholders will be interviewed. We will not gain the same insight through the e-­‐mail correspondences, since we cannot ask follow-­‐up and elaborating questions in the same way as in an interview, or even observe the stakeholders’ reactions. Therefore, when only receiving written feedback to an interview guide, we will lack critical awareness to what the stakeholders express in writing (Nygaard, C. 2011). Another limitation of the e-­‐mail correspondences is that we were not able to ask all of the questions in the interview guide, as stakeholders requested only a few questions. It forced us to assess which of the questions that were the most essential, and here it is important to consider if they were the right questions to ask. In relation to asking questions in both the interviews and the e-­‐mail correspondences it is relevant to consider if the questions were articulated so that the stakeholders were forced to respond and answer the questions in a specific way, which might not illustrate their true reality. A limitation is that we have not received feedback from all of the stakeholders, and this means that the Consumer Council statements are only from articles, hearing statements and the radio debate, and Arla Foods statements are only from articles. This leads to a consideration if they express themselves differently depending on whom they talk to. This consideration is based on our own experience and the fact that we received more useful material, more details and elaborations on the problem when both interviewing and using other materials. Therefore, we are questioning if we would have had other viewpoints, formulations and interests from the Consumer Council and Arla Foods if we had had the chance to do an interview and therefore, had had different source to analyse, which could have benefitted our discourse analysis. In relation to the empirical material, which exclusively has been in Danish, it is important to consider how we have translated the material from Danish into English. This consideration is important because the meaning in Danish is not the exact same when translating directly into 51/53 English. Therefore, we have tried to capture the overall meaning in the statements and translated them to make sure that the statements of the stakeholder are understood the same way in English, as they were expressed in Danish. In relation to the choice of stakeholders we are aware of the fact that other stakeholders could have been relevant to include, since relevant stakeholders include the ones who are likely to be affected by the policy and those who might take action or could be mobilized to do so. However, due to the time available, the length of the thesis and contact to stakeholders, the six stakeholders have been chosen, and we believe that they are the ones who represent the opinions of the sectors most distinctly. 9.0 Conclusion Lack of vitamin D is a problem for the majority of the Danish population and is an essential component for optimal health. This thesis investigated how food fortification can be used as a tool in the prevention of vitamin D deficiency in the Danish population, since it is very difficult to reach the recommended intake solely through the diet. Studies showed that food fortification can be effective by increasing the intake of vitamin D to an adequate level and furthermore maintain the level during the winter season. As a policy solution for the vitamin D problem, the adoption of food fortification is controversial as it has a powerful impact on food composition, food systems, food economies and public health. Unavoidably, many stakeholders have a stake in how the food fortification policy is going to be developed due to opposing opinions and interests. We found that the stakeholders have different ways to talk about food fortification and vitamin D as a matter of consumer rights, health promotion, competition in economy and evidence in nutrition. These discourses captured the stakeholders’ opinions and viewpoints, both agreements and disagreements within the same discourse. All of these discourses are important when the government needs to consider a policy on vitamin D fortification. Our findings have identified the discourse on consumer rights to be the most dominant. It is an ethical question the government needs to consider when deciding if acting for the common good and reaching all Danes, or maintaining the free will of the individual and giving the consumer a choice, is the most important. 52/53 Our findings showed that food fortification policy is intervened and interlinked with debates about ethics, economy, evidence, politics, health, consumer, deceptiveness, promotion, trade and competition, thus making the entire policy process controversial and complicated. Based on our findings it is clarified that food fortification is a complex public health policy topic since there are several disparate opinions and points of view towards addressing food fortification and the vitamin D problem, and therefore there are no unambiguous solutions, which all stakeholders can agree upon. The analysis and discussion conclude that there are pros and cons for both a mandatory and a voluntary fortification policy, and therefore the government need to balance what it finds the most important and beneficial for the individual, for the stakeholders and for society when deciding on the policy. Our findings are important because they show how a policy is influenced by different stakeholders, and that there are opposing viewpoints depending on how they are positioned and which sector they represent. The thesis can be used to strengthening the decision-­‐making of the government and provide the reader with a new way of thinking and addressing how to protect and promote public health by implementing a vitamin D fortification policy. 