Food and Nutrition Security

Community

Health
_____________________________
Maternal and Child Health
Community
Solution Exchange for the Food and Nutrition
Security Community
Solution Exchange for the Maternal and Child Health
Community
Consolidated Reply
Query: Use of Fortified Foods and Micronutrient Malnutrition
in Children - Examples; Experiences
Compiled by Gopi Ghosh and Joy Elamon, Resource Persons and T.N.Anuradha,
Shweta Tyagi and Meenakshi Aggarwal, Research Associates
Issue Date: 17 June 2010

From Vanisha Nambiar, The M.S. University of Baroda, Vadodara,

Gujarat
Posted 20 April 2010
The National Family Health Survey (NFHS) III data reveals a dismal picture of malnutrition,
especially micronutrient malnutrition in children. The percentage of children under 3 years who
are underweight is 45.9 %, who are stunted is 38.4% and who are wasted is 19.1%.

Several international studies have reported that among the various strategies to prevent
malnutrition, food fortification has been proved to be socially acceptable, requires no change in
food habits and is the most cost effective way of reaching large target populations that are at risk
of micronutrient deficiency.

There are several health foods available in the Indian market claiming to be fortified with
vitamins and minerals. However, food fortification is sometimes opposed for professional reasons
(concern about overdoses) or on human rights grounds (consumers should be informed about
the fortification, or should have a choice of a fortified or non-fortified food).

However, fortification in foods for large scale feeding programmes such as Integrated Child
Development Services (ICDS) and Mid day Meal (MDM) Scheme in India has been initiated in the
State of Gujarat via fortified wheat flour, nutri-candy, use of oil fortified with Vitamin A and D and
iodized salt.
I would request members of the Food and Nutrition Security and Maternal and Child Health
community to elucidate on -
• What are the practical and economic issues of introducing fortified foods in National Feeding
Programmes?
• What are the various types of fortified foods available and their impact on health and
micronutrient status of children?
• What is the law related to food fortification and its implementation and auditing criteria at
the production and consumer level?

Your views would enable us to help resolving the ongoing debate on food fortification and to
corroborate the issue of use of fortified foods for reducing micronutrient malnutrition in children.
This discussion will hopefully encourage other organizations, financing systems to introduce
fortified foods for strengthening the ongoing developmental programmes for childhood
malnutrition, especially multiple micronutrient deficiencies in India.

Looking forward to a fruitful interaction.

Responses were received, with thanks, from

1. Prema Ramanchandran, Nutrition Foundation of India, New Delhi
2. Phani Mohan, Consultant, Chennai
3. Umesh Kapil, AIIMS, New Delhi (Response1, Response2)
4. Nira Ramachandran, Independent Consultant, New Delhi
5. Indira Chakravarty, Public Health Engineering Dept, Govt. of West Bengal, West
Bengal
6. Mahtab S. Bamji, Dangoria Charitable Trust, Hyderabad
7. Siddhartha Mukhopadhya, West Bengal Health Service, West Bengal (Response1,
Response2)
8. Bhaskar Goswami, Forum for Biotechnology & Food Security, New Delhi
9. K V Peter, World Noni Research Foundation, Chennai
10. R.K.Baxi, Government Medical College, Baroda (Response1, Response2)
11. Ravishwar Sinha, Independent Consultant, New Delhi (Response1, Response2)
12. Prakash V Kotecha, A2Z, the USAID Micronutrient Project, Academy for Education
Development, New Delhi
13. Uday Pathak, Mahavir Vatsalya Aspatal, Patna
14. Soma Bhowmick, Pink Cascade Foundation, Shillong
15. Kejal Joshi, Department of Foods and Nutrition, The M.S.University of Baroda,
Vadodara
16. Samir K, Tata – CINI, Ahmedabad
17. Joy Daniel, Institute for Integrated Rural Development (IIRD), Aurangabad,
Maharashtra
18. Kaniz Fatima Muneeza, Aga Khan Foundation, New Delhi
19. S. S. Thorat, Mahatma Phule Krishi Vidyapeeth, Rahuri, Maharashtra
20. Keya Chatterjee, Ekjut, Jharkhand
21. Ramit Basu, GoI-UN Joint Programme on Convergence, Programme Management
Unit, New Delhi
22. Arun Gupta, Breastfeeding Promotion Network of India (BPNI), New Delhi
23. Ch. Santakar, Journalist, Koraput, Orissa
24. Chandrakant S Pandav and Kapil Yadav, AIIMS, New Delhi
25. S. Nair, Faculty of Family and Community Sciences, The M. S. University of Baroda,
Vadodara, Gujarat
26. Parimal Parya, National Institute of Health and Family Welfare (NIHFW), New
Delhi
27. Kusum Gopal, UNESCO, United Republic of Tanzania
28. S. Murali Mohan, Visakhapatnam
29. V.R. Jani, The Panchmahal District Cooperative Milk Producers' Union Ltd,
Godhra, Gujarat
30. Purnima Menon, International Food Policy Research Institute (IFPRI), New Delhi
31. Kirtiman Awasthi, UNDP, New Delhi
32. Anshuman Das, Development Research Communication and Services Centre
(DRCSC), West Bengal*

* Offline Contribution

Further contributions are welcome!

Summary of Responses
Comparative Experiences
Related Resources
Responses in Full

Summary of Responses
Fortified foods have variable but useful role in addressing micronutrient malnutrition. The effects
of micronutrient deficiency extend far beyond the known health effects with potential to affect
economic growth and overall development of the population. Food fortification has been a viable
option compared to giving micronutrients as medicinal supplement to overcome micronutrient
deficiency. The practical approach in addressing micronutrient malnutrition though remains a
challenge.

There are specific guidelines under National Iodine Deficiency Disorder Control Programme and a
successful Iodized salt programme in the country. Food fortification can prove to be a beneficial
method of supplying micronutrients provided it is through proper medium, appropriate quantities
and reaches those who need the most.

Salt is one of the most suitable vehicles for fortification. About 70-90% of the population in India
estimated to be iron deficient and majority of the population are anaemic. Double Fortified Salt
(DFS) with iron in addition to iodine fortification is one of the feasible options. The technology
developed by National Institute of Nutrition (NIN) for preparing DFS is useful for combating this
deficiency. Though the amount of iron that it can provide is not worth comparing with amount of
iodine provided but small proportion of iron in DFS can help every child. Members suggested
testing the effectiveness of this technology under public health conditions.

Some States like Uttaranchal, Chattisgarh and Himachal Pradesh have been providing DFS at
subsidized cost through Public Distribution System and to ICDS beneficiaries. In Karnataka, Dual
fortification of salt with iodine and iron under controlled trial were efficacious in reducing the
prevalence of anemia and iron deficiency in school children. Use of DFS in pregnant mother’s diet
did not bring any significant change in iron levels, but contributory roles in iodine levels were
observed. In children, along with dietary counseling and improved food intake, mothers said that
they have become more active with no fatigue. At the same time, the level of iron and iodine
currently used in double fortified salt assumes salt intake of 10 gram per day which is way above
the current recommendation of 2 gram to prevent hypertension.

