FORTIFICATION: WAR ON MALNUTRITION

Today, micronutrient malnutrition is emerging as a silent epidemic and is contributing greatly to the global burden of diseases. Commonly called “hidden hunger”, it refers to diseases caused by a dietary deficiency of essential vitamins or minerals and is prevalent worldwide. More than 2 billion people suffer from micronutrient deficiency in the world today and about one-third of this population are in India. One of the key strategies to address micronutrient malnutrition is food fortification — a process of increasing the content of micronutrients in food so as to improve its nutritional quality. The other strategies include supplementation, dietary diversification and public health and disease control measures. Of these strategies, food fortification is one of the most cost-effective methods to address micronutrient deficiencies. In one of the first countries in the world to start a public health programme to address iodine deficiency disorders, salt was established as the ideal vehicle for iodine fortification due to its widespread consumption and cost effectiveness. Resulting from the successful implementation of the programme, today, 92 per cent households in India consume iodised salt.

While India has been successful in addressing iodine deficiency disorders, vitamins A and D deficiencies are still widespread. According to the National Institute of Nutrition, almost 50-90 per cent of the Indian population, across all socio-economic groups, suffer from vitamins A and D deficiencies. The leading causes for night blindness, rickets, brain damage and bone fragility, diseases caused by vitamins A and D deficiencies call for urgent action. Despite Government recognition of fortification as an effective and measurable tool to address malnutrition, it is yet to be made mandatory in public funded programmes like the public distribution system (PDS).

Opportunely, the present environment for fortification is both positive and encouraging. In 2016, Prime Minister Narendra Modi pushed for universal fortification in meetings with top officials of the Ministries of agriculture, food and public distribution, commerce, health and women and child development and further intensified the fortification discourse when he pledged to end micronutrient malnutrition in India by 2022, earlier this month. Another much needed step in the right direction, the Government has issued guidelines to ensure mandatory fortification of edible oil through the mid-day meal (MDM) scheme with immediate effect. This is further reinforced with a dynamic, supportive and participatory leadership in the Food Safety and Standards Authority of India (FSSAI). It is taking an active role in promoting food fortification and has operationalised the Food Safety and Standards (Fortifications of Foods) Regulation with effect from April 2017 with necessary steps to encourage the production, manufacture, distribution, sale and consumption of fortified food in cooperation with concerned Government departments. Furthermore, owing to State Government initiatives, the entire edible oil industry in Rajasthan and Gujarat is only selling fortified edible oil, and other States like Haryana, Punjab, and Karnataka, etc, have already included fortified edible oil in PDS and MDM.

Certain features make edible oil much easier and cost-effective to fortify than other food items and a suitable vehicle for vitamins A and D. Edible oil is an ideal carrier of vitamins A and D as the vitamins are fat-soluble and the cost of fortification will increase the cost of oil only by 10 paisa per liter. This is reinforced by its high penetration into nearly 99 per cent of households, with average consumption of oil ranging from 12-18 kg per annum per person.

Addressing vitamins A and D deficiencies requires a comprehensive, cohesive and harmonious approach of five catalytic factors. First, assessment of deficiencies and impact evaluation of fortification at the national and State levels is required to establish a landscape for edible oil fortification. Second, among the four public health strategies for addressing vitamins A and D deficiencies, the national and State Governments need to focus on fortification and creating an enabling environment through regulatory mechanisms and advocacy. Third, the private sector needs to voluntarily take up fortification. Fourth, learnings from multilateral organisations and successes in other countries should be used and applied to India. Lastly, knowledge, practices and affordability of consumers with regard to fortification must be kept in mind while developing policies. Building on the success of salt fortification, there is now an urgent need for platforms of open dialogue to create champions to take forward the “idea” of fortification and address micronutrient malnutrition.

Leading the iodisation movement in south Asia, I have witnessed the tremendous success of micronutrient fortification in India and neighbouring countries. With support from highest offices in the country and lessons from previous successful initiatives to build upon, it is time for us to scale up our efforts to eliminate vitamins A and D deficiencies through edible oil fortification.

As I urge us to work together to make India malnutrition free, I quote Swami Vivekananda:

“Take up one idea. Make that one idea your life — think of it, dream of it, live on that idea. Let the brain, muscles, nerves, every part of your body, be full of that idea, and just leave every other idea alone. This is the way to success, and this is the way great spiritual giants are produced. Others are mere talking machines.”

(The writer is the founding member and regional coordinator for South Asia of Iodine Global Network since 1985. Previously, he served as Professor and Head of the Department — Centre for Community Medicine at the All India Institute of Medical Sciences (AIIMS), New Delhi. His long and sustained contribution to public health has been recognised by World Health Organisation and he was recently bestowed the WHO Public Health Champion award. He was also awarded the Mother Teresa Memorial Award for excellent work in USI in Kolkata)