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af-­‐fødevarer.aspx, [Accessed 10 October 2013] 2. Fødevarestyrelsen (2013) Om Styrelsen [online] Available at: http://www.foedevarestyrelsen.dk/OmFoedevarestyrelsen/Om_styrelsen/Sider/forside.aspx [Accessed 19th of November 2013]. Grundnotat til Folketingets Europaudvalg. J.nr.: 2003-­‐4113-­‐0049. D.23 december 2003: Forslag til Europaparlamentets og Rådets forordning om tilsætning af vitaminer og mineraler samt visse andre stoffer til fødevarer Grundnotat til folketingets Europaudvalg. Sagsnr.: 2011-­‐20-­‐221-­‐010696 D. 29 november 2011: Forslag til kommissionens forordning (EU) om implementering af regler om regler for anvendelse af artikel 8 I forordning (EF) nr. 1925/2006 om tilsætning at vitaminer og mineraler samt visse andre stoffer til fødevarer Grundnotat til Folketingets Europaudvalg. J.nr.: 2003-­‐4113-­‐0049. D.23 december 2003: Forslag til Europaparlamentets og Rådets forordning om tilsætning af vitaminer og mineraler samt visse andre stoffer til fødevarer Hansen, K.B. (2013) Skepsis over for berigede fødevarer, FoodSupply.dk [online] The 26th of 56/53 June. Available at: Infomedia[Accessed 7 of November 2013]. Haslund, Elisabeth (2013) Danskerne skal sikres mere D vitamin. Berlingske. 1. Sektion, (online) 28th of July 2013, available at: http://www.b.dk/nationalt/danskerne-­‐skal-­‐sikres-­‐
mere-­‐d-­‐vitamin-­‐for-­‐at-­‐undgaa-­‐sygdomme [Accessed 12 october 2013] Heidemann, H. (2013) Forbrugerne vil ikke have berigede fødevarer, Diabetes [online] The 23rd of February. Available at: Infomedia [Accessed 7 of November 2013]. Holick, M. (2010). The Vitamin D Solution; A three step strategy to cure our most common health problem, Carlton North, Australia, Scribe Publications Høringssvar J.nr.: 2009-­‐20-­‐24-­‐00175 D. 30 maj 2011: Høring om general tilladelse til Frivillig berigelse af mælk og margarine med D-­‐vitamin Høringssvar J-­‐nr.: 2012-­‐20-­‐2301-­‐ 00917 November 2012: Udkast til ny bekendtgørelse (og vejledning) om tilsætning af næringsstoffer til fødevarer Høringssvar J-­‐nr.:2012-­‐27-­‐221-­‐01289 D.25.juni 2012: Berigelsesforordningens artikel 16. Data til Kommissionens evaluering af berigelsesforordningen Høringssvar J-­‐nr.: 2012-­‐20-­‐221-­‐01241 D.17 april 2012: Udkast til gennemførelsesbestemmelser for anvendelsen af artikel 16 i berigelsesforordningen Høringssvar J-­‐nr.:2011-­‐20-­‐269-­‐00077 D. 26 januar 2012: Høringssvar om opdatering af bekendtgørelsen om tilsætning af visse andre stoffer end vitaminer og mineraler til fødevarer Lamberg-­‐Allardt, C. Brustad, M. Meyer, H. Steingrimsdottir, L. (2013) Vitamin D – a systematic literature review for the 5th edition of the Nordic Nutrition Recommendations, Food and Nutrition research (e-­‐journal), Available thorugh: PubMed, [Accessed 12 october 2013]. Lawrence, M (2013) Food Fortification – The evidence, ethics, and politics of adding nutrients to food, Oxford University Press Madsen, K.H. Rasmussen, L.B. Andersen, R. Mølgaard, C. Jakobsen, J. Bjerrum, P.J. Andersen, E.W. Mejborn, H. Tetens, I. (2013) Randomized controlled trial of the effects of vitamin D-­‐
fortified milk and bread on serum 25-­‐hydroxyvitamin D concentrations in families in Denmark 57/53 during winter: the VitmaD study. The American Journal of Clinical Nutrition (e-­‐journal), accessed through PubMed [Accessed 12 October 2013]. Molander, E (2012): Sundhed gennem fødevareberigelse: Myndighedernes overvejelser, Fødevarestyrelsen (pdf) available at: http://www.regionh.dk/NR/rdonlyres/DA0F3636-­‐
9565-­‐48D2-­‐B570-­‐34B4759D380A/0/ElseMolander.pdf , , [Accessed 10 October 2013] NNR 2012 (2013) Part 1. Summary, principles and use, (pdf) 5th edition, Norden, available at: http://www.norden.org/en/publications/publikationer/nord-­‐2013-­‐009, [Accessed 12 october 2013] Nygaard, C (2011) Samfundsvidenskabelige analysemetoder, 1. Udgave, 3. oplag, Forlaget samfundslitteratur OECD (2007) Competition and barriers to entry – policy breif [pdf] Organisation for economy co-­‐oporation and development, Available at: http://www.oecd.org/competition/mergers/37921908.pdf [Accessed 14th of November 2013]. P1 (2013) Ordet er dit: Skal vi tilsætte vitaminer i maden?, DR P1 [online] The 15th of June. Available at: http://www.dr.dk/P1/Ordeterdit/Udsendelser/2013/07/04151431.htm [Accessed 7th of November 2013]. Peetz-­‐Schou, M (2012): Afvisning af fødevarer med tilsatte nærringstoffer er ikke I overenstemmelse med EU-­‐dommen mod Danmark, Danish Food and Drink Federation. Peetz-­‐ Schou, M. (2013) Berigelse med D vitamin virker, ,DI Fødevarer [online] The 1st of October. Available at: Infomedia [Accessed 7 of November 2013]. Rajendram, R. Rajendram, R. Patel, V. Preedy, V. (2013) Handbook of Food Fortification and Health: From Concepts to Public Health Applications vol.2, Nutrition and Health, Springer Sceince + Business Media New York RetailNews.dk (2013) Flere fødevarer med D vitamin, RetailNews.dk [online] The 23rd of September. Available at: Infomedia [Accessed 7 of November 2013]. 