The West Bengal experiments of fortifying khichdi (a mixture of lentils and rice) with a premix
fortified with iron and vitamin A demonstrated a significant positive impact. Other innovative
products like fortified lozenges and multiple micronutrient powders have been tried by
Micronutrient Initiative to improve the intake of vitamins and minerals by young children. Home
fortification with “Sprinkles” containing iron, zinc, iodine, vitamins A, C, and D, and folic acid have
also been used targeting weaning children.

Rice and wheat are best staple foods locally available for fortification. A program jointly initiated
by Delhi Government and Delhi Roller Flour Mills Association is fortifying wheat flour with iron
and folic acid. However, there are several constraints for multiple micronutrient fortification in
wheat flour.

Bio-fortification of rice is of particular interest because it is more difficult and costly to fortify rice
by conventional means than other grains. Feeding trials with high iron varieties of rice have
shown the iron to be bio-available and to lead to higher body iron levels. Golden rice genetically
modified to contain a high beta carotene content aims at providing the recommended daily
allowance of vitamin A. Margarine and spreads are excellently suited for fortification with a whole
range of vitamins both oil-soluble and water-soluble. However, mandatory fortification is only for
Vitamin A for these products.

In Gujarat with the help of District Administrators, children were given Vitamin fortified
pasteurized flavored fresh milk. It lead to significant improvement in the overall health and
growth parameters of the beneficiary children. In Chennai, World Noni Research Foundation has
initiated fortification of juice which facilitates the supply of nutraceuticals and some
micronutrients.

Internationally, flour fortification has been done in many Latin American countries and fortifying
flour with iron and vitamin A has been mandatory in the Philippines since 2004. In Chile and
Venezuela, iron fortification helped overcome iron deficiency. Food fortification of margarine in
Denmark helped reduce high incidences of night blindness occurring due to Vitamin A deficiency
in children. Similarly, fortified milk in Europe and North America helped overcome Vitamin D
deficiency.

Government of India notification mandates eight micronutrients to an amount of 50% RDA

(Recommended Dietary Allowances) in foods provided to children below six as supplementary
nutrition in ICDS scheme. These include, iron, folic acid, Vitamin A, Vitamin C, Thiamine,
Riboflavin, Niacin and Calcium. Further, WHO and UNICEF have two formulae for Multiple
Micronutrient Powder with 5 or 15 micronutrient. Mid Day Meal (MDM) Guidelines also suggest
use of double fortified salt for preparing meals.

The discussion pointed out that while on one hand, most of the sophisticated fortified foods do
not reach the needy and other fortification methods implemented through various programmes,
have often raised questions regarding efficacy, safety, cost and scientific validity. Moreover, for a
country like India where people are largely rural based, like to consume fresh foods and have
such varied dietary habits, fortification of foods is not one of the best options except in some
special cases. Members pointed out that at times the adverse taste of fortified food keeps people
away from it. Thus it is essential that the food selected for fortification is acceptable, available
and affordable to the targeted communities.
Foods fortified with micronutrients alone cannot tackle the problem of undernutrition.
Micronutrient Malnutrition management remains of little value unless Protein Energy Malnutrition
(PEM) is addressed in the true sense. The possibility of fortified foods helping the local village
economy is also low. There is a need to identify ways that will promote rural enterprises while
providing better nutrition to children. Enough studies conclude that millets (sorghum, pearl
millets, foxtail millets, etc) are good sources of vitamins, minerals and other nutrients. It would
do better to identify ways for value addition of millets (for improved taste, shelf life, and
packaging) that suits children. Indigenous people are aware about the rich biodiversity existing
around them which holds the key to reducing malnutrition and hence the need to promote such
agro-biodiversity.

In 1970, the ICDS product for malnourished children called Hyderabad mix was immensely
popular. It was prepared using cereals along with locally available pulses and supplied nearly 600
kilo calories from 100 gram of food.

Discussion suggested developing evidence based National Policy with regard to production,
selling and distribution of DFS in the country with clear objectives. It was stressed that economic
criterion is alone not sufficient to translate any policy into a successful program.

Fortification for branded Atta (Wheat Flour) and Maida (Refined Wheat Flour) both of which are
quite popular products has to be made compulsory. The intake of iodized salt in food preparation
has to be continually reinforced.

Impact on nutritional status is not a function of the product alone and it is unrealistic to expect
different foods to have specific impact on reduction of micronutrient malnutrition. A large number
of factors govern these including, the level of micro nutrient malnutrition, associated conditions,
level of macronutrient malnutrition, morbidities, their age and overall dietary intake of the
beneficiaries. The dynamic evolution of National Iodine Deficiency Disorders Control Program
(NIDDCP) in India provides a unique opportunity to study the interaction between research,
programme policy and decision making and identify solutions for the future. It is imperative to
carry out stakeholder analysis prior to development of any nutrition policy and program
implementation.

To control micronutrient malnutrition, fortification and supplementation apart from regular

nutritious diet along with different approaches have to be tried together to make a difference and
no single approach would ever work.

Comparative Experiences
Gujarat

Flavoured Milk Draws Children to consume milk daily, (V.R. Jani, The Panchmahal District
Cooperative Milk Producers' Union Ltd, Godhra, Gujarat)
In various districts of Gujarat, the primary school children were provided vitamins pasteurized
toned flavored milk. The same was implemented for Aanganwadi children with the help of ICDS.
Children have been provided various flavors like rose, kesar, strawberry, eliachi etc which has
been quite attractive for children to consume milk on a regular basis. This has led to significant
improvement in the overall health of children. Read more

Tamil Nadu
Production of Juice Rich in Micronutrients, Chennai (K V Peter, World Noni Research
Foundation, Chennai)
In Chennai, World Noni Research Foundation has initiated fortification of juice which facilitates
the supply of nutraceuticals and micronutrients. The Noni Juice Concentrate is being used by
polynesians and helpful for energizing the body. This drink is a great product to combat
micronutrient malnutrition. Read more

From Meenakshi Aggarwal, Research Associate

Multiple States

Initiatives to address Micronutrient Malnutrition in Children

Micronutrient Initiative (MI) through various partnerships supports initiatives aiming to reduce
micronutrient deficiency disorders. MI supported the installation of a double fortified salt (DFS)
manufacturing facility in Tamil Nadu, providing Vitamin A Supplements, Wheat Flour Fortification
and other innovative products like Vita-shakti, Anuka and Fortified Lozenges (in West Bengal and
Bihar) to improve the intake of vitamins and minerals of young children. Read More

Combating Moderate Malnutrition using Home Sprinklers

World Food Programme addresses moderate malnutrition in children by providing Fortified
Blended Foods and Ready-to-Use Foods. By treating moderate malnutrition, it helps prevent
children from slipping into severe malnutrition. Home-fortification is done with multi-
micronutrient powder known as sprinklers. It is a viable option when households already have
some food but the food they have lacks important micronutrients. Read More

