Food Fortification: A Proven, Scalable, and Cost-effective Approach to Reduce Micronutrient Deficiencies in India

Food Fortification: A Proven, Scalable, and Cost-effective Approach to Reduce Micronutrient Deficiencies in India

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“The views represented in this article do not necessarily represent those of the Willy Brandt School of Public Policy.”

Micronutrients are the essential vitamins and minerals that are needed for growth and wellbeing of the human body[i]. Deficiency of micronutrients can lead to adverse effects on human health, not all of which are clinically evident, as they rarely show visible signs. They are observed to have long-lasting and devastating effects, including reduced IQ, increased susceptibility to infection, increased child and maternal mortality, reduced cognitive development, and physical incapacity[ii]. Globally, two billion (or one-in-three people) have been affected[iii]. India was ranked 100th (out of 119 countries) in Global Hunger Index in 2017 for prevalent micronutrient malnutrition[iv]. The National Family Health Survey[v] (NFHS4, 2015-2016) indicated the most common micronutrients deficiencies among the population at the household level are: iron (58.5%), iodine and vitamin A (31% risk), vitamin D (80%), folic acid (67%), vitamin B12 (34%), and vitamin D (80%).

In recent decades, India has been one of the fastest growing economies in the world, yet its progress against both child and adult malnutrition has been sluggish at best. There are a number of interacting social, economic, and agricultural drivers behind this, including relative food pricing of energy-dense vs. micronutrient-rich produce, farmer income effects, and inequitable gender access[vi]. Ultimately these drivers result in two fundamental inadequacies – an overall lack of food intake[vii] (exemplified by latest NFHS-4 results in which 20% of adults were classified as underweight, and one-third of children were identified as having low weight for their height, i.e. as “wast[viii]) and poor dietary diversity resulting from an agricultural emphasis on cereal production[ix]. Food fortification is basically an addition of premix (vitamins and minerals) to identified staples. It is cost effective as a strategy and has a number of advantages, as it requires neither changes in existing food patterns nor individual compliance[x].

This strategy can lead to relatively rapid improvements in the micronutrient status of a population, especially if advantage can be taken of existing technology and local distribution networks. It is also necessary to have access to, and to use, fortificants that are well absorbed, yet do not affect the sensory properties of foods. In most cases, it is preferable to use food vehicles that are centrally processed and to have the support of the food industry. Fortification of food with micronutrients is a valid technology for reducing micronutrient malnutrition as part of a food-based approach when and where existing food supplies and limited access fail to provide adequate levels of the respective nutrients in the diet[xi]. In 2004, the Copenhagen Consensus[xii] ranked fortification with micronutrients as one of most feasible and sustainable ideas to reduce micronutrient malnutrition. This was reaffirmed in 2008 and 2012.

Thereby, in order to achieve the outcomes of envisioned Nutrition Security Policies of the country and expand its coverage and effectiveness, the Indian government adopted the strategic move for Food Fortification[xiii] under the aegis of The goal of fortification is not to provide the totality of daily micronutrient requirements, but instead simply to fill the gap between intake from other sources and daily micronutrient needs[xv]. India made salt iodization mandatory with the National Goitre Control Programme in 1962, and tremendous success of the program was seen as indicative of the significant potential of the technology. Voluntary wheat flour fortification practices began in 1970s, but few states have implemented such standards then.

An ongoing process, India’s food fortification campaign has been in motion for some time. However, the 2016 Food Safety & Standards (Fortification) Regulation marked a turning point in this effort[xvi]. Prior to that, manufacturers were not obliged to fortify a significant number of foods-stuffs – exemptions included margarine and infant formula[xvii]. The 2016 legislation introduced the mandatory fortification of rice, salt, and flour with iodine and vitamin A (including Atta, Maida, and Vanaspati) for all 35 state governments and union territories (UTs) in India as part of universal fortification. It has also undertaken targeted fortification initiatives for specific population subgroups, such as complementary foods for young children, supplementary foods for pregnant and lactating women, rations for displaced populations, and subsidized or free food for the poor.