1. Ritzau (2012) Forbrugerrådet frygter vildledning. Nordjyske Stiftstidende [online] the 11th of November. Available at: Infomedia [Accessed 7 of November 2013]. 58/53 2. Ritzau (2012) Nu må fødevarer godt anprises. Sjællandske [online] The 12th of November. Available at: Infomedia [Accessed 7 of November 2013]. Ritzau (2013) Novozymes pønser på sund mad. Landbrugs Avisen [online] the 15th of May. Available at: Infomedia [Accessed 7 of November 2013]. Rothenborg, M (2013) Vi skal have langt mere D vitamin, Politiken [online] The 13th of September. Available at: Infomedia [Accessed 7 of November 2013]. Shao, A. (2009) Evidence-­‐ Based Nutrition [pdf] The World of Food Ingredients Available at: http://www.crnusa.org/pdfs/EBN_TWOFI_10-­‐09.pdf [Accessed 15th of November 2013]. Søgaard, J. (2013) Kunstigt berigede fødevarer kan løse kostproblemer, Kristeligt Dagblad [online] The 16th of August. Available at: Infomedia [Accessed 7 of November 2013]. Vallgårda, S & Koch, L (2011) Forskningsmetoder I Folksundhedsvidenskab, Chapter 7 and 5, Vol. 4, Munksgaard Danmark Virksomhedsforum(2013) Dansk berigelsespraksis (online) available at: http://enklereregler.dk/forslag/534159/19, [Accessed 10 October 2013] Walt, G (1994) Health Policy: an introduction to process and power, Johannesburg: Whitwatersrand University Press. WHO, 2009. Milestones in health promotion – statements from global conferences [pdf] World Health Organization. Available at: http://www.who.int/healthpromotion/Milestones_Health_Promotion_05022010.pdf [Accessed 13th of November 2013]. 59/53 Appendix Appendix 1 – Food Categories and Content of Nutrients for Mandatory and Voluntary Fortification 60/53 Appendix 2 – Different Fortification Practices in 9 EU Countries (Flynn, A. et al, 2009). 61/53 Appendix 3 – Interview Guide How do you think that the authorities should relate to the vitamin D deficiency in Denmark? Could it be a solution to fortify foods as yeast and milk with vitamin D? -­‐ What products do you think should be fortified? -­‐ Should fortification be targeted towards a specific target group? -­‐ Could it be a slippery slope so that more products can be fortified? E.g. the products, which can be considered as unhealthy. What is X’s position towards voluntary fortification? What are the advantages of voluntary fortification? What are the disadvantages of voluntary fortification? What does X mean when the cancer society states that voluntary fortification is purely promotion and an opportunity for the food producers to add more value to their products? Does X mean that there is a risk for the consumer to be deceived by the fortified products? What is X’s position towards mandatory fortification? What are the advantages of mandatory fortification? What are the disadvantages of mandatory fortification? Do you think that fortification can be a sustainable solution to the vitamin D deficiency? Which ethical perspectives do you think are important to consider when focusing on food fortification? Do you think that all products should be fortified? Do you think that there are any risks related to fortified products? Why do you think that it is such a discussed subject and why is it so difficult to find a solution? Do you think that there is evidence enough whether there is a vitamin D deficiency in Denmark? Do you think that there is evidence enough whether food fortification can remedy the vitamin D deficiency? What do you think about the Danish fortification model? -­‐ Do you see a need for harmonized regulation that secures free movement of foods in EU? Who do you think has the responsibility for the health of the Danes? 62/53 The government? The individual? Why do you participate in the debate on fortification and what do you think the debate should focus on? What is the most ideal solution to the vitamin D deficiency from your point of view? 63/53 Appendix 4 – Statements from the radio debate P1 Mette Peetz-­‐Schou (DFDF): Jamen altså det er jo på det område hvor vi har set nogen produkter der er kommet her på det sidste, men der er også mange andre produkter der har tilsatte vitaminer og mineraler og det er jo sådan at vi i fødevarer Industrien synes det faktisk er en rigtig god ting at man har mulighed for at tilsætte vitaminer og mineraler til fødevarer. Det er fordi at det giver forbrugeren en ekstra valgmulighed i forhold til at få opfyldt sine behov og det hænger selvfølgelig sammen med at vi lever ikke som vi gjorde før i tiden. Vi ønsker valgmuligheder og vi ønsker at tilfredsstille vores egne individuelle behov på vores engen måde, og der bliver de berigede fødevarer en rigtig god mulighed. Hvor stor er interessen fra producenternes side til at fremstille dem? Jamen selvfølgelig har producenter en interesse i at producere fødevarer med tilsatte vitaminer og mineraler i det omfang at der er nogen der efterspørger dem og syntes at de efterlever deres individuelle behov, men hvis vi kigger på de her vand kan det godt være at de fremstår som en stor gruppe, men hvis man tænker på læskedrikke som en kategori så er det jo sådan at det er under 1 % af markedet, så det er