An unhealthy nutrition policy

On Independence Day, the prime minister made a grand announcement that iron fortified rice will be supplied through all state food schemes by 2024. Staples like rice, wheat, edible oil, milk and salt are all slated for mandatory fortification. Widespread nutritional deficiencies are being cited as the key reason behind such a move, especially iron deficiency or anaemia, which is being used as the peg to justify such a drastic and expensive overhaul of our food programmes, markets, and food cultures. As doctors engaged in public health policy for decades, we are, however, deeply concerned that this move won’t solve India’s malnutrition crisis. Instead, this will create more health and economic risks. These are some of our concerns:

A flawed approach to malnutrition: There is no doubt that Indians have serious nutritional deficiencies, and on this we are in agreement with the government. But the proponents of fortification have us believe that only one or two vitamins and minerals are missing from our diets. That is far from the real picture. When it comes to malnutrition in India, the problem is calorie insufficiency, protein inadequacy and a severe lack of dietary diversity as a result of monotonous cereal-based diets. Our children have myriad deficiencies because of inadequate food availability and because major food groups like proteins and fats are missing in their diets.

Where anaemia is concerned, haemoglobin synthesis doesn’t happen with just iron alone; many other elements are required in far larger quantities, especially good quality protein, vitamin B and C, folic acid, among others. Adding more iron will only succeed in increasing ferritin—an iron storage protein, but won’t lead to haemoglobin synthesis, or treatment of anaemia.  
 

Loading the system with iron has its own problems. Iron has oxidative properties and it can react with intestinal mucosa, which could become damaged by existing infections, which are widespread in India. Tuberculosis, malaria and other infections become uncontrollable when iron is given at the acute phase of these infections. New evidence shows that high ferritin is associated with diabetes, especially during pregnancy.

So, adding a single chemical nutrient and expecting it to solve malnutrition is not going to work. What we need instead is more natural foods, and especially diverse diets that can provide the nutrients required for the body to function optimally. 

Impact on local economy and livelihoods: Firstly, micronutrients are not produced in India, they are imported. According to the Food Safety and Standards Authority of India (FSSAI), international corporations will have the key role in supplying micronutrients. Indian manufacturers will focus on developing pre-mixes for essential food commodities. There is no mechanism in place for price control of such imported micronutrients. Just five global corporations have derived most of the benefits of fortification trends around the world and these companies have historically engaged in cartelising behaviour leading to price hikes.

Existing evidence shows that mandatory fortification of foods will have an adverse economic impact on consumers as well as micro, small and medium players like rice millers, oil ghanis/ mills, small farmers, and local enterprises. Although the FSSAI claims that medium and large rice millers will be incentivised to fortify rice, the process itself is expensive and prohibitive for small players. An indicative cost of setting up rice fortification infrastructure for a medium-sized mill is Rs 3.2 crore, according to the government. Rice millers’ associations have been protesting against these new norms. Their concerns must be included in any such major policy, but this has not been done. 

Globally, scientific studies have shown that fortification programmes lead to increased market share for larger formal players, and reduce market share of the informal sector. Given the centrality of agrarian livelihoods to India, we are surprised that the FSSAI has not conducted any economic or social impact studies. 

The solutions: For any nutrition programme to succeed, it must be done at scale. However, the process should be decentralised so that local communities can be involved and benefit rather than a handful of large corporations.  

India already has several important nutrition programmes such as mid-day meal scheme, balwaadi, anganwadi and the public distribution system. We also have many programmes under which supplements like iron or folate can be administered and scientifically monitored by health professionals. If there are implementation problems, they should be evaluated and improved. School meals programmes, for instance, should look to enhance dietary diversity by adding animal and plant protein like eggs, dairy, pulses along with vegetables and fruit. Expecting children to eat more cereals to gain iron is a problematic approach as the cerealisation of our diets is linked to diabetes and serious health problems. 

Local communities, farmers, micro, small and medium processors and others can be greatly empowered if they are connected to local nutrition programmes. They can supply the raw materials as well as any locally prepared food-to-food fortificants such as syrups, biscuits, porridge, powders and various products made from local ingredients like starchy foods, vegetables, fruit, flowers, nuts, oils, and animal products. Studies show that such food fortificants greatly improve nutrition, while supporting local livelihoods.

Mandating food fortification is not a well-thought-out or a scientific policy. If the government was serious about malnutrition, it would not have made fortification mandatory and kept dietary diversity as optional. Much more discussion, debate, and evidence on the health and economic impact is needed before large scale implementation of such programmes is undertaken. 

Shatrugna is ex- deputy director of National Institute of Nutrition, and Prasad is founder secretary of Public Health Resource Network