Food fortification is increasingly being recognized as a viable solution to address widespread vitamin and mineral deficiencies in the 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 viewpoints oppose food fortification, however, India should not follow this path. However, I see this as a welcome step that will complement the government’s efforts to tackle anemia and malnutrition through initiatives such as Anemia Mukt Bharat and Bhushan Abhiyan. Rice fortification should be seen as part of an integrated approach that includes dietary diversification, iron supplementation, disease control, nutritional education for consumers, improved sanitation and access to clean water.
In the world, India bears the brunt of anemia. The National Family Health Survey (NFHS)-5 provides insights into the prevalence of anemia in the country, indicating that 57.2% of women ages 15-49 have anemia, up from 49.7% in NFHS-4. The main cause of anemia is iron deficiency. Anemia is further complicated by primary nutritional deficiencies such as folic acid deficiency, vitamin B6 deficiency and vitamin B12 deficiency in India. A recent study from the Indian Council of Medical Research (ICMR) and All India Institute of Medical Sciences (AIIMS) also showed multiple micronutrient deficiencies in pregnant women including anemia and an association with low birth weight.
Low-income groups, including women and children, are most likely to develop anemia. Currently, less than 10% of children and pregnant women follow a varied diet. We need to implement diet diversification programs more aggressively. However, realizing the adequacy of nutrients through the diet will take time. Fortifying foods and supplements are ways to fill in nutrient gaps as we strive to make balanced diets a reality for the majority of the population.
According to some reports, the prevalence of anemia in India is exaggerated. I think more scientific evidence is needed to support this claim. Venous blood has been used in several studies in Indian settings to estimate hemoglobin levels. According to a recent study which used venous blood samples from Haryana, 54.3% of women in the state had anemia, and 58% had iron deficiency anemia. Anemia is defined globally by the WHO limit, which is used by all countries and the scientific literature. Therefore, India’s decision to use the WHO moratorium is a 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 basic foods with added nutrients. Ninety-two percent of Indian households have access to and consume iodized salt, and 84 percent of this salt contains adequate amounts of iodine. Food fortification is therefore a proven and cost-effective intervention that does not alter the eating habits of the consumer. It requires minimal behavioral changes. The fortified blended rice grains are identical to natural rice in terms of 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 should be consumed.
Whether dietary diversity would be possible in India is not in question. The question is what is the situation today? A large number of our population suffer from a large nutrient gap in their diet. The diet of socially and economically disadvantaged women and children remains a major contributor to the country’s ongoing malnutrition crisis. Diets that provide the nutrients needed to lead a healthy life are undoubtedly ideal. For accessibility, affordability, as well as for behavioral reasons the level of nutrition was taken into account when fortifying rice and determining the amount that the population dependent on SSN programs should consume. The standards for fortification should be revised as there is less reliance on cereals.
There are several studies that indicate that rice fortification is an effective preventive strategy and helps increase micronutrient intake. WHO guidelines state that providing rice fortified with vitamins and minerals including iron, when compared to unfortified rice, improves iron status by reducing the risk of iron deficiency by 35% and increasing average hemoglobin concentration by about 2 g/L. A recent case-controlled study from Gujarat in 2019 showed an 11.3-point improvement in cognitive scores and a 10% reduction in the prevalence of anemia in the treatment group with 8 months of the micronutrient-fortified rice intervention in school-going children (6-12). in general). Immunization criteria should be appropriate to the country context based on the prevalence of micronutrient deficiencies. The FSSAI follows a rigorous process to define immunization standards. The criteria will be revised and should be revised on the basis of monitoring data.
Many cellular processes in biology depend 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 per day is absorbed and is tightly controlled. Iron overload is an uncommon condition and can be due to genetic defects that lead to increased iron absorption from the diet or to iron buildup due to frequent blood transfusions in some diseases. Iron supplement programs that have been in operation for the past four decades have been used to provide 60-100 mg of elemental iron per day but now provide 30-60 mg of iron, which women and children do not currently adhere to. On the other hand, fortified rice can provide 7-10 mg of additional iron intake and this is an integral part of the food matrix. The long-term potential of iron fortification to cause iron overload is speculative and the available evidence suggests that homeostatic controls will prevent excess iron accumulation in the normal population.
In short, food fortification is not a magic bullet. It should be viewed as a complementary strategy to prevent and control micronutrient deficiencies. As diet patterns and deficiencies change, periodic monitoring and evaluation will be essential to help make the necessary changes.
(Widget written by Dr. Rajan Sankar, Senior Consultant and Senior Adviser to Tata Trusts)