'Let thy food be thy medicine and medicine be thy food'

Dr Chandrakant Sambhaji Pandav *

This phrase often attributed to Hippocrates rightly lays down the importance of nutrition to prevent or cure disease. As India continues to suffer from a vicious cycle of poor intake of nutrients, poor diversity in diets; the prevalence of people suffering from anaemia and micronutrient deficiencies continues to rise.

This is evident from the recently released National Family Health Survey, 5th round (NFHS-5), with 57% of all women in reproductive age group, (an increase of 4.1 percentage points over NFHS-4) and 67.1%of all young children (an increase of 8.5 percentage points over NFHS-4) and a quarter of all men suffering from anaemia (an increase of 2.3 percentage points over NFHS-4).

A deep dive in understanding the social determinants of anaemia and micronutrient deficiencies suggest that the prevalence of anaemia is comparable across all income quintiles, and geographies (urban vs rural). As expected, the lowest income quintiles are worst affected.

'Anaemia' is a condition in which the number of red blood cells or the haemoglobin concentration within them is lower than normal. Haemoglobin is needed to carry oxygen and if you have too few or abnormal red blood cells, or not enough haemoglobin, there will be a decreased capacity of the blood to carry oxygen to the body's tissues. This leads to symptoms such as fatigue, shortness of breath etc.

Anaemia and micronutrient deficiencies if left untreated, can lead to lowered immunity, increased frequency of illnesses and in the long-term resulting in stunting and malnutrition. Iron deficiency is the most common nutritional disorder in the world. More than two billion people–over 30% of the world's population – are anemic, due to iron deficiency; In developing countries this figure is frequently exacerbated by malaria and worm infections.

As per the World Health Organization (WHO), known measures to control anaemia include i) Dietary Diversification, ii) Supplementation iii) Food Fortification iv) Biofortification v) Public health measures and vi) Nutrition and Health Education so as to change knowledge, attitude, practices and behaviours.

Diet diversity primarily involves consuming diversified diet across multiple food groups, and that too daily. They provide enough nutrients through a healthy diet. Dietary diversification, although desirable depends on the availability, accessibility, affordability, and stability of different varieties of food. As a society, we must continue our thrust to improve all aspects of dietary diversity, especially their coverage under subsidized Government food policies and through innovative initiatives such as "Poshan Vatikas".

Supplementation with iron and other micronutrients, is an effective strategy to address micronutrient malnutrition. With schemes such as National Iron Plus Initiative, Weekly Iron Folic Acid Supplementation, the availability of iron supplements in public institutions has improved. However, the strategy has been largely ineffective in addressing anaemia due to low utilization rates (NFHS-5).

Bio-fortification is the process of improving the nutritional quality of food crops. This can be achieved through agronomic practices, conventional breeding, or biotechnology-based approaches. The current evidence on bio-fortified crops suggests that, only limited micronutrients both in numbers as well as concentration can be provided through bio-fortified crops. However, this could emerge as an important cost-effective intervention in the near future.

Food fortification is the process of deliberately increasing the micronutrient content of food. It improves the nutritional quality and provides a public health benefit with minimal risk to health. It is regarded as one of the top-three priorities for developing countries as per the Copenhagen Consensus Statement, 2008 and well acknowledged under the Sustainable Development Goals (SDGs) for reducing micronutrient malnutrition.

Fortified foods are not new to India. In India, consumption of Iodized Salt, also a type of fortified food, has led to the reduction in prevalence of Iodine Deficiency Disorders and diseases such as Goitre. As per the India Iodine Survey, carried out in 2018-19, the household coverage of adequately iodized salt (>15 parts per million (ppm) at the national level was 76.3%.

The target for achievement of Universal Salt Iodization (USI) is more than 90%. As per the report, the coverage of salt iodised with some iodine, equal to or more than 5 ppm at the household level was 92.4 per cent, estimated to have reached 1.28 billion people. The recent Government announcement on introduction of fortified rice in the food-based safety nets in phased manner with a view to addressing anemia is a viable and welcome step and aims to replicate the successes of Iodized salt.

India's food safety net schemes, namely the Targeted Public Distribution System (TPDS), Pradhan Mantri Poshan Shakti Nirman (PM POSHAN) (erstwhile Mid-Day Meal Scheme) and the Integrated Child Development Services (ICDS) Scheme reach out to more than 800 million people, with subsidized food grains and coarse cereals.

