Transforming India’s health through food fortification

This article is authored by Dr Ambrish Mithal, chairman, endocrinology and diabetes, Max Healthcare.

One of the most important indices of a nation’s development is the nutritional status of its population. India can only truly claim its place as a leading global economy if Indians are well-nourished and healthy. Unfortunately, we currently suffer from a unique nutritional paradox. While we struggle to end undernutrition in large segments of our population, we are also facing the effects of increased exposure to energy-dense foods leading to a burgeoning of lifestyle disorders like obesity, diabetes, and heart disease.

Healthy food (Shutterstock)

Nutrients can broadly be divided into macro - fats, protein, and carbohydrate – and micronutrients, which are needed in smaller amounts. Macronutrients provide energy and aid growth; and low levels can lead to poor or stunted growth in children. India today still has unacceptably high proportions of children who suffer from nutritional growth retardation. Micronutrients, on the other hand, are mostly vitamins and minerals and are required in very small amounts but deficiencies can wreak havoc with our health - both mental and physical, in children and adults - if it remains undetected and unattended.

With the dominance of refined grains and carbohydrates in modern Indian diets, coupled with the lack of fresh vegetables and fruits, deficiencies in micronutrients like iron, folic acid, and Vitamin B12, are commonplace. The former Deputy Executive Director of UNICEF, K.C. Gautam, said, “The ‘hidden hunger’ due to micronutrient deficiency does not produce hunger as we know it. You might not feel it in the belly, but it strikes at the core of your health and vitality”. Two billion people worldwide are thought to suffer from hidden hunger and, sadly, India continues to be a major sufferer in this area, with children and women being impacted most adversely.

Common micronutrient deficiencies in Indians include iron, folate, Vitamin B12, all of which independently or in combination can lead to anaemia. The last Comprehensive National Nutrition Survey, conducted in 2016–18 provided a thorough overview of the prevalence of these deficiencies in India. It observed a gender differential in iron deficiency prevalence among adolescents, with girls having almost a three times higher prevalence compared to adolescent boys (31% vs. 12%). Secondly, nearly one-quarter (23%) of preschool children, 28% of school-age children, and 37% of adolescents had folate deficiency. In terms of B12 deficiency prevalence, it stood at 14% among preschool children, 17% among school-age children, and 31% among adolescents.

According to the National Family Health Survey 5-2019-2021 (NFHS 5), 57% of women aged 15-49 are anaemic, as are 61% of children aged 6 months to 5 years. Besides the overt impact of these deficiencies on the foetus (e.g., folate deficiency and neural tube defects), pregnant women pass their deficiency (deficient stores) to their newborns, who grow into deficient children, adolescents, and ultimately pregnant women, who will then pass this on to their offspring. And so, the cycle of deficiency continues.

These deficiencies are rooted in the type of food we consume. While rice, wheat, and pulses provide energy, leafy vegetables, fruit, and proteins are important sources of micronutrients. It is imperative that in addition to food security, we enable systemic measures for dietary diversity, which is, in the long run, the obvious answer to tackling most - but not all - micronutrient deficiencies. Fortunately, simple, and effective complementary and proven solutions to combat micronutrient deficiencies also exist - in the form of food fortification.

Food fortification involves adding essential micronutrients to widely consumed staples, such as salt, rice, flour, milk, and oil. Let me first share two examples that I have been directly involved with. When I was cutting my teeth in endocrinology, in the 1980s, iodine deficiency was widely prevalent in India. This led to thousands of children being born with mental and physical retardation - ‘cretinism’ - and millions of Indians suffering from sub-cretinous brain damage. The simple act of adding iodine to salt (universal salt iodation) in the 1990s has led to the near eradication of this condition. To me, universal fortification of salt with iodine remains one of India’s shining success stories in the field of health and nutrition.

The second example is the widespread prevalence of vitamin D deficiency in India, particularly in urban India. Lack of vitamin D in our diet, insufficient exposure of bare skin to direct sunlight, and air pollution are the principal reasons for this public health problem. Vitamin D deficiency can lead to soft and weak bones which may become crippling. Vitamin D also helps protect us from viral respiratory infections. Fortifying milk and milk products with Vitamin D is a smart public health strategy, which numerous countries have adopted (the United States being a good example), with almost complete eradication of certain types of bone diseases.

With the huge impact of hidden hunger on India, it is critical that we strengthen fortification programs to fulfil micronutrient requirements. The advantages of being able to deliver nutrients to large segments of the population without changes in food consumption patterns are unquestionable. Globally, more than 140 countries have fortification programs to address micronutrient deficiencies, the majority of these are mandatory. Countries such as the United States and those in Europe have virtually eradicated micronutrient malnutrition due to systematic public health interventions. Our neighboring country, Bangladesh, has made considerable progress in reducing malnutrition since it launched its rice fortification program in 2013. It now distributes fortified rice to more than seven million individuals. Recently, the seventy-sixth World Health Assembly adopted a resolution urging member states to accelerate efforts to prevent micronutrient deficiencies through safe and effective measures, like food fortification.

The Indian government has initiated several programmes in the fortification space, showing its commitment to addressing hidden hunger through this strategy. We must create a conducive environment to encourage industry and experts to actively participate in the fortification efforts. At no level should this take away from our efforts to diversify diets and improve overall nutrition. But truly, fortification is an idea whose time has come- and not all the armies in the world are more powerful than such an idea. Let us ensure an Amrit Kaal without the ravages of micronutrient deficiency.

This article is authored by Dr Ambrish Mithal, chairman, endocrinology and diabetes, Max Healthcare.