For decades, we have been puzzled by the extraordinarily high levels of anaemia in India, affecting women and children equally, and stubbornly resistant to corrective measures like mandatory supplementation of iron tablets. These are dismal optics for our national development, as an anaemic individual has a lower capacity to work and think, and so the collective capacity of society is at stake.
If iron supplements do not work, what is to be done? The policy response has been to “do even more”. This takes the form of adding even more iron to the diet through fortification and, this time, doing it through compulsory rice fortification in safety-net feeding programmes like the ICDS, PDS and school mid-day meals. This was announced by the Prime Minister in his recent Independence Day address to the nation. The mandatory rice fortification programme is being piloted in some districts already, but focuses solely on the logistics of fortification, without examining the intended effect on anaemia. We feel that this programme is not required in India, and that the policy should be re-examined.
The first question is whether anaemia prevalence in India is inflated. Anaemia is diagnosed on the basis of the blood haemoglobin level. The extraordinarily high anaemia figure might, firstly, be inflated because WHO haemoglobin cut-offs are used to diagnose anaemia in India. There is a growing global consensus that these may be too high, and a recent Lancet paper suggested a lower haemoglobin cut-off level to diagnose anaemia in Indian children. Using this will actually reduce the anaemia burden by two-thirds. Secondly, haemoglobin level can be falsely low when a capillary blood sample (taken by finger-prick) is used for measurement, instead of the more reliable venous blood sample (taken with a syringe from an arm vein). The anaemia burden in India is estimated from capillary blood, and global studies, including from India, have shown that using capillary blood inflates the anaemia burden substantially. If the recommended venous blood sample is used, it would halve this burden. There is, thus, a significant overestimation of anaemia burden.
But does iron deficiency cause anaemia? And is our diet really deficient in iron? Iron deficiency is thought to be the primary cause of anaemia in India. But recently, a MoHFW national survey (Comprehensive National Nutrition Survey) of Indian children showed that iron deficiency was related to less than half the anaemia cases. Many other nutrients and adequate protein intake are also important, for which a good diverse diet is required.
The idea for iron fortification comes from the premise that a normal Indian diet cannot possibly meet an individual’s daily iron requirement. This is wrong thinking, and is based on older iron requirements (as per National Institute of Nutrition [NIN] 2010), which were much too high. The latest corrected iron requirements (NIN 2020) are 30-40 per cent lower, with the so-called iron “gap” also being much lower. The iron density of the Indian vegetarian diet, about 9 mg/1000 kCal, can thus meet most requirements and the efforts to mandatorily fortify the dietary iron content for the whole population are unnecessary. Many other nutrients are involved in preventing anaemia, as well as a medley of non-diet factors, including the environment.
Food fortification is considered attractive as it requires no behavioural modification by the beneficiary. It also plays into our fascination for applying technology to create a “future food utopia”. But if the iron present in Indian foods is not well-absorbed, then fortification would be like flogging a dead horse. Layering it over other ongoing iron programmes will do more harm than good. Indeed, salt fortification already exists in some states, as does wheat flour fortification, in addition to the Anaemia Mukt Bharat programme of pharmaceutical iron supplementation.
It is often said that fortification is safe, that it delivers tiny amounts of iron, unlikely to cause harmful effects. This is not true: Ingesting fortified salt (two teaspoons, 10 g/day) or rice (quarter kilo/day) will deliver an additional 10 mg iron/day each to the diet. Compare this to the iron requirement of a woman (15 mg/day) and a man (11 mg/day). Actually, one could exceed this requirement by a lot, without even counting the supplemental iron tablet (60 or 100 mg/week for women). When the iron intake exceeds 40 mg/day, the risk of toxicity goes up. The unabsorbed iron that remains in the gut can wreak havoc among the beneficial bacteria in the large intestine. Iron causes oxidative stress, and more seriously, is implicated in diabetes and cancer risk. Men will also be more at risk.
Importantly, this mandatory fortification will cost the public exchequer Rs 2,600 crore annually (not insignificant in relation to the budget, and worth nearly 4 crore Covid vaccine doses), with poor likelihood of benefit, and posing an unnecessary risk.
Rice fortification is very complex. It requires a fortified rice “kernel” or grain that is composed of rice flour paste, along with the required concentration of micronutrients and binders, extruded into a grain that exactly matches the shape of the rice it is intended to fortify. This fortified kernel, indistinguishable from the grain it is fortifying in appearance, density, cooked characteristics and so on, is mixed with the beneficiary’s rice in a specific grain ratio.
The problem lies in making “matching” kernels for each rice cultivar that is distributed in the food safety-net programmes from year to year and state to state. If it does not match, the instinct of a home cook will be to pick out and discard the odd grains, thereby defeating the purpose of fortification. Moreover, when rice fortification is made mandatory, it is not difficult to imagine that for the sake of expediency, it might even reduce the demand for the naturally-occurring diverse varieties in India.
Going back to the question: If iron supplements do not work, what is the answer? We just need to absorb the existing dietary iron better and complement this with all the other nutrients that are required, by eating a diverse diet (with fruits and vegetables, for example), and improving our environment. The answer does not lie in the techno-utopia of food reductionism, seductive as it is. Indeed, it is well-known that the benefits derived from the nutrients in whole foods are greater than the sum of their parts. In 2010, Time ranked “meals in pill form” as third in the top 10 failed futuristic predictions, in a list that included time-travel, jetpacks, flying cars and cyborgs. We need to rethink our reductionist strategies if we are to deliver food and nutrition security to our people.
This column first appeared in the print edition on August 26, 2021 under the title ‘A flawed recipe’. Kurpad is professor of physiology and nutrition in St John’s Medical College, Bengaluru. Sachdev is a senior consultant in paediatrics and clinical epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi. Views are personal