ikke så stort som mange gerne vil gøre det til. Og det sammen på andre områder så er det lidt beriget minariner, men ellers er der ikke mange berigde produkter så det er lidt ærgerligt at der bliver så fokuseret på det fordi at forskning viser jo at berigede produkter kan hjælpe dem som ikke få nok vitaminer og mineraler, til at få det. Og det er det vi syntes at man skal koncentrere diskussionen omkring, det er positivt at få en ekstra mulighed for at opfylde sine behov også må vi være gode til at fortælle om hvordan de kan få det. Det du siger er altså at der er videnskabelig belæg for at det her hjælper til at øge vores sundhed? Ja altså man ved fra de undersøgelser der lavet fra de lande der har relativt mange berigede produkter f.eks. i England og Irland at der kan man jo gå ind og se at det hjælper til at løfte niveauet så at dem der ellers ikke få nok vitaminer og mineraler, at de får det. Man kan også se det i Danmark i forhold jod med berigede produkter, så får man pludselig det man skal bruge , men det vigtige er jo også at sige vi vil jo ikke gøre os til dommere over hvordan folk vælge at opfylde deres behov. Vi syntes at der skal være så mange muligheder som muligt, man kan gøre det ved at spise almindeligt, man kan gøre det ved at supplere op der hvor man synes man har behov for det og man kan gøre det ved at tage en vitamin pille hvis man syntes det. Det må den enkelte selv bestemme ud fra deres livsstil hvordan de ønsker at leve deres liv, det syntes jeg ikke vi skal være dommere overfor. 64/53 Folk er bekymret for om det kan blive en glidebane, for man har jo også mulighed for at berige usunde varer – hvad tænker du om det? Jamen altså man kan jo være bekymret for mange ting, men det jeg tænker det er at der er jo ingen der siger at man skal have sine ting derfra, det der er vigtigt det er, at det er et valg. At man selv kan vælge hvor man får det fra og det syntes jeg ikke vi skal være dommere overfor.. Vi vælger jo ikke når vi står nede i 7/11 om vi vil have en flaske vitaminvand eller om vi vil spise et æble , det er jo ikke sådan at verden fungere. Vi ved jo godt at det er en sodavand at vi er i gang med at købe, så det syntes vi at folk selv skal vælge.. (Debatten skal være fokuseret på at man kan få et ekstra behov dækket. Vi skal ikke være dommere overfor hvordan folk vil dække deres behov. Der skal være mulighed ud fra den enkeltes livstil.) Hvad siger du til sådan nogle drikke som er dem vi sidder og diskutere? Camilla Udsen (Consumer Council): Jamen de her vitamindrikke syntes jeg jo er et eksempel på at det jo kan være rigtig forvirrende for forbrugerene når man går ud og begynder at berige produkter med en masse forskellige vitaminer, fordi de ser jo rigtig rigtig sunde ud men langt de fleste vitaminer som er tilsat til at drikke, det er noget som vi får rigeligt af i kosten også er der ikke nogen ekstra sundhedsgevinst ved at få et ekstra tilskud. Der er så lige den her undtagelse omkring D vitamin, hvor man jo har dokumenteret at der er et problem i befolkningen med at få vores D vitamin og det må man jo forsøge at løse helt konkret omkring D vitamin, men det er meget vigtigt at man adskiller den diskussion at der er et konkret problem i befolkningen med et bestemt vitamin også med den generelle diskussion om vi bare skal vitamin berige alle vores fødevarer. Syntes du at der er hele grundlæggende at hvis man kan dokumentere at store dele af befolkningen der mangler et bestemt vitamin f.eks. så er det helt i orden at berige fødevarer med det? Hvis det er solid dokumentation for at mangler vitaminer og mineraler, så støtter vi at man går ud og laver en obligatorisk berigelse som man jo i årevis har gjort, som du også har nævnt, som er jod i salt. Og det kunne være en mulighed for D vitamin problematikken. Det der er problemet når man bare giver det frit ud til at det ligesom kan være mange forskellige fødevarer som kan beriges frivilligt, det er så lægger man det ud til forbrugerene og vælge det og så kan måske spekulere lidt over dem som ville finde på at betale mere for en D vitamin 65/53 beriget mælk eller et eller andet, når de måske i virkeligheden ligeså godt kunne taget det som en kosttilskud.. Og når man så ligesom får alle de andre vitaminer med i pakke løsningen så skaber det mere forvirring end gennemskuelighed. Men hvis nu vi taler mit eget frie valg og hvis jeg f.eks manglede D vitamin, så kunne jeg jo købe sådan en vitamin drik – er det ikke mit eget frie valg? Det er helt sikkert dit eget frie valg, det du bare skal vide det er at du betaler ekstra for sådan et produkt og det bliver markedsført meget kraftigt, så spørgsmålet er om det er pengene værd. Det er jo det, det syntes jeg er det første man skal overveje.. Hvis du er en bevidst forbruger der gerne vil træffe dit eget valg og du gerne vil have mere D vitamin, så er det jo også den mulighed at du tager det som et kosttilskud og det er jo meget nemt. Det som vi også mener er en problematik når man ser flere at den slags produkter på hylderne det er jo at der fokuseres meget på at de er sunde og de skriver ting omkring immunforsvaret, energi osv. Og i virkeligheden så fjerner de fokus fra det der i virkeligheden er vores sundhedsproblem i Danmark, vores sundhedsproblem er at vi ikke spiser nok frugt og grønt, vi spiser ikke nok fisk, vi spiser ikke nok