Fortified Staples: The way forward

Malnutrition in all its forms – undernutrition, over nutrition and micronutrient deficiencies –throughout the world continues to place an intolerable burden not only on national health systems, but on the entire cultural, social and economic fabric of nations. Globally, 2 billion people suffer from vitamin and mineral deficiencies and one-third of this population lives in India.  Over 38% of children under the age of five years are stunted and more than 35% of children in this age group are underweight.

The green revolution brought about self-sufficiency in food grain production, but the varieties of foods grown have drastically reduced, thereby limiting sources of vitamins and minerals. Dietary deficiency of essential vitamins and minerals, also known as micronutrient malnutrition, is widespread in the country. Micronutrient deficiencies are mainly caused by inadequate intake of nutritious foods and other factors like infectious disease as well as poverty and unhealthy environments. 

More than half the population across all age group consumes less than 50 per cent of their daily needs of iron, zinc, vitamin A, folate and other B vitamins. Of these, deficiencies of vitamin A and iron continue to pose a serious challenge to public health in India.  More recently, vitamin D deficiency is being reported across the country, especially among the urban population. 

In this regard, three strategies have been globally recognised as key measures to address micronutrient deficiencies, namely diet diversification, supplementation and food fortification. Diet diversification involves encouraging consumption of nutritious foods in one’s daily diet, through behaviour change communication. However, economic constraints limit large sections of the population from diversifying their diets and with a large vegetarian population in the country, rich sources of vitamins and minerals, such as meat and poultry, are often culturally unacceptable. 

Targeted supplementation, through provision of vitamin and mineral supplements, has been implemented through government programmes for over three decades, to address vitamin A deficiency and anaemia. However, the programmes have not seen the desired results with iron and vitamin A deficiencies continue to affect all segments of the population. Perhaps, targeted supplementation fails to address large populations and a more universal approach is needed to address this issue. 

Nutrition-sensitive food-based approach focuses on the essential role of food, including fortified foods, for improving the quality of diet to overcome and prevent micronutrient malnutrition. Food fortification refers to the process of adding micronutrients to commonly consumed foods to make them sources of vitamins and minerals, and has several benefits over the other strategies. Food fortification is a sustainable and cost-effective measure to address micronutrient malnutrition and does not require any change in the existing food habits of the population. 

With the aim to facilitate implementation of food fortification, Food Safety and Standards Authority of India (FSSAI) has launched guidelines specifying the level of micronutrients to be added to each staple, after careful scientific scrutiny.

As per the recommendations of the committee set up for food fortification, staples can be fortified with different nutrients: wheat and rice with iron, folic acid and vitamin B12; edible oil and milk with vitamins A and D; and salt with iodine and iron. State governments have made appropriate arrangements to introduce fortified atta through the Public Distribution System (PDS) and food companies have already started manufacturing fortified atta and fortifying rice kernals with iron, folic acid and vitamin B12. Edible oil fortification with vitamins A and D also proves to be advantageous. The recent ban on sale of unpackaged edible oil has paved the way for feasible implementation of its fortification through oil manufacturing industries. 

Elimination of iodine deficiency disorders through mandatory implementation of iodized salt is an example of a global public health success, including India. In India, the rural population and marginalised communities are most affected by vitamin and mineral deficiencies as they often do not have the resources or awareness to diversify their diet. In these circumstances, government safety net schemes such as the PDS, Integrated Child Development Services (ICDS) and Mid-Day Meals (MDM) provide the ideal opportunity to reach this population.

The PDS reaches nearly 800 million people through subsidised rations, while the ICDS scheme provides hot cooked meals and take home rations to the most vulnerable segments of the population. Similarly, the MDM scheme is implemented in over 1,60,000 schools across the country, catering to lakhs of children daily. The Ministry of Women and Child Development has already issued orders for using only fortified food for all ICDS programmes and is a step towards elimination micronutrient deficiencies, including vitamin A and D, in the diets of the marginalised communities.

Opportunely, the mechanisms to support fortification through these schemes are already in place. With guidelines, regulatory mechanisms and budgetary allowances, it is now up to the states to begin implementation. Although several states governments have expressed a keen interest to adopt fortification, there is a need to scale up efforts. As we strive to end malnutrition, I urge the state governments to effectively use existing systems to introduce fortified staples through PDS, ICDS and MDM to ensure that our children have a healthy future. 

By: Dr Thingnganing Longvah 
(Writer is a former Director of National Institute of Nutrition, Hyderabad, and is Global Vice Coordinator of INFOODS)