Related Resources
Recommended Documentation

From Umesh Kapil, AIIMS, New Delhi

Dual Fortification of Salt with Iodine and Iron: A randomized, double-blind, controlled
trial of micronized ferric pyrophosphate and encapsulated ferrous fumarate in
southern India
Abstract; by Maria Andersson, Prashanth Thankachan, Sumithra Muthayya, Ramakrishna B Goud,
Anura V Kurpad, Richard F Hurrell and Michael B Zimmermann; American Journal of Clinical
Nutrition; November 2008
Available at: http://www.ajcn.org/cgi/content/abstract/88/5/1378 (HTML)
Elucidates how fortification of salt with iodine and iron can be beneficial in combating
micronutrient deficiencies

The Great Vitamin A Fiasco

Manuscript, by Prof Michael Latham, Chairman, Department of Nutrition, Cornell University, USA,
World Nutrition, May 2010, Volume 1 , Number 1
Available at ftp://ftp.solutionexchange.net.in/public/mch/resource/res-45-310510-05.pdf (PDF,
Size: 463 KB)
The commentary challenges the wisdom and validity of the current practice of providing
to children between 6 months and 5 years, regular supplements of massive medicinal
doses of vitamin A

The Economics of Food Fortification (from Nira Ramachandran, Independent Consultant,

New Delhi)
Article; by Sue Horton, American Society for Nutrition Journal of Nutrition, Volume 136, April
2006
Available at http://jn.nutrition.org/cgi/content/full/136/4/1068
Paper summarizes some of the literature on the cost effectiveness and cost benefit of
food fortification with selected micronutrients most relevant for developing countries.

Strategies for Children under Six (From Arun Gupta, BPNI, New Delhi)
Paper; by Arun Gupta, Biraj Patnaik, Devika Singh, Dipa Sinha, Jean Drèze, Radha Holla, Samir
Garg, T Sundararaman, Vandana Prasad and Veena Shatrugna; June 2007
Available at: ftp://ftp.solutionexchange.net.in/public/mch/resource/res20041002.pdf (PDF, Size:
253 KB)
Highlights the state of the children below the age of six and also discusses how to
combat micronutrient malnutrition in this age group

Delhi Fortified Wheat Flour Scheme A Big Hit (from Kirtiman Awasthi, UNDP, New Delhi)
Article; by Gaurav Vivek Bhatnagar; The Hindu; 1 January 2010
Available at http://beta.thehindu.com/news/cities/Delhi/article74013.ece
Reports the Delhi Government’s scheme to sell reasonably priced fortified wheat flour at
Rs.139 for a 10-kg bag has proved a great success with over 65,000 bags being sold

The Weaning Period (from Siddhartha Mukhopadhya, West Bengal Health Service, West
Bengal (response 2))
Chapter; by Oxford Journals; Mother and Child Nutrition in the Tropics and Subtropics
Available at http://www.oxfordjournals.org/our_journals/tropej/online/mcnts_chap6.pdf (PDF
Size: 2.25 MB)
The Hyderabad mix provides 9 g of protein and 260 kcal with 500 mg sulphur amino
acids and 400 mg lysine per meal.

From T N Anuradha, Research Associate

Community-level Micronutrient Fortification of a Food Supplement in India: A

Controlled Trial in Preschool children aged 36-66 months
Abstract; by Jessica L Varma, Soumita Das, Rajan Sankar, Marthi G Venkatesh Mannar, F James
Levinson and Davidson H Hamer; American Journal of Clinical Nutrition, Vol. 85, No. 4, 1127-
1133, April 2007
Available at: http://www.ajcn.org/cgi/content/abstract/85/4/1127
Assessed the efficacy of a premix fortified with iron and vitamin A and added at the
community level to prepared khichdi in increasing iron and vitamin A stores

Home Fortification with Multiple Micronutrients: Effectively Preventing Iron

Deficiency Anaemia in Infants and Young Children
Joint Statement; by Micronutrient Initiative, International Nutrition Foundation and the Sprinkles
Global Health Initiative at Sick Kids
Available at: http://www.sghi.org/resource_centre/MISGHIIDPAS.pdf (PDF, Size: 111 KB)
Elaborates on the Sprinkles Global Health Initiative doing home Fortification with Multiple
Micronutrients

Acceptability of Double-Fortified Salt in Foods (Table 5)

Food and Nutrition Bulletin Vol. 17, No. 1; UN University Press; March 1996
Available at: http://www.unu.edu/unupress/food/8f171e/8F171E0e.htm
Article gives information about organo-leptic properties of DFS in various food items and
trials on loss of iron and iodine on transportation.
India's Control Programs for Iron Deficiency Anemia in Preschool Children: Past,
Present, and Future
By Tara Gopal Das; Proceedings: Interventions for Child Survival; The Opportunities for
Micronutrient Interventions; May 1995
Available at: http://www.jsi.com/intl/omni/fe_ch13.htm
A review article on iron deficiency anemia in children and information on pilot project in
Rajasthan, where DFS will be given to children

New Weapon in War on Micronutrient Deficiencies

By Michael Boulet; International Development Research Centre; July 1996
Available at: http://archive.idrc.ca/books/reports/1996/17-01e.html
Article on breakthrough in food-fortification technology allowing iodine and iron to be
added to salt, represents major advance in efforts to prevent micronutrient deficiencies

From Shweta Tyagi, Research Associate

Development of a New Tapioca Product with Tropical Fruit Pulp and Soy Extract
Article; by Wiley Interscience; 2007;
Available at:
http://www3.interscience.wiley.com/cgi-bin/fulltext/114179607/PDFSTART (PDF; Size: 68.9 KB)
Elucidates about the various methods of food fortification and also the various products
that can be used for the same

Micronutrient Fortification of Foods- Rationale, Application and Impact

Paper; by M G Venkatesh Mannar and R Shankar; Indian Journal of Pediatrics; Ottawa;
November 2004
Available at:
http://resources.metapress.com/pdf-preview.axd?code=w05718n5370578x4&size=largest
(HTML; Size: 186.95 KB)
Highlights the importance of food fortification especially in the developing countries and
minimize malnutrition

Nutrition
Annual Report; by National Institute of Nutrition; 2000-2001
Available at: http://www.icmr.nic.in/annual/an_report2000/nut.pdf (PDF; Size: 361 KB)
Evaluates the research carried out on macronutrient malnutrition in various states in
India

Mid Day Meal Scheme (from Meenakshi Aggarwal, Research Associate)

Guidelines; Department of Elementary Education and Literacy, Ministry of Human Resource
Development
Available at http://education.nic.in/mdm/FINAL_Guidelines_MDM_19_sept.pdf (PDF, Size: 200
KB)
Provides information on the national feeding programme providing nutritional support to
primary school children, covering nearly 12 crore children

Recommended Organizations and Programmes

National Institute of Nutrition (NIN), Hyderabad (from Prema Ramanchandran, Nutrition

Foundation of India, New Delhi)
Jamai-Osmania, Hyderabad 500007, Andhra Pradesh; Tel: 91-40-2719-7200; Fax: 91-40-2701-
9074; nin@ap.nic.in; http://www.ninindia.org/nin.htm;
 Has developed various technologies for food fortification, especially for iodine and iron
fortification of salt

