Opinion ORS-like drinks pose real health risks. India needs dialogue and consensus on their sale
The dangers of high sugar content in these fluids, as well as administering non-WHO formulations, are real, particularly for young children. The FSSAI and the courts have rightly flagged this as a public health risk
The ambiguity in its over-the-counter usage stems from its transformation from a rehydration fluid to a hydration fluid, driven at least in part by the burgeoning wellness culture. (Photo: Freepik) Over the last fortnight, there have been several judgments on the issue of using the Oral Rehydration Solution (ORS) label for certain widely marketed drinks. The litigation is in response to paediatricians pointing out the dangers of high levels of sugar in “rehydration drinks” that are labelled as ORS but worsen diarrhoea on account of the high sugar content. The Food Safety and Standards Authority of India (FSSAI) responded to this issue, and it was subsequently challenged by industry representatives. The Delhi High Court has clarified its position. While the legalities will be ironed out in court, it is the science that needs to be decoded to arrive at a scientifically consistent legal position.
The ambiguity in its over-the-counter usage stems from its transformation from a rehydration fluid to a hydration fluid, driven at least in part by the burgeoning wellness culture. It is increasingly being interpreted and used as a preventive intervention rather than a purely therapeutic one. It is widely recommended for all age groups in Heat Action Plans, for example, without specific advisories in most cases regarding appropriate quantities for different age groups of children.
ORS is unambiguously a therapeutic intervention in its genesis. Its historical context is often overlooked in its current multifarious usage. ORS is an iso-osmolar glucose-electrolyte solution with base and citrate, administered to treat dehydration and restore lost electrolyte balance. The combination of glucose and sodium facilitates the absorption of water in the small intestine by creating electrochemical gradients. It is a highly impactful public health intervention that has remarkably reduced mortality and morbidity from dehydration and electrolyte imbalance in children on account of acute diarrhoeal diseases (caused by several microbes). This is a universally acknowledged first-line treatment for diarrhoea in children and adults and is available both in frontline healthcare settings as well as at home.
Maintaining adequate fluid balance in the body is a physiological need. Low levels of water intake are a common cause of headaches, lethargy, and dry mouth. Prolonged periods of low intake are associated with urinary tract infections and the formation of kidney stones. The Indian Council of Medical Research advises a daily average of about eight glasses or 2.5 litres of water and recommends limiting sugary drinks in summer; intake of sugar should not exceed 30 grams for adults and 24 grams for children aged seven to ten years. It needs to be emphasised that water is enough to maintain adequate hydration for most forms of day-to-day exercise; electrolytes, including salt and minerals, are necessary only for those engaged in endurance sports.
ORS does have a preventive role in averting worsening dehydration in cases of acute diarrhoeal diseases, particularly in very young children. With increasing emphasis, therefore, on its preventive role as a “hydration” fluid, there is a need to issue more nuanced advisories for a wide spectrum of intended conditions.
The original composition of ORS underwent a modification in 2003 when WHO and UNICEF recommended that the osmolarity of ORS be reduced from 311 to 245 mOsm/L. The Low Osmolarity ORS (LORS) contains lower amounts of glucose and sodium compared to standard ORS. High sugar content, therefore, certainly worsens diarrhoea, as the paediatric community has correctly pointed out. Oral rehydration salts are mostly available in sachets, distributed free through public health service institutions or widely available over the counter. There is also increasing availability of premixed solutions in cartons. Reconstitution of sachet contents in the correct quantity of (potable) water is critical for young children, as it affects the osmolarity of the solution, potentially resulting in adverse effects.
Currently, several “rehydration fluids” or “electrolyte drinks” are sold over the counter in pharmacies alongside ORS; these are not considered WHO-ORS formulations if they do not conform to the specified composition. The global market for ORS and rehydration drinks is expected to nearly double in the coming decade, from $5.87 billion in 2024 to $9.56 billion by 2035, with a handful of companies dominating the market. The moving annual turnover of ORS more than doubled in the last four years in India, up from Rs 3,340 million in May 2020 to Rs 7,160 million in May 2024, and the brand leader holds more than 50 per cent market share. Its signature product recorded a 26 per cent-plus year-on-year increase in sales in 2024 and was the fourth-most-sold medicine in April 2024, up from its 20th position in the previous month — signifying a sharp rise in sales of ORS and rehydration products as summer ensues.
The dangers of high sugar content in these fluids, as well as administering non-WHO formulations, are real, particularly for young children. The FSSAI and the courts have rightly flagged this as a public health risk. There is an urgent need for dialogue and consensus on these issues among physicians, paediatricians, the pharmaceutical industry, and retail pharmacists. Public health technical leadership and governance bear the responsibility to strengthen health literacy for the public at large.
The writer is chairperson, Centre of Social Medicine & Community Health, JNU. Views are personal
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