Context

To deal with the high prevalence of anaemia, the government has been pursuing the policy of food fortification with iron. This policy needs a rethink.

Rice-fortification policy

• There are high levels of anaemia in India, affecting women and children equally.
• This is despite the corrective measures like mandatory supplementation of iron tablets through Anaemia Mukt Bharat programme of pharmaceutical iron supplementation.
• To deal with the issue, the government has decided on compulsory rice fortification in safety-net feeding programmes like the ICDS, PDS and school mid-day meals.
• This was announced by the Prime Minister in his recent Independence Day address to the nation.
• The mandatory rice fortification programme is being piloted in some districts already.
• Food fortification is considered attractive as it requires no behavioural modification by the beneficiary.

Why iron fortification policy needs re-examination?

1) Over-estimation of anaemia burden

• High WHO cutoff for Hg levels: WHO haemoglobin cut-offs are used to diagnose anaemia in India.
• There is a growing global consensus that these may be too high.
• A recent Lancet paper suggested a lower haemoglobin cut-off level to diagnose anaemia in Indian children.
• Using this will actually reduce the anaemia burden by two-thirds.
• Capillary Vs venous blood sample: Haemoglobin level can be falsely low when a capillary blood sample (taken by finger-prick) is used for measurement, instead of the more reliable venous blood sample (taken with a syringe from an arm vein). The anaemia burden in India is estimated from capillary blood, which inflates the anaemia burden substantially.
• If the recommended venous blood sample is used, it would halve this burden.
• There is, thus, a significant overestimation of anaemia burden.

2) Other nutrients and protein intake

• A MoHFW national survey (Comprehensive National Nutrition Survey) of Indian children showed that iron deficiency was related to less than half the anaemia cases.
• Many other nutrients and adequate protein intake are also important, for which a good diverse diet is required.

3) Iron requirement over-estimated

• The idea for iron fortification comes from the premise that a normal Indian diet cannot possibly meet an individual’s daily iron requirement.
• This is wrong thinking, and is based on older iron requirements (as per National Institute of Nutrition [NIN] 2010), which were much too high.
• The latest corrected iron requirements (NIN 2020) are 30-40 per cent lower.
• The iron density of the Indian vegetarian diet, about 9 mg/1000 kCal, can thus meet most requirements.

4) Challenges in rice fortification

• Rice fortification is very complex.
• It requires a fortified rice “kernel” or grain that is composed of rice flour paste, along with the required concentration of micronutrients and binders, extruded into a grain that exactly matches the shape of the rice it is intended to fortify.
• The problem lies in making “matching” kernels for each rice cultivar that is distributed in the food safety-net programmes from year to year and state to state.
• If it does not match, the instinct of a home cook will be to pick out and discard the odd grains, thereby defeating the purpose of fortification.

Risks involved

• Ingesting fortified salt (two teaspoons, 10 g/day) or rice (quarter kilo/day) will deliver an additional 10 mg iron/day each to the diet.
• When the iron intake exceeds 40 mg/day, the risk of toxicity goes up.
• The unabsorbed iron that remains in the gut can wreak havoc among the beneficial bacteria in the large intestine.
• Iron causes oxidative stress, and more seriously, is implicated in diabetes and cancer risk. Men will also be more at risk.

Way forward

• We just need to absorb the existing dietary iron better and complement this with all the other nutrients that are required, by eating a diverse diet (with fruits and vegetables, for example), and improving our environment.
• Indeed, it is well-known that the benefits derived from the nutrients in whole foods are greater than the sum of their parts.

 Conclusion

We need to rethink our reductionist strategies if we are to deliver food and nutrition security to our people.

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