When it comes to nutrition, or more specifically micronutrient malnutritionthere is an urgent need to address the diseases that poor nutrition can cause in the masses, especially given the diversity of populations in India.
Malnutrition exacerbates the magnitude of the public health crises we face and is India’s most serious challenge and concern. As in the National Family Health Survey-5 data, one in two Indian women is anemic, one in three children is stunted and malnourished, and one in five children is emaciated. According to an FAO Food Security Report for 2021, India ranks 101 out of 116 countries in the 2021 World Hunger Index, with 15.3% of its population undernourished, the highest proportion of stunted children ( 30%) and children with emaciation (17.3%).
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The picture that the Global Nutrition Report 2021 paints is cause for concern, noting that stunting among children in India is significantly higher than the Asian average of 21.8%.
Since the 1920s, developed countries and high-income countries have successfully addressed the problem of malnutrition by fortifying foods. Lately, low- and middle-income countries such as India have been looking at food fortification as one of the strategies to address micronutrient malnutrition. Simply put, food fortification is the process of adding nutrients to food. For example, rice and wheat are fortified with iron, folate, and B vitamins. 12and salt fortified with iron and iodine. Iodized salt has been in use for the past few decades.
The rice program and anemia
Pilot projects on the distribution of fortified rice have been undertaken in selected states, including Maharashtra (Gadchiroli district), as part of a mass public distribution programme. The program has been a success in terms of preventing cases of anemia—from 58.9% to 29.5%—in a period of two years, which led the central government to declare the expansion of the distribution of fortified rice, the main staple food of 65% of the population, through the existing platform of social safety nets such as the PDS, ICDS and PM-POSHAN.
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The experiences of the different States on the fortified rice project, so far, are consistent with the results of global programs that use fortified foods as a cost-effective strategy. The health benefits derived from food fortification have caused 80 countries to develop laws for the fortification of cereal flour and 130 countries with iodized salt, where 13 countries have mandated the fortification of rice. The encouraging results of the pilot program in Gadchiroli have given impetus to the proposed large-scale food fortification programme, which includes fortified rice in all government safety net schemes. The study found a promising reduction (29.5%) in the prevalence of anemia among women, adolescent girls, and boys together in the Gadchiroli district.
Gujarat Midday Meal Scheme
In Gujarat, an eight-month study of multi-micronutrient-fortified rice intervention for school-age children (6-12 years) in 2018-2019, as part of the Midday Meal Program, found a higher concentration of hemoglobin, a 10% reduction in the prevalence of anemia and, most importantly, better average cognitive scores (by 11.3%).
Iron deficiency anemia is a major public health problem, accounting for 3.6% of disability-adjusted life years or DALYs (years of life lost due to premature mortality and years lived with disability) according to the World Organization for Health (WHO) — that is, a loss of 47 million DALYs, or years of healthy life lost due to disease, disability, or premature death (2016).
According to NITI Aayog (based on the WHO meta-analysis on the impact of rice fortification), a rice fortification budget of around Rs 2.8 billion per year can save 35% of the total or 16.6 million DALYs per year. year with no known risk of toxicity. In India, the cost of a missed DALY due to iron deficiency anemia (IDA) is approximately Rs 30,000, while the cost of avoiding an IDA-related DALY is only Rs 1,545, resulting in a cost-benefit ratio of 1:18. Rice fortification, which costs less than 1% of the food subsidy bill (2018-19), has the potential to prevent 94.1 million cases of anemia, saving Rs 8,098 crore over a five-year period.
need for precautions
Despite the proven effectiveness of the programme, activists have raised concerns that excessive iron overload from fortified rice has been dangerous for Jharkhand’s tribal population who suffer from sickle cell disease and thalassemia. Iron levels in fortified rice range from 28mg to 42.5mg, folic acid levels from 75mcg to 125mcg, and vitamin B 12 levels from 0.75 mcg to 1.2 mcg (FSSAI standards). Considering the per capita intake, in a family of three members with a rice consumption of approximately 60 grams per person, the additional intake is 2.45 mg of iron. In fact, this makes up for our daily iron losses from the body, which is 1mg to 2mg per day.
Food fortification, according to nutrition stalwarts, is a cost-effective complementary strategy to address multiple micronutrient deficiencies. Therefore, given its proven efficacy and cost-effectiveness, food fortification can help us reduce micronutrient deficiencies and address overall health benefits. The intervention, carried out cautiously, is the key to the problem of malnutrition that the nation continues to face.
Sirimavo Nair is a Senior Lecturer in the Department of Food and Nutrition at Maharaja Sayajirao University in Baroda, Gujarat.