National Iodine Deficiency Disorder Control Programme, New Delhi (from Umesh Kapil,
AIIMS, New Delhi)
Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi 110108, Delhi; Tel: 91-11-2306-
1238, 2306-2647; http://www.mohfw.nic.in/kk/95/i9/95i90901.htm
Working towards the iodine deficiency in the country, also has specific guidelines
concerning the iodine fortification

World Noni Research Foundation, Chennai (from K V Peter, World Noni Research
Foundation, Chennai)
No. 12, Rajive Gandhi Road, Old Mahabalipuram Road, Perungudi, Chennai 600096, Tamil Nadu;
Fax : 91-44-2442-3601; mail@nonifamily.net; www.nonifamily.net
Working towards the goal of creating a healthy population in a world of wellness and
wellbeing, also developing fortified juices and other products

From Ravishwar Sinha, Independent Consultant, New Delhi

Indian Council of Medical Research (ICMR), New Delhi

V. Ramalingaswami Bhawan, Ansari Nagar, New Delhi 110029, Delhi; Tel: 91-11-2658-8895,
2658-8980, 2658-9794; Fax: 91-11-2658-8662, 2658-8713; icmrhqds@sansad.nic.in;
http://www.icmr.nic.in/
Has been working on formulation and promotion of biomedical research in India, carrying
out research on malnutrition and food fortification

Indian Academy of Pediatrics (IAP), Mumbai

Kailas Darshan, Kennedy Bridge, Mumbai 400007, Maharashtra; Tel: 91-22-2388-9565, 22-2388-
7922, 22-2388-7906; Fax: 91-22-2385-1713; centraloffice@iapindia.org; http://www.iapindia.org
Has been committed to the improvement of the health and well being of all children
especially regarding the micronutrient malnutrition

Micronutrient Initiative (MI), New Delhi

11, Zamroodpur Community Centre, Kailash Colony Extension, New Delhi 110048, Delhi; Tel: 91-
11-4100-9801, 4100-9807; Fax: 91-11-4100-9808; miasia@micronutrient.org;
http://www.micronutrient.org/english/View.asp?x=603
Contributing to initiate awareness on micronutrient malnutrition and devising ways and
methods to combat the same

From Ravishwar Sinha, Independent Consultant, New Delhi and Prakash V Kotecha, A2Z, the
USAID Micronutrient Project, Academy for Education Development, New Delhi

United Nations Children’s Fund (UNICEF), New Delhi

73 Lodi Estate, New Delhi 110003, Delhi; Tel: 91-11-2469-0401, 2469-1410; Fax: 91-11-2462-
7521, 2469-1410; newdelhi@unicef.org; http://www.unicef.org/india/children_2356.htm
Actively working for safeguarding health of children and working on issues of
malnutrition

World Health Organization (WHO), New Delhi

537, “A” Wing, Nirman Bhawan, Maulana Azad Road, New Delhi 110011, Delhi; Tel: 91-11-4759-
4800, 2306-1955, 2306-3632, 2306-1993; Fax: 91-11-23062450; wrindia@searo.who.int;
http://www.who.int/nutrition/publications/anaemia_iron_pub/en/index.html
 Has been working for improving public health and implementing programmes to tackle
micronutrient malnutrition

United States Agency for International Development (USAID), New Delhi

American Embassy, Chanakya Puri, New Delhi 110021, Delhi; Tel: 91-11-2419-8000; Fax: 91-11-
2419-8612, 2419-8454; http://www.micronutrientforum.org/
Has been taking initiatives on combating micronutrient malnutrition and improving the
health status of people around the globe

International Food Policy Research Institute (IFPRI), New Delhi (from Purnima Menon)
NASC Complex, CG Block, Dev Prakash Shastri Road, Pusa, New Delhi 110012, Delhi; Tel: 91-11-
2584-6565, 2584-6566, 2584-6567; Fax: 91-11-2584-8008;
ifpri-NewDelhi@cgiar.org; http://www.ifpri.org/book-741/ourwork/program/diet-quality-and-
health-poor
Initialized a programme on diet quality and health of the poor which included assessing
the micronutrient malnutrition in children

Panchmahal District Cooperative Milk Producers' Union Ltd., Godhra, Gujarat(from V R

Jani)
Panchmahal District Cooperative Milk, Producers' Union Ltd. Godhra, Dist. Panchmahals, Gujarat-
389001; Tel: 91-02672-261782; Fax: 91-02672-260327; amulpan@panchmahalunion.coop
http://www.panchamrutdairy.org/sgsy/about_projects_cattle.html
Provide fortified milk to school children and aanganwadi centres helping them improve
their nutritional status

World Food Programme, New Delhi (from Meenakshi Aggarwal, Research Associate)
2, Poorvi Marg, Vasant Vihar, New Delhi – 110057, Tel: 91-11-26150000, 46554000; Fax: 91-11-
26150019, 4655405; wfp.newdelhi@wfp.org; http://www.wfp.org/nutrition/special-nutritional-
products
Undertaking various programme on improving the nutritional value of food products like
fortified blended foods and ready to eat foods.

Related Portals and Information Bases

Golden Rice Project (From Bhaskar Goswami, Forum for Biotechnology & Food Security, New
Delhi)
http://www.goldenrice.org/
The portal provides information on the project based on the need for a sustainable
biofortification approach to contribute to alleviating the scourge of micronutrient
deficiencies worldwide

Integrated Child Development Services Scheme (from Meenakshi Aggarwal, Research

Associate)
http://wcd.nic.in/icds.htm
Portal provides the details of the ICDS scheme and the supplementary nutrition provided
to the beneficiaries.

Related Consolidated Replies

Iron Fortification of Millet Flours, Priya Naik, Poverty Action Lab MIT, Cambridge
(Advice), Food and Nutrition Security Community, Solution Exchange, India
Issued 2 March 2006. Available at: ftp://ftp.solutionexchange.net.in/public/food/cr/cr-se-food-
02030601-public.pdf (PDF; Size: 196 KB)
 Deals with causative factors of anaemia and various coping strategies including the pros
and cons of food fortification, dietary diversification and iron supplementation

Double Fortified Salt for Combating Anaemia, Rita Patnaik, NFI, New Delhi
(Experiences), Food and Nutrition Security and Maternal and Child Health
Community, Solution Exchange, India
Issued 6 October 2006. Available at: ftp://ftp.solutionexchange.net.in/public/food/cr/cr-se-food-
mch-06100601-public.pdf (PDF; Size: 185 KB)
Shares experiences with Double Fortified Salt (DFS) as a way to reduce anemia, also
explores the utility of DFS and appropriateness of employing it in national programs.

Combating Iodine Deficiency Disorders (IDD) in India, Anna Somos, Columbia

University, New York (Experiences), Food and Nutrition Security and Maternal and
Child Health Community, Solution Exchange, India
Issued 27 February 2007. Available at: ftp://ftp.solutionexchange.net.in/public/mch/cr/cr-se-
mch-food-06020701-public.pdf (PDF; Size: 186 KB)
Shares experiences of working with various stakeholders to combat IDD, provides
suggestions for improving iodine consumption.

