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India is at present confronting a significant burden of malnutrition, being home to one in three of the world’s malnourished children, and with the second highest level of wasting among children globally. Also, a high percentage of women in the reproductive age are anaemic. This elevated level of malnourishment is essentially due to poor food quality intake lacking in important micronutrients such as iron, zinc, vitamins, and folate which are necessary for human growth and development. We shall explore the viable measures that can be taken and examine the efforts already underway.
Findings from a recent study substantiate that about 45-64 per cent of the rural poor population in India cannot afford a nutritious diet that meets Recommended Dietary Allowances (RDA) as per India’s dietary guidelines. Concurrently, consumption of ultra-processed food is increasing at an alarming rate; increased consumption of these foods is found to be significantly and inversely associated with the content of vitamin B12, vitamin D, vitamin E, niacin, pyridoxine, copper, iron, phosphorus, magnesium, selenium, and zinc. Furthermore, as the adverse health and socio-economic impacts of COVID-19 continue to disrupt livelihoods and food and health supply chains, the nutritional status of millions of people is likely to worsen, since both the availability of food and the ability to pay for it, adversely impacts the poor.
To arrest and reverse the progress of micronutrient deficiencies globally, the 2012 edition of the Copenhagen Consensus identified large scale food fortification as the number one priority. A great body of evidence exists, including a recent systematic review and meta-analysis of large-scale food fortification (LSFF) programmes, which confirmed the impact of fortification on nutritional outcomes. Food fortification is a scientifically established, cost-effective, and highly scalable process that helps reduce the high load of hidden hunger or micronutrient malnourishment. It is indicated that for addressing iron deficiency, food fortification is the most cost-effective intervention with a cost of $66 per disability adjusted life year (DALY), whereas supplementation and dietary diversification have estimated costs of $179 and $103 per DALY, respectively. It is estimated that every dollar spent on fortification results in USD 9 in benefits to the economy.
In today’s scenario, as the world continues to confront the catastrophe of COVID-19, the importance of micronutrients to boost immunity is well recognised. Fortified staples deliver needed micronutrients such as vitamins A and D (in edible oil and milk) and vitamin B12, folic acid, and iron (in wheat-flour and rice) and iron and iodine in double fortified salt. It is essential to understand that fortified staples can achieve universal reach at the population level, especially in poor and vulnerable communities with 25 to 30 per cent of the required daily allowances of essential micronutrients, thereby contributing to mitigating the severe consequences of micronutrient deficiencies.
Fortification of staple foods is not a new intervention, dating back to the early 1920s with salt iodisation in Switzerland, and since then the consumption of fortified foods has increased significantly globally. Currently, over 140 countries have guidance or regulations in place for fortification programmes, the majority of which are mandatory. 85 countries mandate at least any one kind of cereal grain (maize or rice or wheat) be fortified with iron and folic acid. Edible oils and milk are increasingly becoming the common vehicles for fortification, and so far, 27 countries have mandated edible oil fortification with vitamin A; and 14 countries have mandated milk fortification, with 11 countries fortifying milk with both Vitamins A and D. Fortification does not lead to changes in taste, colour, or other sensory attributes of the staple food, thereby resulting in high acceptance among the consuming population, through both open market as well as safety net programmes, leading to its increasing adoption worldwide.
Governmental initiatives
India’s journey with food fortification began in the 1950s with the fortification of vanaspati with vitamin A, and salt iodisation. Other commodities such as fortified rice, oil and wheat flour were introduced in the early 2000s. This momentum accelerated in the year 2016 when India’s food regulator—the Food Safety & Standards Authority of India (FSSAI) established national standards for fortification of rice, wheat flour, edible oil, double fortified salt (DFS), and milk.
In 2017, the Government of India also issued new directives to use fortified staples in safety net programmes, such as DFS, fortified wheat flour and fortified edible oil through mid-day meals (MDM) and Integrated Child Development Schemes (ICDS). In his Independence Day speech on August 15, 2021, the Prime Minister of India, citing malnutrition and micronutrient deficiency as an obstacle to the development of the poor, particularly women and children, announced that by 2024, all rice being provided through social protection schemes such as the Public Distribution System (PDS), and the school mid-day meals will be fortified.
Fortification: Scope and scaling-up
A large-scale staple food fortification programme is a population-based, cost-effective, preventive strategy, which aims to improve the nutritional status of all and not just high-risk groups. Given the multifaceted nutrition challenges in India, fortification of staple foods can be an effective approach in complementarity to diet diversity, micronutrient supplementation, provision of safe water and sanitation, nutrition education and enabling policies, all of which are needed to holistically combat malnutrition in all its forms.
Success in scaling-up of staple food fortification, however, is predicated on designing high-quality programmes with effective reach, ensuring compliance to fortification standards, monitoring of reliable data, and usage of technology enablers at the production and market levels to ensure fortification quality at one end, and appropriate regulatory monitoring and micronutrient testing at the other.
It is recommended that states consider the inclusion of edible oil in Fair Price Shops (FPS) as a non-PDS item (without provision of subsidies) to be made available to all PDS beneficiaries.
Procuring directly from industry through tendering processes can potentially make the product more affordable in the hands of the consumer. In this way, the provisioning of fortified edible oil in PDS will also facilitate the Anganwadi Centres and schools to mainstream fortified edible oil into the cooking of ICDS supplementary nutrition meals and school mid-day meals.
Currently, most states provide wheat grain instead of wheat flour through PDS. We also recommend the introduction of fortified wheat flour in PDS through appropriate strengthening supply chains and warehousing. Some states, such as Himachal Pradesh have set an example through their state-wide adoption of fortified wheat flour supply to PDS beneficiaries and more states may adopt similar models.
Finally, as we scale-up staple food fortification, it is imperative to ensure compliance with the FSSAI standards by producers. The nutritional benefits will only be delivered to the consumer in case the staples are adequately fortified and conform to national standards. Additionally, we need to strengthen the capacity of accredited laboratories for effective micronutrient testing in fortified staples. This is crucial for effective and sustained monitoring of the quality of fortified foods.
Tarun Vij, Country Director- India, Global Alliance for Improved Nutrition (GAIN), New Delhi