Don’t chase the mirage of iron-fortified rice

Relevance: about rice fortification programme

Synopsis: Rice fortification programme might not be the answer to India’s food security and nutritional challenges. A push to a balanced and diverse diet is a far more superior strategy. Issues with the recently announced mandatory rice fortification programme.

Background

Read these articles in sequence

• PM announces rice fortification plan to tackle malnutrition
• Is grain fortification the only way to meet India’s nutritional challenge
• How rice fortification is done?
• Food fortification in India – Explained

Note: Only new points, those not covered in above articles, have been covered in this article.

The problem

There’s extraordinarily high levels of anaemia in India, affecting women and children equally, and despite the mandatory supplementation of iron tablets, it still persists.

• And an anaemic individual has a lower capacity to work and think, and so the collective capacity of society is at stake.

The govt recently announced the compulsory rice fortification program through PDS. Hence, policy response to the problem of iron supplements not working has been to add even more iron to the diet via fortification.

Is fortification prog necessary?

No. As per some experts, the mandatory rice fortification programme is not required in India and the policy should be re-examined.

There’s a need to examine the intended effect of the programme on anaemia.

Issues/Concerns

1]. Overestimation of anaemia burden: There is a significant overestimation of anaemia burden due to following two factors:

• High WHO haemoglobin cut-offs: Anaemia is diagnosed on the basis of the blood haemoglobin level. There is a growing global consensus that, the WHO haemoglobin cut-offs used presently, may be too high, resulting in an inflated anaemia figure. 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.
• Using capillary blood samples: 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. 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.

2]. Does iron-deficiency cause anaemia?

• Not the primary cause: 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.

3]. Is Indian diet really deficient in iron?

The belief that normal Indian diet is iron-deficient 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.

4]. Rice fortification is complex: It requires a fortified rice “kernel” which should be indistinguishable from the grain it is fortifying in appearance, density, cooked characteristics and so on. The problem lies in making “matching” kernels for each rice variety that is distributed in the food safety-net programmes. 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.