Adequate nutrition is a basic human need and pre-requisite for health and well-being of all, especially for children and adolescents. Article 47 of the Constitution outlines Government of India’s commitment to improve the health and nutrition status of its people. It states: “The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties.”
This is further iterated in Government’s National Policy for Children, 2013, which states that, “Every child has a right to adequate nutrition and to be safeguarded against hunger, deprivation and malnutrition. The State commits to securing this right for all children through access, provision and promotion of required services and supports for holistic nurturing, well-being with nutritive attainment of all children.”
Despite the commitment at the highest level, nutrition situation in India stands grim. The prevalence of underweight among children in India is amongst the highest in the world and this has dire consequences for mobility, mortality, productivity and economic growth. We need to focus on malnutrition, including on micronutrient malnutrition, because it stunts growth intellectually and physically, leading to premature deaths, disability, life-long susceptibility to illness, poor cognitive and learning skills, low achievement in school, low productivity, reduced work capacity in adulthood and low wages. Malnutrition in all forms perpetuates the cycle of poverty. Malnutrition starts early, right from the womb. Consequences are more severe when malnutrition affects children below 24 months of age. The impact of malnutrition though irreversible, could be preventable.
The Current Nutrition Scenario
India has a very high burden of malnutrition, including micronutrient malnutrition. As per the recent fifth National Family Health Survey (NFHS-5) 2019-21 conducted by the Ministry of Health and Family Welfare, Government of India, India carries a significant burden of the 4 key forms of under nutrition namely stunting (35.5%), underweight (32.1%), wasting (19.3%) and severe wasting (7.7%) among children under 5 years of age. Total children aged 6-23 months, who receive an adequate diet, are just 11.3%. This data is almost similar to the Comprehensive National Nutrition Survey (CNNS), 2016-18 data.
Recently released results of NFHS 5 (2019-2020) show that anaemia continues to be very high in all age groups, across all the States. Almost 67% of children in the age group of 9-59 months are anaemic, while 57% of all women in the age group of 15-49 years, and 25% men in the same age group are anaemic. Also, as per the selected state-wide surveys conducted by the National Nutrition Monitoring Bureau (NNMB) of National Institute of Nutrition (NIN), Govt. of India, almost 62% of Indian population has low serum blood levels of vitamin A and 50-94% of people in different states across India, suffer from vitamin D deficiency.
Studies by World Bank have shown that countries whose populations suffer from micronutrient deficiencies encounter economic losses as high as 5% of Gross Domestic Product (GDP).
India’s 1/3rd population, being children and youth is considered as its demographic dividend. But with such high levels of malnutrition that seriously impair the development of human capital, labour productivity and future social and economic development, malnutrition needs to be addressed with urgency, if we are to reap the benefits of our demographic dividend.
Micronutrient Deficiencies can be prevented and even eliminated if optimal quantities of micronutrients are consumed by populations on a regular basis.
The three key strategies identified to address Micronutrient Deficiencies (MNDs) are:
i. Dietary diversification and improvement
ii. Micronutrient supplementation and
iii. Food fortification
These strategies need to be supported with focused nutrition and health education and other public health measures such as infection control, availability of clean drinking water and sanitation.
While dietary diversification is the best option to get optimal nutrition, it is not accessible to or affordable by all. Various surveys conducted by the National Nutrition Monitoring Bureau (NNMB), the Household Consumer Expenditure Surveys and the recent NFHS-5 reveal that Indian diets are primarily simple staple-based diets, without much dietary diversification. The consumption of fruits and vegetables is very low and hence the intake of micronutrients is far less than the recommended levels.
Micronutrient Supplementation is a short-term strategy of giving large doses of the micronutrient as a medicinal supplement. It is effective in providing the required micronutrients immediately, but as per NFHS-5 data, the status of micronutrient supplementation in India is also poor.
Food Fortification stands out among public health interventions as one of the most effective methods of preventing nutritional deficiencies. Food fortification helps to bridge the gap between the recommended dietary allowances and the actual intake of various micronutrients. Food fortification is recognized both by WHO as well as the National Nutrition Mission (POSHAN Abhiyaan), Government of India (GOI), as one of the most cost-effective methods to reduce micronutrient malnutrition. It has been instrumental in lowering the incidence of micronutrient deficiencies amongst all population groups across the globe.
It also has the added advantage of not requiring much behaviour modification or compliance at the end-user level, which is expected in strategies such as micronutrient supplementation. In industrialized countries, food fortification started a century ago in 1922. It has played a major role in the substantial reduction and elimination of a number of micronutrient deficiencies in these countries.
