Food Fortification with Vitamin D A political debate on a public health problem

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1 Food Fortification with Vitamin D A political debate on a public health problem

2 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 7 th semester, Bachelor Thesis Supervisor: Sanna Fisker Characters: Date: 19 th of December, /53

3 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

4 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

5 Table of Content Abbreviation... 7 Figures and tables... 7 Responsible for Introduction and field of interest Research question Delimitation and justification of problem Contribution of new knowledge The structure of the thesis and reaching the goal Definition of key concepts Methodology and Philosophy of Science Theory Food Fortification What is food fortification Food Fortification Regulations in Denmark Mandatory fortification Voluntary fortification Food Regulations outside Denmark - Finland Vitamin D Nutritional importance of vitamin D Previous studies on vitamin D and food fortification Stakeholders Ethical perspective Theoretical Framework Discourse analysis Steps in a discourse analysis Method Interview and e- mail correspondences Interview E- mail Correspondences Documentary method Data collection from fieldwork Stakeholder Presentation Result Analysis Consumer Rights Health Promotion Competition in Economy /53

6 7.4 Evidence in Nutrition Discussion The Current Situation Limitations and Considerations Conclusion References Appendix Appendix 1 Food Categories and Content of Nutrients for Mandatory and Voluntary Fortification Appendix 2 Different Fortification Practices in 9 EU Countries Appendix 3 Interview Guide Appendix 4 Statements from the radio debate P Appendix 5 Calculation of the Energy Intake Appendix 6 E- mail Correspondences Appendix 7 Non- available hearing statements Appendix 8 Numbered Empirical material Appendix 9 Transcription of the Minister s Statements /53

7 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

8 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 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

9 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

10 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

11 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

12 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

13 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

14 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

15 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 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

16 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) 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

17 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 foods 1 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/ /53

18 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 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

19 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 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

20 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 % is obtained from the diet, where especially fatty fish is a good source. The Danish dietary guidelines recommend eating 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) 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

21 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 4 th edition of the NNR. The 5 th 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

22 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

23 Therefore, it is essential to get an understanding of the stakeholders and how they interact and are influenced by the processes and the context 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

24 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

25 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

26 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

27 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 stakeholders 2 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

28 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

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