fuldkorn. Vores generelle sundhedsproblem er ikke at vi ikke får nok vitaminer sådan over den brede kam. Hvis man så erkender at vi ikke spiser sundt nok i Danmark, er det så ikke fint at få nogle vitaminer og mineraler på den her måde, selvom det måske er den lette og måske også den dyreste løsning? Jamen man kan sige altså for de forbrugere der ligesom aktivt vælger det, der er det forbrugere der i forvejen er bevidste omkring deres sundhed og det er formenelig også de forbrugere der i forvejen spiser sundt og evt. Godt kan finde ud af at supplere med kosttilskud. Det der selvfølgelig vil være den værste situation udover at man måske spiller penge på noget der overhovedet ikke har nogen effekt, vil den værste situation være den hvor man snupper en vitamin vand og tænker det var dejligt, nu har jeg ordnet min sundhed for i dag nu kan jeg roligt.. Det er det psykologiske i det at man lige pludselig flytter folks opmærksomhed fra hvad det egentlig drejer sig om at spise nogle ordentlige basisvarer til at det er det her quick fix at tage den her. Det syntes vi er et problem. Er der ikke en pointe i, at det i forvejen er de bevidste forbrugere der vælger de her produkter? Mette Peetz-­‐Schou (DFDF): Jamen altså det ved vi jo ikke helt bestemt hvem det er, der vælger det. Om det er dem eller hvad, men jeg vil sige at vi jo alle sammen har jo lov til at lave et bevidst valg og man kan sige at det er jo op til den enkelte at vurdere om de syntes at de vil sikre sig på den måde. Så derfor kan man sige at jeg syntes måske lidt at når forbrugerrådet går ind og siger at i værste fald så spilder folk deres penge, må vi respektere de valg at folk træffer for at hvordan de vurdere 66/53 hvad der er rigtig for dem selv og hvis folk vælger at de syntes at de vil gerne vælge at købe en mineral vand hvor der er tilsat nogle vitaminer og mineraler i stedet for at tage en vitaminpille, jamen så skal de jo have lov til det. Det syntes jeg ikke vi skal gøre os til dommere overfor. Mette Peetz-­‐Schou (DFDF): Folk skal have mulighed for at få vitaminer på den måde det er bedst for dem. Synd det bliver et spørgsmål om, om der er nogen som prøver at snyde nogen. Folk skal blive opmærksomme på det. Forskellige muligheder for at løse problemerne. Camilla Udsen (Consumer Council): Berigelse er mere en nødløsning. Ærgerligt at der er sådan et pres til at markedsføre produkter som kan give et quick fix. 67/53 Appendix 5 – Calculation of the Energy Intake 68/53 Appendix 6 – E-­‐mail Correspondences Cancer Society 8/10/13 Hej Agnete & Sofie. Se svar nedenfor. Held og lykke med opgaven. MVH Anja I anbefaler at danskerne skruer ned for solen, men solen er en af de vigtigste kilde til D vitamin, har I derfor overvejet om det kan have betydning for vitamin D manglen i Danmark? Der er ingen modsætning mellem at omgås solen med omtanke og dannelse af D-­‐vitamin ud fra solen. Det er velbekræftet at kroppens biologiske feed back mekanismer stopper hudens produktion af D-­‐vitamin længe før huden skades af solens stråler -­‐ dvs. før en forbrænding begynder. Det er naturligvis en balance at få formidlet anbefalinger omkring soladfærd så nuanceret at ingen helt undgår solen, men dette har vi stort fokus på. De negative følger af usund soladfærd er så alvorlige at det er strengt nødvendigt at tage dem alvorligt. Vi har verdens højeste forekomst af modermærkekræft! Evidens viser, at der kan være en sammenhæng mellem vitamin D mangel og visse former for kræft, hvordan forholder I jer til det? Der er studier der peger på, at personer med lave D-­‐vitamin niveauer har en højere forekomst af tarmkræft -­‐ i forhold til de øvrige kræftformer er litteraturen ikke entydig. Der er også studier der peger på, at personer med lave D-­‐vitamin niveauer oftere er rygere, overvægtige, fysisk inaktive og har uhensigtsmæssige kostvaner. Interventionsstudier med D-­‐vitamin givet som kosttilskud har ikke vist en beskyttende effekt i forhold til kræftudvikling. Der er ikke påvist en kausal sammenhæng mellem D-­‐vitamin (mangel) og kræft -­‐ dermed skal man være meget påpasselige med at tilskrive vitaminet positive virkninger før dette er endeligt bevist. Kræftrisiko er tidligere fundet korreleret til lave blodniveauer af mikronæringsstoffer -­‐ hvor det efterfølgende har vist sig at der ikke har været tale om en kausal sammenhæng. Her er det særdeles væsentligt at holde for øje, at nogle studier har fundet øget kræftforekomst relateret til både lave OG høje D-­‐vitaminniveauer. Hvordan mener I at man skal forholde sig til vitamin D manglen i Danmark? 