When it comes to nutrition, or more specifically micronutrient malnutrition, there is an urgent need to address the diseases that poor diets can inflict on the masses, especially given the diverse populations in India.
Malnutrition exacerbates the scale 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 suffer from stunting and malnutrition, and one in five children suffer from wasting. According to an FAO food security report for 2021, India ranks 101st out of 116 countries in the 2021 Global Hunger Index, with an undernourished population of 15.3%, the highest proportion high number of stunted children (30%) and wasted children (17.3%).
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The picture painted by the Global Nutrition Report 2021 is concerning, noting that child stunting in India is significantly higher than the Asian average of 21.8%.
Since the 1920s, both developed and high-income countries have successfully addressed the problem of malnutrition through food fortification. Lately, low and middle income countries like India have been pursuing food fortification as one of the strategies to combat micronutrient malnutrition. Simply put, food fortification is the process of adding nutrients to food. For example, rice and wheat are fortified with iron, folic acid and vitamin B 12, and salt fortified with iron and iodine. Iodized salt has been used for several decades.
The rice and anemia program
Pilot projects on distribution of fortified rice have been started in some states including Maharashtra (Gadchiroli district) under a targeted public distribution program for the masses. The program was successful in preventing anemia cases – from 58.9% to 29.5% – within two years, prompting the central government to declare the scaling up of distribution of fortified rice, the main staple for 65 years. % of the population, through the existing platform of social safety nets such as PDS, ICDS and PM-POSHAN.
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State experiences with the fortified rice project so far align with results from global programs that use fortified foods as a cost-effective strategy. The health benefits from food fortification have led 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 sparked the planned large-scale food fortification program, which includes fortified rice in all government safety net programs. The study revealed a promising reduction (29.5%) in the prevalence of anemia among women, adolescent girls and children gathered in Gadchiroli district.
Gujarat Midday Meal Diet
In Gujarat, an eight-month study of multi-micronutrient fortified rice intervention for schoolchildren (six to 12 years old) in 2018-2019, as part of the midday meal program, found an increase in the concentration of hemoglobin, a 10% reduction in the prevalence of anemia and, more importantly, an improvement in average cognitive scores (by 11.3%).
Iron deficiency anemia is a major public health problem, as it is responsible 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 Health Organization (WHO) — that is, a loss of 47 million DALYs, or years of healthy life lost due to illness, disability or of an untimely death (2016).
According to NITI Aayog (based on the WHO meta-analysis on the impact of rice fortification), a rice fortification budget of around ₹2,800 crore per year can save 35% of the total or 16 .6 million DALYs per year with no known risk of toxicity. In India, the cost of a lost DALY due to iron deficiency anemia (IDA) is around ₹30,000, while the cost to avoid an IDA-related DALY is only ₹1,545, which gives a cost-benefit ratio of 1:18. Rice fortification, which costs less than 1% of the food subsidy bill (2018-2019), has the potential to prevent 94.1 million cases of anemia, saving ₹8,098 crore on a period of five years.
Despite the programme’s proven effectiveness, activists have expressed concern that excessive iron overload from fortified rice is dangerous for the tribal population of Jharkhand suffering from sickle cell anemia and thalassemia. Iron levels in fortified rice range from 28 mg to 42.5 mg, folic acid levels from 75 mcg to 125 mcg, and vitamin B 12 levels from 0.75 mcg to 1.2 mcg (FSSAI standards). Considering the per capita intake, in a three-member family with a rice consumption of about 60 grams per person, the additional intake is 2.45 mg of iron. This actually compensates for our daily iron losses from the body, which are 1mg to 2mg per day.
Food fortification, according to the pillars of nutrition, is a cost-effective complementary strategy to address multiple micronutrient deficiencies. So, given its proven effectiveness and cost-effectiveness, food fortification can help us reduce micronutrient deficiencies and provide overall health benefits. Careful intervention is the key to the malnutrition problem the nation continues to grapple with.
Sirimavo Nair is Senior Professor in the Department of Foods and Nutrition, Maharaja Sayajirao University, Baroda, Gujarat
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