Despite recognizing imbalanced food intake as the root cause, the primary focus is on technological fixes for micronutrients
India is not doing well on the nutrition front, as under-nutrition (low body weight) is perceived to persist, as per the National Family Health Survey (NFHS) report 5. Equally, over-nutrition (high body weight) is showing an increase. Both under and over nutrition exist simultaneously with their own risks for infectious or non-communicable disease. This is the tip of the iceberg: the truth is that India is already well into this problem, probably due to an inappropriate response to feeding those who are undernourished. If we look beyond high body weight, a massive number of Indian children (over 50%) show metabolic signs of overfeeding—like a high blood sugar or high serum cholesterol or triglycerides. Even in thin or stunted children. Similarly, anaemia prevalence appears stagnant too. All these events are not isolated and reflect inadequate or inappropriate dietary intake, particularly in feeding programs designed to lift the population out of undernutrition. Solutions, therefore lie in prioritising the quality of dietary intake offered in food policies, and monitoring the food-based diets that are implemented. It is only this way that will tackle the underlying inadequacy without causing over-nutrition, which single (or few) nutrient fortification does not seem to address.
The BJP’s manifesto in 2014, stated, “One of our main targets will be to eradicate the curse of malnutrition. We will do so by revamping existing programmes and launching a multi-pronged war against malnutrition across the nation, especially in the under-developed areas, with the help of State Governments. All resources will be provided to achieve this goal.” Aware of the current debate around mandatory rice fortification, we like to draw the attention of Hon’ble Prime Minister and his advisers to many misconceptions about the science, safety and offer solutions that will help the government in keeping their promises.
The motivation for rice fortification as a short-term viable solution to address malnutrition comes from the NFHS findings, where anaemia among women aged 15-49 years has apparently been shown to increase from 2015 to the present. This is despite the Intensified National Iron Plus Initiative of the Indian Government, which provides pharmacological doses of iron and folic acid supplements to women and adolescent children (100 mg iron and 500 mcg folate weekly) as well as to younger children.
We argue that this motivation and its solution (fortification) are suspect. One, that anaemia prevalence was stagnant should have at least raised the suspicion that the method of measuring anaemia might be part of the problem. Estimates of anaemia burden in India are based on capillary blood. Global studies, including from India, have now shown that using capillary blood underestimates the haemoglobin substantially; using the recommended venous blood sample (taken with a syringe from a vein on the arm) would halve the anaemia burden.
Two, it is incomprehensible to think that just one or two nutrients can solve the problems of a deficient diet. Only a diverse diet (food) can solve the problems of multiple deficiencies. The flawed reductionist (fortification of one or two nutrients) thinking is amplified by another notion, that the deficiencies in the Indian diet are so vast, that a normal diverse Indian diet could not possibly meet the daily nutrient requirement. Not true! The latest nutrient requirements published by Government of India’s National Institute of Nutrition in 2020 (including for iron), show that a normal, economical, vegetarian and diverse diet can meet most (including iron) requirements. The same institute presented a report, “What India Eats”, showing low consumption of nutritious food like fruits, vegetables, milk, pulses, meat, poultry, etc.
Three, it is also noteworthy that recent Comprehensive National Nutrition Survey of Indian children, under the auspices of MoHFW, showed that iron deficiency was related to less than half of anaemia cases in the country’s children. Many other nutrients, like Vitamin B12, folate and good protein intake are also important; their intake is achieved through a good and diverse diet.
However, the proponents for fortification will say that any argument against it is irresponsible and ignores the implications of nutrient deficiencies. That is also not true. Everyone acknowledges that the poorest 20% of the population do have low-quality diets. But that can, and should, be addressed through diversifying their diets, to include more fruits, vegetables, pulses, and animal source foods like milk or eggs. Unless we deal with the underlying cause, success may not come handy.
Let’s explore the scientific evidence.
