An Indian recipe to quell micronutrient malnutrition

When it comes to nutrition, or more specifically micronutrient deficiencies, there is an urgent need to address the ills that poor nutrition can bring to people, especially given India’s diverse population.

Malnutrition exacerbates the magnitude of the public health crisis we face, and is India’s most serious challenge and concern. As per National Family Health Survey-5 data, every second Indian woman is anemic, every third child is stunted and malnourished, and every fifth child is wasted. According to the FAO Food Security Report for 2021, India ranks 101 out of 116 countries in the Global Hunger Index 2021, with 15.3% of the population malnourished, the highest proportion of stunted children (30%), and wasted children (17.3%).

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The picture painted by the Global Nutrition Report 2021 is alarming, noting that the problem of stunting among children in India is much higher than the Asian average of 21.8%.

Since the 1920s, developed countries and high-income countries have successfully addressed the issue of malnutrition through food fortification. Lately, low- and middle-income countries, such as India, have implemented food fortification as one of the strategies to address micronutrient deficiencies. Simply put, food fortification is the process of adding nutrients to food. For example, rice and wheat are enriched with iron, folic acid and B vitamins 12, and salt enriched with iron and iodine. Iodized salt has been used for decades.

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Rice and anemia program

A pilot project on distribution of fortified rice has been taken up in selected States, including Maharashtra (Gadchiroli district) as part of a targeted Public Distribution program for the masses. The program has been successful in terms of preventing cases of anemia — from 58.9% to 29.5% — within two years, prompting the central government to announce increased distribution of fortified rice, the main staple diet of 65% of the population, through existing social safety net platforms such as PDS , ICDS and PM-POSHAN.

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Experiences from different countries on fortified rice projects, so far, match the results of global programs that use fortified foods as a cost-effective strategy. The health benefits accruing from food fortification have led 80 countries to legislate for the fortification of cereal flour, and 130 countries with iodized salt, of which 13 countries have mandated the fortification of rice. Encouraging results from the pilot program in Gadchiroli have prompted proposals for a large-scale food fortification programme, which includes fortified rice in all safety net government schemes. The study found a promising reduction (29.5%) in the prevalence of anemia among women, adolescent girls, and children combined in Gadchiroli district.

Mid-day meal scheme in Gujarat

In Gujarat, an eight-month study of a multi-micronutrient fortified rice intervention for school children (six-12 years) in 2018-2019, as part of the Mid-day Meal Scheme, found an increase in hemoglobin concentration, a 10% reduction in the prevalence of anaemia, and, more importantly, the average cognitive score improved (by 11.3%).

Iron deficiency anemia is a major public health concern, as it is responsible for 3.6% of disability-adjusted life years or DALYs (years lost due to premature death and years lived with disability) according to the World Health Organization (WHO) — that is, the 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 a WHO meta-analysis on the impact of rice fortification), a rice fortification budget of around ₹2,800 crore per year could save 35% of the total or 16.6 million DALYs per year with no known toxicity risk. In India, the cost of one DALY lost due to iron deficiency anemia (IDA) is approximately ₹30,000, while the cost of avoiding an IDA-related DALY is only ₹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 anaemia, saving ₹8,098 crore over five years.

Take precautions

Although the effectiveness of the program is proven, activists have expressed concern that the excess iron from the fortified rice has been harmful to Jharkhand’s tribal population 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-125 mcg, and B vitamins 12 levels from 0.75 mcg to 1.2 mcg (FSSAI standard). Considering the per capita intake, in a family of three with rice consumption of about 60 grams per person, the additional intake is 2.45 mg of iron. This actually compensates for our daily loss of iron from the body, which is 1 mg-2 mg per day.

Food fortification, according to nutritionists, is a cost-effective complementary strategy to address various micronutrient deficiencies. Therefore, given its proven effectiveness and cost-effectiveness, food fortification can help us in reducing micronutrient deficiencies and addressing overall health benefits. The intervention, carried out with precautionary measures, is key to the malnutrition issue that the country continues to face.

Sirimavo Nair is a Senior Professor in the Department of Food and Nutrition, Maharaja Sayajirao University of Baroda, Gujarat

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