Food fortification is a necessity, not a myth
The piece is authored by Dr Rajan Sankar, senior consultant physician and senior advisor, Tata Trusts
Food fortification is increasingly being recognised as a viable solution to address the widespread vitamin and mineral deficiencies in Indian population. Earlier this year, Prime Minister Narendra Modi welcomed the decision to fortify rice for distribution under the Public Distribution System and the Mid-Day Meal Scheme.
Some perspectives oppose food fortification, however, arguing India shouldn't follow this path. However, I see this as a welcome step that will complement the government's efforts to tackle anaemia and malnutrition through initiatives such as Anaemia Mukt Bharat and POSHAN Abhiyaan. Rice fortification should be seen as part of an integrated approach involving dietary diversification, iron supplementation, disease control, nutrition education for consumers, and improved sanitation and access to clean water.
In the world, India has the largest burden of anaemia. National Family Health Survey (NFHS)-5 provides insights into anaemia prevalence in the country, indicating that 57.2% of women ages 15 to 49 are anaemic, up from 49.7% in NFHS-4. The main cause of anaemia remains iron deficiency. Anaemia is further complicated by underlying nutritional deficiencies such as folic acid deficiency, vitamin B6 deficiency, and vitamin B12 deficiency in India. A recent study from Indian Council for Medical Research (ICMR) and All India Institute of Medical Sciences (AIIMS) also showed multiple micronutrient deficiencies in pregnant women including anemia and linkage to low birth weight.
Lower-income groups, including women and children, are the most vulnerable to anaemia. Currently, fewer than 10% of children and pregnant women have a diverse diet. We need to implement diet diversification programmes with greater vigour. Realising nutrient adequacy through diet, however, will take time. Fortification of foods and supplementation are methods of filling nutrient gaps as we strive to make balanced diets a reality for the majority of the population.
According to some reports, the anaemia prevalence in India is exaggerated. I think more scientific evidence is needed to support this claim. Venous blood has been used in many studies in Indian settings to estimate hemoglobin levels. According to a recent study[1] that used venous blood samples from Haryana, 54.3% of women in the state suffer from anemia, and 58% of anaemia is due to iron deficiency. Anaemia is defined globally by the WHO cut-off, which is used by all countries and scientific literature. Therefore, India's decision to use the WHO cut-off is the right and wise decision.
The main advantage of mass fortification is the addition of micronutrients at the processing stage. As a result, it is largely invisible, and consumers continue to consume staple foods with added nutrients. Ninety-two per cent of Indian households access and consume iodised salt, and 84% of that salt contains adequate amounts of iodine. Food fortification is therefore a proven and cost-effective intervention that does not change the consumer's eating habits. It requires minimal behavioural changes. Fortified Rice kernels that are blended with natural rice match in size, shape, and bulk density to resemble natural rice. It is a good idea to inform the population that fortified rice has some benefits and must be consumed.
Whether dietary diversity will ever be possible in India is not in question. The question is, what is the situation today? A significant amount of our population suffers from huge nutrient gap in their diet. The diet of socially and economically disadvantaged women and children remains a major contributor to the continuing malnutrition crisis in the country. Diets that provide the nutrients required to live a healthy life are unquestionably ideal. It is for accessibility, affordability, and also behavioural reasons that the level of nutrition has been considered when fortifying rice and deciding the quantity that should be consumed by the population dependent on social safety-net programmes. Fortification standards should be revised as cereal dependence decreases.
There are numerous studies which suggests that rice fortification is an effective preventive strategy and helps to increase micronutrient intake. The WHO guidelines states that the provision of rice fortified with vitamins and minerals including iron, when compared with unfortified rice, improves iron status by reducing the risk of iron deficiency by 35% and increasing the average concentration ofhaemoglobin by almost 2 g/L. The recent case controlled study from Gujarat in 2019 showed an 11.3 point improvement in cognitive scores and reduced anaemia prevalence by 10% in the treatment group with 8 months of multiple micronutrient fortified rice intervention in school going children (6-12 years). Fortification standards need to be tailored to a country's context based on the prevalence of micronutrient deficiencies. FSSAI follows a rigorous process to define standards for fortification. The standards will be and should be revised based on monitoring data.
Numerous cellular processes in biology rely on iron. Too much or too little iron can be harmful. This is why iron metabolism is strictly regulated by the body and levels are balanced by regulating iron absorption. Approximately 0.8 mg to 2 mg of iron is absorbed daily and is tightly controlled. Iron overload is an uncommon condition and can be due to genetic defects resulting in increased absorption of iron from diet or due to iron accumulation due to repeated blood transfusion in certain disease. Iron supplementation programmes running for the past four decades used to provide 60-100 mg of elemental iron daily but now offer 30-60 mg of iron, which at present has low adherence among the women and the children. Fortified rice on the other hand could provide 7-10 mg of incremental iron intake and that too embedded in food matrix. The long-term potential of iron fortification to cause iron overload is conjectural and the available evidence suggests that homeostatic controls would prevent excess iron accumulation in the normal population.
In short, food fortification isn't a magic bullet. It should be viewed as a complementary strategy for the prevention and control of micronutrient deficiencies. As dietary patterns and deficiency states change, monitoring and periodic evaluation will be essential in helping to make necessary changes.
(The piece is authored by Dr Rajan Sankar, senior consultant physician and senior advisor, Tata Trusts)