Responses in Full
Prema Ramanchandran, Nutrition Foundation of India, New Delhi
Salt is consumed by all segments of the population. It is inexpensive and therefore one of the
most suitable vehicles for fortification if the micronutrient deficiency is wide spread. In India
about 70-90 % of the population is estimated to be iron deficient and majority of the population
are anaemic. Under these conditions salt fortification with iron (in addition to the mandatory
fortification with iodine) is one of the feasible methods for combating iron deficiency anaemia.

There are several technologies available for iron and iodine fortification. The one developed by
National Institute of Nutrition (NIN) has been widely tested and has been approved by PFA. It is
acceptable and affordable.

Chattisgarh has been providing Double Fortified salt (DFS) at subsidized cost through PDS (Public
Distribution System). Himachal Pradesh has been providing DFS to the ICDS beneficiaries. Mid
Day meal (MDM) guidelines suggest use of DFS for MDM. However, the supply constraints have
come in the way of its wider use.

There have been several reviews of multiple micronutrient fortification in Atta (Wheat Four) and
several constraints in use of this have been identified. The fact that more than half the country is
rice eaters will also have to be taken into account.

Fortifying multiple products with multiple nutrients may result in some segments of the
population who may not have the deficiencies getting more than the requirements; it will also
inevitably push up the cost of the product. All these have to be considered while deciding what
product is to be fortified with what micronutrient.

Phani Mohan, Consultant, Chennai

Fortification of Tapioca Starch has been an ongoing process in Africa for malnutrition.

As India has been glutinous for sugar and with growing concerns of its usage and shortage, its
fortification has been a subject under study of Sugar technologists but has not moved much, but
is really worthy consideration and enforcement by GOI which some how has not been the
enforcing food labeling in Sugar.

Umesh Kapil, AIIMS, New Delhi (response 1)

DFS (Double Fortified Salt) developed by NIN (National Institute of Nutrition) needs to be tested
under public health conditions to demonstrate its effectiveness both on iodine and iron status.
The results of limited controlled field studies undertaken in residential schoolchildren do show the
effectiveness of the DFS. However, before DFS is introduced as a National Programme like ICDS,
we need to have effectiveness studies of DFS under public health conditions. According to Dr
Kamala Krishnaswamy, former director NIN Hyderabad - DFS developed by NIN will provide only
1 mg/gram of salt and with low iron absorption; it will take a long time to demonstrate a rise in
Hemoglobin. Over a period of time (2-5 years), the Hemoglobin curve is likely to shift to the
right.

Do we have studies on DFS under public health conditions to demonstrate its effectiveness
leading to improvement on haemoglobin and iodine status? If yes then I would request members
to share the details of the same. There is no doubt that by consuming the DFS there will be
increase in iron intake. Indian scientists should find the Indian solutions to Indian problems and
DFS is one such promising intervention.

The problem of iron and iodine deficiency is so common that the state governments adopt the
intervention strategies recommended by the scientists in the states. In Chhattisgarh state iron
and iodine fortified salt is being provided at a subsidized cost through public distribution system.
In Uttaranchal, double fortified salt has been introduced in ICDS scheme. I understand that in
Tamil Nadu also, DFS made by an Industry under the State Government is producing and
distributing DFS.

There are many private manufacturers, which are producing and selling DFS. It will be useful to
know how the industry is producing and selling the same?

We need to develop an evidenced based National Policy with regard to production and selling /
distribution of DFS in the country with clear objectives. Some issues which need to be addressed
are:
• Do we want to distribute DFS for increase in Hemoglobin?
• If yes, how much increase in Hemoglobin in how many years? (do we have adequate
evidence based data in this regard) or
• Do we want to distribute DFS "only" to increase in the intake of iron and iodine by
beneficiaries along with common salt?

We need to carefully deliberate on many other issues related to DFS so that there is objectivity in
the programme. This approach will help us to meaningfully evaluate the DFS programme after a
specific number of years of implementation. We do have specific guidelines under National Iodine
Deficiency Disorder Control Programme and a successful Iodized salt programme in the country.
We should not disturb it unless we have adequate scientific evidence on DFS.

Nira Ramachandran, Independent Consultant, New Delhi

The case for micro-nutrient fortification of food for pre-school and school children is a strong
one. Even in purely economic terms, studies have revealed that the benefits of investments in
micronutrient fortification far outweigh the costs (the costs tend to be a few cents per person per
year). Horton S makes very rough estimates of the annual potential costs attributable to iodine
deficiency in the developing world - $35.7 billion prior to widespread salt iodization, as compared
with an estimated $ 0.5 billion annual cost for salt iodization, i.e., a 70:1 benefit : cost ratio. A
more detailed incidence study for iron fortification (Horton and Ross) estimates that the benefit :
cost ratio has a median value of 6:1 for effects on physical productivity, which rises to 36:1 if
cognitive benefits are also included.

The nutrients most relevant for developing countries are iodine, iron, and vitamin A, with newly
emerging concern- zinc (for diarrhea prevention).

Home fortification with sprinkles which may contain iron, zinc, iodine, vitamins A, C, and D, and
folic acid has also been used to target weaning-age children. The unit costs tend to be higher
than for commercial fortification, but the intervention can be targeted to weaning-age children
who are particularly vulnerable to deficiency and who are unlikely to obtain enough of selected
micronutrients from foods fortified for the general population.

Estimates for Sprinkles for Pakistan, when primarily targeted to children 6–12 months, suggest
that cost per disability adjusted life year (DALY) saved could be as low as $12 (based on the
effects of zinc on averting diarrhea), and the benefit : cost could be 37:1 (based on the effects of
iron on future productivity due to cognitive benefits), which are quite similar to estimates for
commercial fortification. These estimates are based on intervention trials rather than a full-scale
program, but could be useful as similar conditions prevail in India.

In regions where rice is the preferred staple, bio-fortification may be considered, whereby higher
micronutrient density is either bred, or introduced via genetic modification, into staple food crops.
Bio-fortification of rice is of particular interest because it is more difficult and costly to fortify rice
by conventional means than the other grains. Preliminary work suggests this could be very cost
effective. For rice, high iron varieties have been identified and feeding trials have shown the iron
to be bio-available and to lead to higher body iron levels. Golden rice genetically modified to
contain a high beta carotene content aims at providing the recommended daily allowance of
vitamin A (in the form of beta carotene) per 100-200 grams of rice, which is the daily rice
consumption of children in rice eating countries, including India.

References: Horton S, The Economics of Food Fortification accessed at

http://jn.nutrition.org/cgi/content/full/136/4/1068

Indira Chakravarty, Public Health Engineering Dept, Govt. of West Bengal, West
Bengal
The questions being raised on fortification have been debated several times.

The main problem is that the sophisticated fortified foods only reach a few who really do not
need them. The other fortification methods implemented through various programmes, mostly
supported by the Government, has often raised questions with regards to their efficacy, safety,
cost as well as scientific reasons. And many of them are short time trial strategies supported by
various organizations.