69/53 Første trin må være at afdække i hvilket omfang vi har et mangelproblem. En mangeltilstand er en situation hvor for lidt af et vitamin medfører sygdom. Hvor mange der lider af sygdom som følge af deres D-­‐vitamin status er uvist. Insufficiens og mangel er ikke det samme. Hvad syntes I om berigelse af fødevarer som en løsning på vitamin D manglen i Danmark? Berigelse kan være en vej til at sikre et minimumsindtag blandt enkelte, udsatte grupper. Det skal blot gøres afbalanceret, så man sikrer at man når de relevante grupper, uden at andre dele af befolkningen udsættes for mængder der kan være uhensigtsmæssige. Et berigelsesprogram kræver et stort forarbejde i forhold til at sikre at man når de relevante grupper, ligesom effekten af en berigelse bør monitoreres tæt. Kunne det være en løsning at berige fødevarer med vitamin D? Se ovenfor -­‐ Hvilke produkter mener I at der skal beriges? Det må afhænge af omhyggelige afvejninger jvf ovenfor -­‐ Skal berigelse være rettet mod en specifik målgruppe? Hvis det er muligt at identificere og ramme den del af befolkningen der ER i mangel er det naturligvis ideelt. I praksis sikkert umuligt. Hvad er jeres holdning til obligatorisk kontra frivillig berigelse? Hvis der skal beriges skal det være obligatorisk. Frivillig berigelse er ren markedsføring og mulighed for at producenter kan tilføje "merværdi" til deres produkter. En sådan berigelse vil, med stor sandsynlighed, ikke ramme den primære målgruppe. Hvad mener I er fordelene og ulemperne er ved at berige fødevarer? Fordele: Mulighed for at ramme den del af befolkningen der ikke kan nås via anbefalinger. Ulemper: Behandling af en hel befolkning hvor majoriteten ikke har nogen gavn af behandlingen. Risiko for negative effekter af høje indtag blandt nogle. Hvilke etiske overvejelser mener I der er ved berigelse af fødevarer? Se ovenfor Syntes I at alle produkter skal kunne beriges? Hvorfor, hvorfor ikke? Udvælgelse af produkter må bero på en vurdering af effekt. Ser I nogle folkesundhedsfordele ved berigelse? Hvilke? / Hvorfor ikke? Mulighed for at nå personer i mangel. Sandsynligvis en lille, men sårbar, del af befolkningen. Mener I at der er nogle risicis ved berigede fødevarer? 70/53 Hvorfor, hvorfor ikke? Ulemper: Behandling af en hel befolkning hvor majoriteten ikke har nogen gavn af behandlingen. Risiko for negative effekter af høje indtag blandt nogle. Hvorfor tror I at det er sådan et omdiskuteret emne og hvorfor er det så svært at finde en fælles løsning? Vi ved for lidt om: 1) status i befolkningen, 2) mulige negative effekter af suboptimale indtag, 3) mulige negative effekter af for høje indtag. D-­‐vitamin er mere kompliceret end andre vitaminer, fordi kosten ikke er den eneste kilde. Det er meningsløst at tale om D-­‐vitamin indtag løsrevet fra overvejelser relateret til D-­‐vitamin status. Man behøver slet ikke indtage D-­‐vitamin via kosten -­‐ derfor er det vanskeligere at identificere hvem der får "for lidt". Der har været en "hype" omkring D-­‐vitamin de seneste år og derfor stor fokus. For år tilbage diskuterede vi carotenoider eller C-­‐vitamin eller folat. Om et par år diskuterer vi sikkert noget nyt :-­‐). Hvilke parter mener I har ansvar overfor danskernes sundhed? Der er mange parter -­‐ primært danskerne selv. Men uden viden er det svært at påtage sig et ansvar. Derfor er det nødvendigt med en balanceret debat. Hvorfor deltager I, i debatten om berigelse? Vi har forholdt os til D-­‐vitamin i relation til kræft. Desuden er vi i gang med at lave en undersøgelse for netop at afdække danskernes D-­‐vitamin status, afdække prædiktorer for mangel etc (se evt statusd.dk). Vi mener at alle sundhedsrelaterede beslutninger bør være stærkt vidensbaserede -­‐ og påtager os et medansvar for at skaffe den nødvendige viden når den ikke findes. Hvad er den mest ideelle løsning I jeres optik? Personligt mener jeg at det er for tidligt at iværksætte berigelse. Som ovenfor beskrevet er vi i gang med en undersøgelse der kan give os nogle af de svar vi har brug for. Internationalt set er der gang i flere store interventionsstudier der har til formål at afdække sundhedseffekter af øget D-­‐vitamin indtag. Der er ingen tungtvejende argumenter for at berigelse bør ske netop nu. Jeg er bekymret for utilsigtede negative konsekvenser og ville gerne kunne opveje dem mod den forventede positive på et stærkere videnskabeligt grundlag. 71/53 DTU Food 2/10/13 Kære Agnete og Sofie Tak for henvendelsen. Jeg må lige pointere at vi ikke har nogle holdninger til berigelse. Vi vurderer på baggrund af den videnskabelig dokumentation der findes. Hvis I har nogle konkrete spørgsmål vil jeg være parat til at svare pr mail. Jeg har for mange andre ting lige pt til at stille op til interviews. / Inge 10/10/13 Kære Sofie og Agnete Det er nogle gode spørgsmål, som I har sendt. Jeg vil foreslå, at I læser jer til nogle af svarene. De er ikke alle ligetil – og der er ikke noget entydigt svar til en del af jeres spørgsmål. Jeg vedlægger en af vores tidligere rapporter, hvor I vil kunne en del af svarene. Desuden kan I gå ind på vores hjemmesiden og finde andre rapporter mv, som måtte være relevante. http://www.food.dtu.dk/Resultat?qt=GoogleQuery&fr=1&sc=coll_i-­‐
foedevare&sw=vitamin%20d God fornøjelse. I er velkomne til at vende tilbage, hvis I skulle have yderligere spørgsmål. Vh Inge MFAF 28/10/13 Kære Agnete Nedefor det som styrrelsen kan hjælpe jer med at svare på. Med Venlig Hilsen Hanne Høberg Hansen Mener Fødevarestyrelsens at der er en mulighed for at forbrugeren kan blive vildledt med 72/53 berigede produkter? Hvorvidt forbrugeren kan blive vildledt af berigede produkter hænger i høj grad sammen med, om produktet anprises for indholdet af det pågældende vitamin eller mineral. Det er klart, at det i nogle tilfælde kan være vildledende for forbrugeren hvis der er tale om produkter med en uhensigtsmæssig sammensætning, f.eks. et højt indhold af salt, sukker og mættet fedt. Forordningen om ernærings-­‐ og sundhedsanprisninger fastsætter, at EU-­‐
