Representational Image | Photo Credit: R.V. Moorthy
There is a need for “extreme caution” in implementing food fortification to address micronutrient deficiencies in India and attention must be paid to the consequences of excess intake when such schemes are offered along with food supplements, a new paper has argued.
The report makes a case for improving dietary diversity instead.
The paper is authored by Dr. Anura V. Kurpad, St. John’s National Academy of Health Sciences, Bengaluru; Dr. H.P.S. Sachdev, Senior Consultant in Pediatrics and Clinical Epidemiology at Bhartia Institute of Science & Research, New Delhi, among others.
It examines the issue of food fortification by looking into iron fortification for fighting anaemia. The paper comes at a time the government is implementing a pilot programme across 15 States for iron fortified rice under the public distribution system (PDS), following which, it is likely to decide on extending the programme nationwide.
The study argues that there is under-estimating of haemoglobin (Hb) and over-estimating of anaemia in the country primarily due to three factors — use of inappropriate Hb cut-offs; adoption of finger prick or capillary blood sampling method instead of venous blood sampling; and inflated daily nutrient requirement for iron, which has recently been revised downwards.
It cites a recent paper published in The Lancet on Hb thresholds in the country to highlight that Hb cut-off to define anaemia in Indian children and adolescents could be lower than the present World Health Organization (WHO) Hb cut-off, bringing down anaemia prevalence to 11% from the current 30%.
The paper also alludes to the difference in anaemia prevalence in two surveys to raise questions about the methodology for blood sampling — the National Family Health Survey 4, which used the finger prick method for blood sampling and found 56% of children between 1-to-4 years to be anaemic, while the Comprehensive National Nutritional Survey 2018, which used the venous method, found this to be at 41%.
Thirdly, the authors argue that policymakers have relied on older daily nutrient requirement (RDA) numbers, which were almost double and have since been revised by the Indian Council of Medical Research and National Institute of Nutrition in 2020. For example, the requirement for an adolescent girl or boy was 30 mg per day as per the old norms, which now stand halved.
“Is there an Indian diet that can meet these requirements? Indeed, there is. You don’t need to fortify to meet the requirements of 15-18 mg of iron per day in the Indian diet,” Dr. Kurpad explained in a webinar.
The authors have also cautioned against layering new interventions such as fortification of rice with iron on top of existing programmes such as those that give iron supplements to beneficiaries at anganwadis.
“There is a need for restraint in considering unnecessary fortification. We need to consider whether we truly have an iron deficient diet, or is it that we are not absorbing that iron, or is it that there are many other factors involved in anaemia? Just putting more and more into the diet places a part of the population at risk of exceeding the tolerable upper limit of intake at which adverse events begin to occur,” says Dr. Kurpad.