Fortified foods are promoted through the open market and government safety net programmes. The fortified foods that are distributed through safety net programmes include biscuits, wheat flour, double fortified salt, and hot cooked meals (khichdi). These are distributed through three Central Governments existing national policies namely the:[xviii]

  • Integrated Child Development Services (ICDS) scheme,
  • Mid-Day Meal Programme (MDM), and Public Distribution  System
  • Public Distribution System (PDS)

The following step in 2016 is reflective of the advocacy efforts of the Indian government, Food Safety and Standards Authority of India (FSSAI), and other engaged stakeholders in food business industry to promote the fortification of food. The present table shows fortification levels of mandatory nutrients in each food. Additional nutrients can be added to flour and other foods on a voluntary basis.

 

Since 2016, 62 top food business operators and 110 brands have actively started manufacturing fortified variants of the five staple commodities that are widely available in the open markets: salt, rice, oil, milk, and wheat.

As per the Ministry of Women and Child Development, the ICDS scheme has catered to 84.4 million beneficiaries[xix]. As per the Ministry of Human Resource Development (MHRD), fortified hot cooked meals were provided to 94.6[xx] million school going children in the year 2017/18. As the beneficiaries are provided with only one meal through these safety net programmes, the consumption of these fortified products has ensured in meeting 30-50%[xxi] of the Recommended Dietary Allowance (RDA), along with dietary diversification. According to the 2013 National Food Security Act, under the PDS Scheme, 70% of the rural and 50% of the urban population is covered. In total, the government has targeted to reach out about 800[xxii] million population through this scheme.

Presently, 24 of the 35 states/UTs, have developed infrastructure and effective mechanisms to conduct food fortification of staple foods under the legislation of 2016A State Food Fortification Index (SFFI) has also been created to profile the states and UTs based on their performances with respect to fortification of staples.

In India, people from diverse social, economic, and cultural attributed backgrounds, living both in the rural and urban regions, are suffering from and prone to the adverse effects of micronutrient deficiencies. The fortification of foods acts an effective short-term approach to address the nutrition gaps within a population. The long-term, sustainable approach would be to diversify people’s dietary patterns by encouraging higher consumption of locally produced, seasonal food. While simultaneously building such sustainable approaches in bringing diversity to the dietary habits of its citizens, food fortification can be seen as one of the important ways forward in improving the health of the citizens of India.

[i] https://publichealthreviews.biomedcentral.com/track/pdf/10.1007/BF03391600

[ii] http://www.fao.org/3/a-i3434e.pdf

[iii] http://www.fao.org/3/a-i3434e.pdf

[iv] https://reliefweb.int/sites/reliefweb.int/files/resources/WFP-0000073010.pdf

[v] http://rchiips.org/nfhs/NFHS-4Reports/India.pdf

[vi] https://link.springer.com/article/10.1007%2Fs12571-011-0161-0

[vii] http://rchiips.org/NFHS/pdf/NFHS4/India.pdf

[viii] https://www.unicef.org/progressforchildren/2007n6/index_41505.htm

[ix] https://www.ncbi.nlm.nih.gov/pubmed/25098622

[x] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

[xi] https://www.who.int/nutrition/publications/micronutrients/GFF_Part_1_en.pdf?ua=1

[xii] https://www.gainhealth.org/knowledge-centre/lessons-learned-10-years-experience-africa-sharing-experiences-food-fortification/

[xiii] http://wcd.nic.in/sites/default/files/OM%20-%20Fortification%20Website1.pdf

[xiv] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

[xv] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

[xvi] https://www.leatherheadfood.com/files/2017/07/White-paper-51-Food-fortification-in-India.pdf

[xvii] https://www.leatherheadfood.com/files/2017/07/White-paper-51-Food-fortification-in-India.pdf

[xviii] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366258/

[xix] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

[xx] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

[xxi] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

[xxii] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

[xxiii] https://ffrc.fssai.gov.in/ffrc/documents/doc/whats_new/niti_report.pdf

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Kankana Dutta is a first-year MPP candidate at the Willy Brandt School of Public Policy. She earned a Bachelor's of Arts in Political Science from the University of Delhi and a Master’s in Sociology (specialised in Health Sociology) from the Ambedkar University, Delhi. She spent the next three years working in Human Rights Research and Monitoring & Evaluation of Social Development Programmes. Her areas of interest include food & nutrition security, law, early years education, improving child and maternal health, international development, peace & border security, and human trafficking.