Kommissionen skal etablere såkaldte ernæringsprofiler, der skal regulere, under hvilke omstændigheder, ernærings-­‐ og sundhedsanprisninger kan bruges. Ernæringsprofilerne er dog endnu ikke fastsat, men deres formål vil netop være at sikre, at anprisninger ikke anvendes på fødevarer, som har en uhensigtsmæssig sammensætning, f.eks. et højt indhold af salt, sukker eller mættet fedt. -­‐ Mener du at berigelse kan være en langsigtet løsning på vitamin D manglen? Fødevarestyrelsen har siden 2005 opfordret fødevareindustrien til at berige udvalgte fødevaregrupper med D-­‐vitamin -­‐ Hvad mener du om den danske berigelses model? Den danske berigelsesmodel, der bruges ved risikovurdering af tilsætning vitaminer og mineraler er med til at sikre, at tilsætning af vitaminer og mineraler til fødevarer ikke medfører at nogle befolkningsgrupper får de pågældende vitaminer og mineraler i så store mængder, at det kan være potentielt sundhedsskadeligt. Risikovurderingerne sker på baggrund af beregninger, der bl.a. baseres på store undersøgelser om danskernes kost, indtaget af kosttilskud m.v. Beregningerne tager højde for forskellige aldersgrupper, herunder børn. Den danske berigelses model er dermed et nyttigt redskab. -­‐ Hvad er den mest ideelle løsning på vitamin D manglen i jeres optik? Fødevarestyrelsen er p.t. ved at revurdere de D-­‐vitamin anbefalinger der gives, blandt andet på grund af at De Nordiske Næringsstofanbefalinger nu har sat det anbefalede niveau op fra 7,5 mikrogram til 10 mikrogram. 73/53 Appendix 7 – Non-­‐available hearing statements 74/53 75/53 76/53 Appendix 8 – Numbered Empirical material Article Source Forbrugerrådet Nordjyske Stiftstidende frygter vildledning Debat: Leder: Stop Børsen Hækkerups statsvitaminer Fødevarer: BT Fødevarestyrelsen: Ikke flere berigede fødevarer Novozymes pønser Landbrugsavisen på sund mad Nu må fødevarer godt anprises Sjællandske Flere fødevarer med D vitamin RetailNews.dk Vi skal have langt mere D vitamin Politiken Berigelse med D vitamin virker Fødevarer.di.dk Statements from Number and Reference -­‐Consumer Council 1. 1.Ritzau (2012) Forbrugerrådet -­‐ DFDF frygter vildledning. Nordjyske Stiftstidende [online] the 11th of November. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Consumer Council 2. C, Arzrouni. (2013) Debat: Leder: -­‐ Ministry Stop Hækkerups statsvitaminer. Børsen [online] the 15th of October. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ MFAF 3. Christensen, L (2012) Fødevarer: -­‐ DFDF Fødevarestyrelsen: Ikke flere -­‐ Arla Foods berigede fødevarer. B.T [online] The 8th of December. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Consumer Council 4. Ritzau (2013) Novozymes pønser på sund mad. Landbrugs Avisen [online] the 15th of May. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Consumer Council 5. 2.Ritzau (2012) Nu må fødevarer -­‐ MFAF godt anprises. Sjællandske [online] -­‐ DFDF The 12th of November. Available at: -­‐ Arla Foods Infomedia [Accessed 7 of November 2013]. -­‐ Ministry 6. RetailNews.dk (2013) Flere -­‐ DFDF fødevarer med D vitamin, RetailNews.dk [online] The 23rd of September. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Ministry 7. Rothenborg, M (2013) Vi skal have -­‐ Consumer Council langt mere D vitamin, Politiken [online] The 13th of September. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ DFDF 8. Peetz-­‐ Schou, M. (2013) Berigelse -­‐ DTU Food med D vitamin virker, 77/53 Kunstigt berigede Kristeligt Dagblad fødevarer kan løse kostproblemer D vitamin på vej i brød og mælk Midtjyllands Avis Hækkerup vil putte Søndagsavisen vitaminer i din mad Danskerne syge af vitaminmangel Søndagsavisen Forbrugerne vil Diabetes ikke have berigede fødevarer Mælk med sunde bakterier kræver særlig renlighed Ingeniøren Vitaminer og mineraler er et godt supplement, også tilsat I fødevarer DI.dk ,DI Fødevarer [online] The 1st of October. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ MFAF 9. Søgaard, J. (2013) Kunstigt berigede fødevarer kan løse kostproblemer, Kristeligt Dagblad [online] The 16th of August. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ MFAF 10. FoodCulture.dk (2013) D vitamin -­‐ Consumer Council på vej i brød og mælk, Midtjyllands Avis [online] The 26th of June. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Ministry 11. 1.Fahnøe, S.(2013) Hækkerup vil putte vitaminer i din mad, Søndagsavisen [online] The 8th of September. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Ministry 12. 2.Fahnøe, S. (2013) Danskerne syge af vitaminmangel, Søndagsavisen [online] The 8th of September. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Arla Foods 13. Heidemann, H. (2013) Forbrugerne -­‐ MFAF vil ikke have berigede fødevarer, -­‐ DTU Foods Diabetes [online] The 23rd of February. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ Arla Foods 14. Biotechacademy.dk (2012) Mælk med sunde bakterier kræver særlig renlighed, Ingeniøren [online] The 5th of December. Available at: Infomedia [Accessed 7 of November 2013]. -­‐ DFDF 15. DI (2013) Vitaminer og mineraler er et godt supplement, også tilsat I fødevarer, DI.dk [online] The 10th of July. Available at: Infomedia [Accessed 7 of November 2013]. 78/53 Skepsis over for FoodSupply.dk berigede fødevarer -­‐ Arla Foods -­‐ DTU Food -­‐ MFAF Danskerne er berigelse puritanere FoodCulture.dk -­‐ Arla Foods -­‐ DTU Food -­‐ MFAF Danskerne skal sikres mere D-­‐ vitamin Berlingske -­‐
-­‐