I tend to agree with views by Dr Prema Ramachandran that salt is possibly the best option as a
vehicle. Other options which are rather enrichments and not fortification in the true sense could
be products like skimmed milk.

For a country like India where people are largely rural based, like to consume fresh foods and
have such varied dietary habits, fortification of foods is not one of the best options excepting in
some special cases.
Finally, trying out different methods through Government programs or otherwise on population
groups, which can be withdrawn after a period, is not at all recommended, as till date we have
no report what so ever on the withdrawal effects of these so called innovative products. It is
most unethical.

Mahtab S. Bamji, Dangoria Charitable Trust, Hyderabad

Food fortification is a good method of supplying micronutrients, provided the vehicle is consumed
by those who need the supplements. The level of iron and iodine fortification currently used in
double fortified salt assumes salt intake of 10gram per day. This is way above the current
recommendation of 2 gram to prevent hypertension. The issue needs to be re-visited and the
level of fortification increased without affecting the taste and stability.

Bio-availability of iron from fortified wheat flour may not be very good and needs to be carefully
studied.

Siddhartha Mukhopadhya, West Bengal Health Service, West Bengal (response 1)

I advise use of common salt to be fortified with iron, zinc, iodine along with vitamins such as
Vitamin A, C, D if it is possible and supply the salt in the Public Distribution System (PDS) to the
poor.

I also want to remind about the Hyderabad mix which was available for the malnourished
children. We should produce or create something which is indigenous in nature and which can
help our poor countrymen.

Bhaskar Goswami, Forum for Biotechnology & Food Security, New Delhi
The potential of Genetically Engineered (GE) foods to combat malnutrition in children is usually
overestimated - Golden Rice being a classic example. Given the rate of cereal intake of children,
Golden Rice can perhaps meet only 8-12.5% of Vitamin A requirement of one-three year old
children and 12.5-18.7% of those in the four-six years age group. Similarly, back in 2003 GE
Potato was touted as the answer to meet protein requirements of children by the Department of
Biotechnology. This is despite the fact that this protein enriched potato contains barely 2.5-2.8%
of protein as compared to pulses with 20% plus protein content.

K V Peter, World Noni Research Foundation, Chennai

Mother natures complete food for children below 3 years is mother’s milk. Lactating mothers
needs balanced diet and at least 2-3 litre of pure water and good air. Exposure to sunlight at
sunrise and sunset would be desirable. Consumption of common leaf vegetables like amaranth,
palak, pumpkin flower and drumstick leaf is recommended for high fibre and micronutrients.

We at World Noni Research Foundation, Chennai have come out with a Noni Juice
Concentrate which facilitates supply of nutraceuticals and micronutrients. Noni (Morinda
citrifolia L.) is called Indian Mulberry and used by polynesians for energizing the body. Details are
available in www.nonifamily.net

R.K.Baxi, Government Medical College, Baroda (response 1)

Salt consumption pattern studies in early eighties have shown that we consume about 12 to 15
grams of salt per head per day. Changing Biochemistry then recommended not more than 10
grams a day per head and now a doctor would recommend 5 to 7 grams per day per head and
cardiologists do not go beyond 5 grams per day per head. Hence, the time has come to think
beyond salt.

Ravishwar Sinha, Independent Consultant, New Delhi (response 1)

Thank you for the very interesting discussions on food fortification. It is very educative and
brings out differing concerns, which I respect. Sharing the deep concerns, I believe, of the
different discussants to eradicate / minimize micronutrient malnutrition I would like to submit -

Need -

There are different studies both nationally and internationally that show the efficacy of food
fortification in combating micronutrient malnutrition. NIN (National Institute of Nutrition), ICMR
(Indian Council of Medical Research), IAP, UNICEF, WHO, USAID, MI (Micronutrient Initiative)
are some of the leaders and would willingly share them to those who need them. There is data
on Iodine, Iron and Vitamin A in different program situations and is overwhelming.

Vehicle and Mode -

In India, a country but a continent programmatically, local variations from state to state and
within states are common in food intake and habits. There are solutions well in reach through
research and local adaptation. There are many examples. I believe the genius of the caring
development experts can find the solutions and have been doing so. This is not the situation to
let up but to enforce efforts. Sprinkles is a good option for reaching the un-reached with
micronutrient food fortificants.

Overdosing or adverse events in fortification -

The fortificant is in such doses that it is very unlikely to reach levels of overdose. The regulators
are strict. Some incidents that have been cited have other issues of adulteration, found to be the
cause. However strict quality control and training is a must for the care givers and the users.

Prakash V Kotecha, A2Z, the USAID Micronutrient Project, Academy for Education
Development, New Delhi
Fortified foods has variable but useful role of addressing micronutrient malnutrition in children.
This has been often discussed but the practical approach to major micronutrient malnutrition
issue remains a challenge and fortification has been more often found resistance both by
Government and by pure scientists for different reasons in India.

Double Fortified Salt (DFS) is fairly accepted now. But amount of iron that it can provide is not
worth comparing with amount of iodine it provides since 100% RDA (Recommended Daily
Allowance) of iodine can be given and we have no fear of toxicity. For iron we can provide small
fraction of RDA for number of reasons and theoretical but fear of toxicity remains. But small
proportion of iron in DFS would help every child. We need to see salt as food and not medicine.
We do not count or plan to measure how much a piece of bread would increase the WAZ score
(Weight-for-Age Z-score), we know it is food and would do good to a child who needs it, similarly
in 85% anemic child population small fraction of hemoglobin would improve with additional iron
gone in DFS.
For Supplementary nutrition in ICDS scheme according to Government of India's orders F/No/5-
9/2005/ND/Tech Vol (II) dated 24th February 2009 eight micronutrients to an amount of 50%
RDA need to be added in foods provided to children under six years of age. These include, iron,
folic acid, Vitamin A, Vitamin C, Thiamine, Riboflavin, Niacin and Calcium. Available at
ftp://ftp.solutionexchange.net.in/public/mch/resource/res20041001.pdf (PDF, Size: 678KB). How
far this is practiced is variable from state to state and from time to time. Further WHO/UNICEF
has two formulae for Multiple Micronutrient Powder and they have either 5 or 15
micronutrient while GOI has 8 micronutrients.

Other option is Biscuits fortified with micronutrient. Tiger biscuits are iron fortified. But content is
only small portion and like DFS would only be contributing slightly and cannot be in isolation be
relied to address micronutrient malnutrition in children.

Micronutrient to be fortified to foods with the objective of reducing micronutrient malnutrition is

purview of Drugs Control or Food Control is not clear as of today to the best of my knowledge
and that brings further confusion to practical approach on community level.

Expecting type of foods with specific impact in reducing micronutrient malnutrition by that food is
unrealistic. Impact is NOT a function of product alone. It is governed by large number of factors
that include, the level of micro nutrient malnutrition present, associated conditions in the
children, level of other malnutrition, other morbidities, their age and overall dietary intake of the
beneficiaries

We need to learn however from the global experience that to control micronutrient malnutrition
fortification, supplementation and other approaches will all have to be tried together to make a
difference and no single approach would ever work.