People in India consume large amounts of cereals (about 200-300g/day) and fair amount of oil (about 25g/day) and milk (about 170 -200g/day), but their intake of other foods such as vegetables, fruits and eggs / meat and fish is low. Consumption of vegetables other than potatoes is about 50g/day and of fruits is about 30g/day. The average weekly consumption of eggs is about 2 eggs per person and of meat is about 70g.
Considering the very low consumption of vegetables, fruits, eggs and meat, which are the prime source of micronutrients, it is important that a considered decision is taken by policy makers and the Food Processing Industry to fortify staple foods such as cereals, oil and milk with suitable micronutrients.
Fortification of multiple staple foods that are consumed by various population groups, which are either distributed through the public funded programmes like the Public Distribution System (PDS), Integrated Child Development Service (ICDS), Mid-Day Meals (MDM) scheme and / or also sold through the open market commercial channels, offers an excellent opportunity to provide micronutrients on a sustained basis.
Fortification is most efficient because, comparatively, its implementation is cost-effective and it yields significant results within a short period of time. Cost of fortification depends upon the food to be fortified and the micronutrients to be added, but it is generally just about a fraction (0.04 – 1.2%) of the sale price of the commodity/product.
Fortification Works – The Evidence from India
Several research studies have been conducted in India and at global level that have demonstrated the positive impact of food fortification in India. Government of Rajasthan encouraged all the edible oil processors / packers /suppliers to sell only fortified edible oil in the State, from 01st July 2016. This has led to substantial reduction in vitamin A deficiency among children (10-19 years) (1.9% against the national average of 15.6%, CNNS 2018-19). It is possible that perhaps state-wide production and availability of edible oil fortified with vitamin A contributed towards this change.
Fortified Foods in Public Funded Programmes
Food fortification is not a new concept for India, especially in the government funded programmes such as the ICDS and MDM. Policy documents of GoI advocate food fortification as a part of the overall strategy to eliminate micronutrient malnutrition. Fortified foods have been provided under the public funded programmes, especially in the ICDS programme since long.
Since operationalization of fortification standards for staples in 2016, food fortification has gained momentum in India. Many states are providing one or more fortified staples such as wheat flour, rice, fortified edible oil, etc. through the PDS or through various public channels such as ICDS and MDM. Rice fortification is gaining a lot of traction, because of strong political will to combat micronutrient malnutrition. “Our Hon’ble Prime Minister, Mr. Narendra Modi has strongly advocated for mainstreaming fortified rice in the PDS, as an effective complementary strategy to bring down the unacceptably high levels of Anaemia.”
Industry and Government Initiatives for Adopting Fortification
Various oil, milk and wheat flour industry partners are voluntarily fortifying their products. At present, around 70% of total fortifiable edible oil is fortified in country with vitamin A and D. In the milk sector, 55% of the dairy co-operatives and private dairies are fortifying their different milk variants. Wheat flour fortification in the country is also slowly gaining momentum. Some of the pan-India players and e-commerce brands have started fortifying their wheat flour variants in the open market.
Advantages of Staple Food Fortification
The biggest advantage is that it is a preventive measure for micronutrient malnutrition, which “fills the gap” between intake from other sources and daily micronutrients needs. It poses no risk for the normal individual as food consumption is self-limiting and the micronutrient absorption falls, as their stores increase. This protects against excessive micronutrient accumulation. Also, the cost of micronutrients is clearly negligible on a per-person-per-year basis and hence is easily, a self-sustaining option.
However, for staple food fortification to scale-up and successfully reduce the burden of micronutrient malnutrition requires active collaboration among several sectors. Conditions for successful fortification programmes require: (a) political support; (b) industry support; (c) adequate legislation; (d) consumer acceptance; (e) availability of micronutrients on a sustained basis; and (f) economic benefits.
Though, fortification has a significant potential of enriching the nutritional quality of food and in turn, enriching the life of millions of children; it remains an underutilized opportunity and micronutrient malnutrition remains a public health problem. Effective adoption of food fortification, however, needs to be supported by adequate food regulations and labelling, quality assurance and monitoring to ensure compliance and desired impact.
An effective ecosystem is being created to address these issues: FSSAI has already gazetted the standards for Staple Food Fortification; FSSAI has created a logo ” +F ” that needs to be printed on the fortified food pack; Industry is slowly but surely adopting fortification voluntarily, regulatory compliance is being put in place; and the National Institute of Food Technology Entrepreneurship and Management (NIFTEM), Sonepat, Haryana, a deemed University and an Institute of National Importance, set up by the Ministry of Food Processing Industries, Government of India, has set-up a Centre of Excellence for Food Fortification to build the capacity of food industry, students, academia and development sector partners, to undertake quality-assured fortification of staples like rice, wheat flour, edible oil and milk. This Centre is set up with the technical support of Hexagon-Nutrition Limited and Global Alliance for Improved Nutrition, a development sector organization, working in food fortification domain.
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