MFAF Arla Foods 16. Hansen, K.B. (2013) Skepsis over for berigede fødevarer, FoodSupply.dk [online] The 26th of June. Available at: Infomedia [Accessed 7 of November 2013]. 17. Olsen, K. (2013) Danskerne er berigelse puritanere, Foodculture.dk [online] The 25th of June. Available at: Infomedia [Accessed 7 of November 2013]. 18. Haslund, E. (2013) Danskerne skal sikres mere D-­‐ vitamin, Berlingske[online] The 28th of July. Available at: Infomedia [Accessed 7 of November 2013]. Memorandum Title Forslag til Europaparlamentets og Rådets forordning om tilsætning af vitaminer og mineraler samt visse andre stoffer til fødevarer Forslag til kommissionens forordning (EU) om implementering af regler om regler for anvendelse af artikel 8 I forordning (EF) nr. 1925/2006 om tilsætning at vitaminer og mineraler samt visse andre stoffer til fødevarer Sender MFAF MFAF Number and Reference 19. Grundnotat til Folketingets Europaudvalg. J.nr.: 2003-­‐4113-­‐0049. D.23 december 2003: Forslag til Europaparlamentets og Rådets forordning om tilsætning af vitaminer og mineraler samt visse andre stoffer til fødevarer 20. Grundnotat til folketingets europaudvalg. Sagsnr.: 2011-­‐20-­‐221-­‐010696 D. 29 november 2011: Forslag til kommissionens forordning (EU) om implementering af regler om regler for anvendelse af artikel 8 I forordning (EF) nr. 1925/2006 om tilsætning at vitaminer og mineraler samt visse andre stoffer til fødevarer Hearing Statements Title Forslag til Europaparlamentets og Rådets forordning om tilsætning af vitaminer og mineraler samt visse Statement from -­‐ DFDF -­‐ Consumer Council Statements to Number and Reference -­‐ MFAF 21. Grundnotat til Folketingets Europaudvalg. J.nr.: 2003-­‐4113-­‐
0049. D.23 december 2003: 79/53 andre stoffer til fødevarer Forslag til Europaparlamentets og Rådets forordning om tilsætning af vitaminer og mineraler samt visse andre stoffer til fødevarer Høring om general tilladelse til Frivillig beriglese af mælk og margarine med D-­‐vitamin -­‐ Consumer Council -­‐ MFAF Udkast til ny bekendtgørelse (og vejledning) om tilsætning af næringsstoffer til fødevarer -­‐ DFDF -­‐ MFAF 22. Høringssvar J.nr.: 2009-­‐20-­‐
24-­‐00175 D. 30 maj 2011: Høring om general tilladelse til Frivillig berigelse af mælk og margarine med D-­‐vitamin 23. Høringssvar J-­‐nr.: 2012-­‐20-­‐
2301-­‐ 00917 November 2012: Udkast til ny bekendtgørelse (og vejledning) om tilsætning af næringsstoffer til fødevarer Berigelsesforordningens artikel 16. -­‐ DFDF Data til Kommissionens evaluering af berigelsesforordningen -­‐ MFAF Udkast til gennemførelsesbestemmelser for anvendelsen af artikel 16 i berigelsesforordningen -­‐ DFDF -­‐ MFAF Høringssvar om opdatering af bekendtgørelsen om tilsætning af visse andre stoffer end vitaminer og mineraler til fødevarer -­‐ Cancer Society -­‐ MFAF 24. Høringssvar J-­‐nr.:2012-­‐27-­‐
221-­‐01289 D.25.juni 2012: Berigelsesforordningens artikel 16. Data til Kommissionens evaluering af berigelsesforordningen 25. Høringssvar J-­‐nr.: 2012-­‐20-­‐
221-­‐01241 D.17 april 2012: Udkast til gennemførelsesbestemmelser for anvendelsen af artikel 16 i berigelsesforordningen 26. Høringssvar J-­‐nr.: 2011-­‐20-­‐269-­‐00077 D. 26 januar 2012: Høringssvar om opdatering af bekendtgørelsen om tilsætning af visse andre stoffer end vitaminer og mineraler til fødevarer Other sources and documents Title Ordet er dit: Skal vi tilsætte vitaminer i maden? Source Radio Debate, DR P1 Statements from -­‐ DFDF -­‐ Consumer Council Number and Reference 27. P1 (2013) Ordet er dit: Skal vi tilsætte vitaminer i maden? DR P1 [online] The 15th of June. Available at: http://www.dr.dk/P1/Ordeterdit/Udsendelser/20
13/07/04151431.htm [Accessed 7th of November 2013]. 80/53 Interviews and e-­‐mail correspondences Title E-­‐mail correspondence E-­‐mail correspondence Interviewee Anja Olsen – Cancer Society Inge Tetens – DTU Food Number and Reference 28. Message to Olsen, A. ([email protected]) Sent the 8th of October 2013 29. DTU Fødevareinstitut (2010) D-­‐vitamin. Opdatering af videnskabelig evidens for sygdomsforebyggelse og anbefalinger, DTU Fødevareinstitut – Afdeling for ernæring, 1.udgave, available at: http://www.altomkost.dk/NR/rdonlyres/6A87881E-­‐
37D6-­‐47EC-­‐B991-­‐
C9CB6F0CE412/0/Dvitaminrapport.pdf, [Accessed 12
october 2013] E-­‐mail correspondence Interview Hanne H. Hansen -­‐ MFAF Mette Peetz-­‐ Schou -­‐ DFDF 30. Message to Hansen, H.H. ([email protected]) Sent the 15th of October 2013 31. Interview with Peetz-­‐ Schou, M. On the 27th of September 2013 81/53 Appendix 9 – Transcription of the Minister’s Statements 26/11/13 Stort engagement til at der er rigtig god sundhed til alle. Vi ved godt at der er en del af befolkningen der aldrig læser om det, interesserer sig for det eller vil gøre noget ved det. Hvorfor er det man skal være afhængig af om man husker at tage sin vitamin pille og man prioriterede det og læser om det .. nogen mennesker tumler måske med andre ting I tilværelsen. Derfor synes jeg også at det er enormt vigtigt at vi har fokus på dem der ikke kan klare sig selv.. og ikke selv kan være opmærksomme på de her ting. Men når det så er sagt er det vigtigt at vi kan tjene penge og at der er vækst og arbejdsplader, men lige når det handler om folkesundhed og sundhedsmæssige problemer, så tænker jeg måske at vi er imod en frivillig berigelse. 82/53