Uday Pathak, Mahavir Vatsalya Aspatal, Patna

Yesterday, I attended the meeting on Use of Zinc and Low Osmolar ORS in Management of
Childhood Diarrohea in Bihar by UNICEF and Govt. of Bihar advocating Zinc use over the counter.
The news is available at
http://epaper.livehindustan.com/ArticleImage.aspx?article=27_04_2010_008_001&mode=1

Zinc as we know interferes with iron absorption and there are other issues of how frequently it
can be used, how do we determine toxicity levels? Please share if there are any studies.

Soma Bhowmick, Pink Cascade Foundation, Shillong

Intake of iodized salt is definitely prescribed however its use in food preparation should be
continually reinforced. The distribution through the PDS (Public Distribution System) needs to be
done with a lot of caution coupled with scrutiny given the public perception about the efficacy
and integrity of the PDS in India.

Kejal Joshi, Department of Foods and Nutrition, The M.S.University of Baroda,

Vadodara

I am a Ph.D. student working on the impact of DFS (Double Fortified Salt) supplementation
amongst school children in rural areas. During our work its been observed that the rural
population is reluctant to consume any other food item which we supply as supplement other
than their daily foods due to negligence and limited resources. In such a situation salt can work
as a best vehicle in the population and may give some results.

Towards the end, the data may give some hint on efficacy of DFS on iodine and iron status of the
children after consumption for a long time.

R.K.Baxi, Government Medical College, Baroda (response 2)

Last and concluding part of response from Dr. Prakash V.Kotecha makes most sense. Otherwise,
all these efforts are like trying to fill up a bucket with a hole at the bottom.

Unless, PEM (Protein Energy Malnutrition) is addressed in the true sense of the word,
Micronutrient Malnutrition management remains of little value. If we take care of PEM, most
others will take care of themselves!

Samir K, Tata – Cini, Ahmedabad

Today, when we talk about fortified food, the adverse taste of latter keeps people away.
Contrastingly people turn towards foods which are enjoyable in taste or cheaper to consume
(especially for rural masses). Nothing fortified with vitamins and minerals has become extremely
or widely popular - maybe because of potential side effects or because the population in large is
not yet prepared to buy fortified food products which give positive health benefits rather than low
fat food or more healthy food stuffs.

The major shift in India would specially be focused on approach of people who today consider
fortified foods as some kind of drug and not really food! Moreover it would require some
determined and experienced expertise to conclude what amount of vitamin and mineral should
be present in fortified food. However the use of larger labels on food packets is tempting
consumers to check nutrient content in fortified foods and they have already started making wise
decisions (in urban areas). Considering rural mass, it might be a decade or more in adoption of
fortified food products in their daily diet by some or other means.

For addressing malnutrition issues in resource poor areas, fortified food could be a combating
solution right away. But specific and customized approach needs to be undertaken. Areas which
really require iodine should be supplied with it. Today almost every household in urban area uses
iodized salt (whereas it is unnecessary in many areas). Similarly micro nutrient study needs to be
undertaken as to which types of fortified foods are necessary.

Joy Daniel, Institute for Integrated Rural Development (IIRD), Aurangabad,

Maharashtra
I wonder if fortified foods can help the local village economy. The ICDS programme usually tap
into the local SHGs (Self Help Groups) for the preparation of foods for the mid day meals and
Anganwadis. This definitely improves incomes of the SHG members and the rural economy.
However, if fortified foods are introduced from outside, it does not do much good to rural
economy. We have to identify ways that will promote rural enterprises while at the same time
bring about better nutrition to the children.

There are enough studies to conclude that millets (Sorghum, Pearl millets, Foxtail millets, etc)
have a good amount of minerals and other nutrients. In areas where millets are grown (which
are incidentally the most backward and driest regions), it would be better to introduce millets to
the mid-day meals. The policy makers and civil society organizations would do better to identify
ways for value addition of millets (for improved taste, shelf life, and packaging) that suits
children. This value addition and marketing if done in the respective villages will have positive
impact on the rural economy.

Umesh Kapil, AIIMS, New Delhi (response 2)

The common salt is possibly the best vehicle for fortification with iron and iodine. It is consumed
in almost equal quantity by all segment of the population in all socioeconomic groups. I
understand that in Karnataka state DFS (Double Fortified Salt) developed by an international
agency, has been utilized for effectiveness trial. Kindly see the article mentioned below.

Dual fortification of salt with iodine and iron: a randomized, double-blind, controlled
trial of micronized ferric pyrophosphate and encapsulated ferrous fumarate in
southern India by M Andersson, Prashanth Thankachan, Sumithra Muthayya, Ramakrishna B
Goud, Anura V Kurpad, Richard F Hurrell and Michael B Zimmermann; American Journal of
Clinical Nutrition, Vol. 88, No. 5, 1378-1387, November 2008

Background: Dual fortification of salt with iodine and iron could be a sustainable approach to
combating iodine and iron deficiencies.

Objective: We compared the efficacy of dual-fortified salt (DFS) made by using 2 proposed
contrasting formulas—one fortifying with iron as micronized ground ferric pyrophosphate
(MGFePP) and the other with iron as encapsulated ferrous fumarate (EFF)—with the efficacy of
iodized salt (IS) in schoolchildren in rural southern India.

Design: After stability and acceptability testing, a double-blind, household-based intervention

was conducted in 5–15-y-old children (n = 458) randomly assigned into 3 groups to receive IS or
DFS with iron as MGFePP or EFF, both at 2 mg/g salt. We measured hemoglobin, iron status, and
urinary iodine at baseline, 5 mo, and 10 mo.

Results: Median serum ferritin and calculated median body iron improved significantly in the 2
groups receiving iron. After 10 mo, the prevalence of anemia decreased from 16.8% to 7.7% in
the MGFePP group (P < 0.05) and from 15.1% to 5.0% in the EFF group (P < 0.01). The median
urinary iodine concentration increased significantly in the IS and EFF groups (P < 0.001) but not
in the MGFePP group. Losses of iodine in salt with 1.8% moisture were high for MGFePP,
whereas the EFF segregated in salt with 0.5% moisture and caused color changes in some local
foods.

Conclusions: Both DFSs were efficacious in reducing the prevalence of anemia and iron
deficiency in school-age children. Local salt characteristics should be taken into consideration
when choosing an iron fortificant for DFS to achieve optimal iodine stability and color.

Abstract Available at www.ajcn.org/cgi/content/abstract/88/5/1378

We need to have DFS for combating the problems of iron and iodine deficiencies which is present
in all parts of the country. However, we need to have hard scientific data to select a particular
DFS, otherwise it will be like any routine fortified food available in the market, which increases
the intake of micronutrient but do not claim any health benefits.

Kaniz Fatima Muneeza, Aga Khan Foundation, New Delhi

The answer to the problem of under nutrition may not completely be tackled by food micro-
nutrient fortification. As stated by one of the scholars earlier PEM (Protein Energy Malnutrition)
also has to be taken into account with the problem of under nutrition. Here are a few
suggestions:
1. Given the agricultural diversity of the country, a mix of locally available food grains and
at times other foods available outside have to be judiciously mixed to be provided to
children.
2. Creation of local recipes for complementary feeding of children, wherever possible.
3. Persistent education of parents on hygiene and feeding practices.