The food safety nets provide an excellent opportunity to provide nutritional benefits to the most vulnerable populations reached through the food safety net schemes by bridging the gap between the actual intake and the requirement of a particular nutrient. Rice being the cereal of choice for distribution as well as utilization among most Indian people (As per the National Sample Survey Office (NSSO) report, 2011 – 65% Indians consume rice as a staple cereal), its fortification could be a "game- changer" for the country.

Fortifying rice by adding micronutrients is a scientifically proven, and cost-efficient way to improve body stores of Iron, in order to address micronutrient malnutrition. More so, it does not involve any behaviour change on part of the consumer. There are multiple studies from the global as well as Indian context, including large-scale pilot projects in India, which have examined the operational feasibility, acceptability and impact of rice fortification in reducing micronutrient deficiencies.

Several of these have been conducted by United Nations agencies and development partners in Odisha, Uttar Pradesh, Kerala, Karnataka and Gujarat through the Government food safety net schemes. Further, fortification of staple foods as a strategy is mandatory in 84 countries around the world.

In an initiative led by the Department of Food and Public Distribution, Government of India; between 2019-21; the Centrally Sponsored Pilot Scheme for Distribution of fortified rice through PDS was successfully operationalized across 11 districts/States in the country. In its plans to scale-up fortified rice distribution, in accordance with the vision of the Hon. Prime Minister, Shri Narendra Modi, fortified rice distribution has been operationa- lized under ICDS and PM-POSHAN schemes across the country as Phase-1 which ended on Mar-22.

With Phase-2, the Government plans to cover all aspirational and high burden districts for stunting (total 291 districts) by March 2023 and in Phase-3 cover all remaining districts by Mar-24. NITI Aayog has been tasked with conducting concurrent evaluation of fortified rice distribution across the country, along with premier institutions such as NIN and ICMR, to assess the medical as well as nutritional efficacy of fortified rice distribution.

As per the Food Safety Standards Authority of India (FSSAI) standards for fortified rice, micronutrients added to rice provide 30% - 50% of recommended dietary intakes (RDI) of nutrients. It is important to note that, the balance gap in nutrients is expected to be addressed by diets consumed at home, hence all claims regarding adverse effects of fortified rice consumption are premature and only speculative.

It must be understood that fortified rice distribution aims to complement and not replace the existing dietary patterns and strategies. Rice fortification is a proven solution to addressing the urgent concern of micronutrient malnutrition. The focus on strengthening other public health measures such as improving water, sanitation and hygiene (WASH), deworming, biofortification etc must continue to be addressed through the respective Ministry initiatives and regularly monitored.

With the advent of science and technology, evidence and policy, over the past decade, our country has been able to develop a robust ecosystem for fortified rice, while addressing demand and supply-side challenges, standards, quality. Efforts are ongoing to continuously address consumer awareness so as to change and sustain behaviours.

I believe that, as put forward by nutrition scientist – GH Beaton, "in the field of nutrition, as in politics, the task is to do what is possible without forgetting what is necessary". It must be understood that prevention is always better than cure and "the best should not be the enemy of good". The public health dictum of "good for many, rather than best for few" holds the key.

(Footnotes)

1 Total children age 6-23 months receiving an adequate diet : 11.3% (National Family Health Survey- 5)
2 National Family Health Survey-4; Detailed report
3 WHO

About the author:

Padma Shree Awardee 2021, Dr. Chandrakant Sambhaji Pandav, MBBS, MD, MSc., FAMS, FIAPH, FIAPSM, is former Professor & Head of the Department – Centre for Community Medicine, All India Institute of Medical Science (AIIMS), New Delhi.Popularly known as the "Iodine Man of India" for his relentless efforts and unwavering commitment towards bringing to light the dire consequences of Iodine Deficiency on health and well-bring.

Dr. Pandav completed his MBBS and later MD in Community Medicine from AIIMS, New Delhi and M.Sc from McMaster University Hamilton, Canada with specialization in Health Economics, Clinical Epidemiology and Biostatistics. Dr. Pandav is also an alumnus of the Department of Human Nutrition, at the London School of Hygiene and Tropical Medicine, London (UK).

Presently, he is a Member of National Council on India Nutrition Challenges under Poshan Abhiyan which is chaired by Vice-Chairman of NITI Aayog, President of Association of Indian Coalition of Control of Iodine Deficiency Disorders (ICCIDD), Regional Coordinator for Iodine Global Network (IGN) South Asia and Chairman of Coalition of Food and Nutrition Security, India (2018-19). He has authored more than 650 research papers in national and international journals and published more than 100 books and reports.