A Cochrane review of all studies on rice fortification concluded that rice fortification was unlikely to prevent anaemia or iron deficiency. If one believes this, how do you expect that this will eliminate anaemia? Evidence that has been used for decision-making is perhaps a recent study from Gujarat, that reported a reduced anaemia prevalence in school children eating their mid-day meal with fortified rice. But as the authors state, this was a quasi-experimental study, with no randomization, which is a critical omission. Also, haemoglobin was measured by a pulse-oximeter that has a high error, which the manufacturer states is only meant for adults. Other quoted Indian studies make untenable claims and are not peer reviewed in the scientific domain. Just 1 out of 6 kids of 6-23 months’ age get to eat enough diverse food.
SAFETY ISSUES
Ignoring the precautionary principle, proponents of fortification say that fortification is safe—that it delivers tiny amounts of iron—unlikely to cause harmful effects. Again: not true. Fortified salt or rice could each deliver an additional 10 mg iron/day to the diet, compared to the daily iron requirement, which for a woman is 15 mg and for a man is 11 mg. This could certainly lead to an intake that is more than what is required: an overload. However, the purveyors of fortification will say that micronutrient overload is a “distant possibility”, and that toxicity is a “myth”. There is a well-defined “risk” of chronic non-communicable diseases like diabetes, hypertension and high cholesterol with high body iron status. This can occur at all ages. Other harms come from unabsorbed iron that remains in the gut—wreaking havoc among the beneficial bacteria in the large intestine. We all know how important the gut micro biome is for long-term health. Calling it “safe” is actually dangerous.
OBESITY ISSUES
That brings us to the second part of malnutrition; child overweight has almost doubled in last 5 years, and metabolic ill-health stands at a staggering 50% in children. Part of this is due to aggressive cereal (rice and wheat) overfeeding in programmes. Another important part is due to the consumption of unhealthy commercial food “products”, which are aggressively marketed through media and endorsed by celebrities. India has been extremely slow in controlling the consumption and spread of ultra-processed food (UPF) products, usually high in salt, sugar and bad fats. India already has too much chronic disease (some call us the “diabetes capital” of the world), and we should not be magnifying this through our feeding policies.
SOLUTIONS AND CONCLUDING THOUGHTS
Nutritional health, child development and general well-being comes from eating a balanced diet with many nutrients and the Government of India’s policy think tank and the nutrition council agrees with it. The difference of opinion lies in prioritising. We believe a switchover is needed here. Provision and monitoring of diverse and adequate food for all should come first, both as short and long-term strategy. Mandatory fortifying rice will contrarily blunt the effort to provide diverse diets already being considered expensive. The benefit derived from nutrients in whole food will always be greater than the sum of its parts. We suggest, as a process, calling for a consultation of public nutrition experts (to develop a conceptual framework to decide about technological interventions such as fortification), which takes into account social and ecological determinants of nutrition deficiency and is based on its risks, benefits and ethics. For rising obesity we suggest for enacting a law to urgently ban advertising, marketing and celebrity endorsement of UPF, especially to children, because it is the promotion that drives the consumption. The National Nutrition Strategy 2017 mandates that policy development should be free from conflicts of interest.
What we need is adequate funding, strengthening human resources in health facilities and communities, health system support for exclusive breastfeeding for the first 6 months and continued breastfeeding for 2 years or beyond, universal food security at household level, availability of adequate diverse foods for infants young children after 6 months, preventing early child bearing, strengthening primary preventive health care, skill and capacity of frontline providers, enhancing literacy and improving water supply and sanitation. Therefore, the malnutrition endgame requires a plan with clear objectives; not short -term quick fixes.
Dr Arun Gupta MD FIAP is a paediatrician, convener of Nutrition Advocacy in Public Interest and former member of PM’S Council on India’s Nutrition Challenges.
Prof Anura Kurpad (MD, PhD, FRCP) is Professor of Physiology and Nutrition in St John’s Medical College, Bengaluru.
Prof Harshpal Singh Sachdev (MD, FRCPCH) is a Senior Consultant in Paediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi.
Views are personal