S. S. Thorat, Mahatma Phule Krishi Vidyapeeth, Rahuri, Maharashtra

For enriching diets with micro-nutrients particularly minerals the most neglected minor millets
(with some pretreatments) and their value added formulations should be included in diets of the
vulnerable groups.

By doing so we can improve the nutritional value and also farmers can get remunerative prices
for these millets. This will be more economical also.

Keya Chatterjee, Ekjut, Jharkhand

This debate on fortification is turning out to be very interesting. I have just two queries:

(a) Is there any evidence that fortification of food has improved health?
(b) What are the commercial stakes/ interest, since I see it as a huge potential market?

Ramit Basu, GoI-UN Joint Programme on Convergence, Programme Management

Unit, New Delhi
I would take a very different view to this entire issue of using fortified foods to combat
malnutrition as if we are left with no other option. This is just like advocating for GM (Genetically
Modified) crops to meet the rising food grain demand in our country without having done a
comprehensive assessment of the potential of current agricultural system as to whether it is able
to meet the requirements and what all need to be done to raise productivity.

I think using fortified foods in a country which has a rich practice of using indigenous and locally
available food materials (with high nutrient content) is not at all a viable proposition - both from
the social as well as economic view points.

Using fortified foods as a supplement will take away the opportunity or rather will put much less
emphasis on the local agricultural system to be improved which answers most of the nutrition
related issues. It will be in stark contrast to every effort to revive our dying agriculture.

Indigenous people are aware about the rich biodiversity existing around them which holds the
key to reducing malnutrition and there is every reason why we should promote such agro-
biodiversity. This will raise local production levels, will become economically viable for the small
and marginal farming communities and will most importantly move towards a degree of self
reliance thus reducing the dependency on external food products. It will in a way strengthen the
internal money circulation.

This will also be socially and culturally acceptable as against fortified foods and I think all of
these can be achieved by converging existing government programmes like NREGA, RKVY, NFSM
which focuses on rejuvenation of the natural resources and giving impetus to improved
agricultural systems at decentralized levels.
Once we achieve the above which is certainly do-able, only then we should consider mapping the
gaps and if needed supplement it with fortified foods.

Arun Gupta, BPNI, New Delhi

I totally concur with views expressed by Ramit Basu, and our country also faces the threat of
"products" for severely malnourished children, essentially using the same arguments. These
products do not look at the underlying factors at all. What should we do to tackle is a
comprehensive set of strategies, for convenience put together by the Working Group of Children
Under Six.

The paper is available at ftp://ftp.solutionexchange.net.in/public/mch/resource/res20041002.pdf

(PDF, Size: 253 KB). Full document can be requested from Right to Food Secretariat.

The basics have to be set right, e.g. let people get food first and if they are deficient then one
may resort to giving what ever the deficiency is.

Siddhartha Mukhopadhya, West Bengal Health Service, West Bengal (response 2)

The Hyderabad mix was an ICDS product of 1970 for the malnourished children of India. It was
prepared by the cereals along with locally available pulses. It was immensely popular and was
able to supply energy of nearly 600 kcal from 100 gram of food.

If we can add zinc, iron and other vitamins we can prepare a low-cost meal for the poor
undernourished children.

Ch. Santakar, Journalist, Koraput, Orissa

Rather than fortification of food items, more suitable option could be to promote the concept of
having a balanced diet in the rural families. This is because even if the fortified food was made
available for its richness and the promises of well being, the poor who are the really deprived of
qualitative food select their items on the basis of easy accessibility which very often is not the
fortified food. Hence once they are sensitized on the importance of a balanced diet, it is possible
that they might start taking more nutritious food.

Chandrakant S Pandav and Kapil Yadav, AIIMS, New Delhi

It has been widely acknowledged that micronutrient fortification has one of the highest cost
benefit ratio not only amongst available health interventions but even amongst all development
related interventions. Based on our experience with salt iodine fortification we have realized that
only economic criterion is not sufficient to translate any policy into a successful program.

The dynamic evolution of National Iodine Deficiency Disorders Control Program (NIDDCP) in
India provides a unique opportunity to study the interaction between research, programme policy
and decision making and identify solutions for the future. The sudden lifting of ban on sale of
non-iodized ban in India in year 2000 was a shock for academician and researchers engaged in
IDD research. The arguments forwarded by the proponents advocating removal of ban
highlighted the importance of “values” in influencing the formulation of policies in a democratic
setup like India. The academicians and researchers realized, though in hindsight, that the lack of
focus in previous years on influencing the “Values” of different stakeholders and community at
large was one of the major failures of NIDDCP in India.
Lessons Learnt From NIDDCP: Values in form of core values, beliefs, interests have an important
bearing on implementation and sustainability of policies. Implementation of policy based only on
scientific evidence will not only achieve less than optimum results but more seriously may also
lead to a retrograde step as seen in the case study of NIDDCP. In an ideal scenario “values”
should form a valuable input in policy formulation and program implementation along with other
essential inputs like problem identification and scientific evidence.

It is imperative that stakeholder analysis is carried prior to development of any health policy and
program implementation. Stakeholder analysis is a process of systematically gathering and
analyzing qualitative information to determine whose interests should be taken into account
when developing and/or implementing a policy or program. Stakeholders include persons or
organizations, who have a vested interest in the policy that is being promoted are considered
stakeholders in the process. These stakeholders or “interested parties” can usually be grouped
into the following categories: international, public, national political, commercial/private,
nongovernmental organization (NGO)/civil society, labor, and users/ consumers. Knowing who
the key actors are, their knowledge, interests, positions, alliances, and importance related to the
policy allows policy makers and managers to interact more effectively with key stakeholders and
increase support for a given policy or program. By carrying out this analysis before implementing
a policy or program, policy makers and managers can detect and act to prevent potential
misunderstandings and/ or opposition to the implementation of the policy or program. A policy or
program will more likely succeed if a stakeholder analysis, along with other key tools, is used to
guide its implementation.

S. Nair, Faculty of Family and Community Sciences, The M. S. University of Baroda,

Vadodara, Gujarat
All the contributors worded meaningfully from own areas and perspectives. My experiences with
fortification are suggestive that, it is highly beneficial in urban as well as rural scenario. Major
success remains when we are able to convince the consumers who are using it, especially it is
their right to know what deficiency do they have, thus they need to consume the fortified items.

I have used Double fortified salt as a replacement from the daily salt though minor, the changes
are playing a contributory role when it is used in long term strategies and programmes mainly
because of sustained release of Iron and Iodine.

Using it in a pregnant mother’s diet did not bring any significant change in iron, but contributory
roles in Iodine levels were observed. In children, along with dietary counseling and improved
food intake, mothers opined that they have become more active and fatigue is not seen. This is
suggestive that we need to promote consumer education before introducing the fortificant. It
would add more meaning to our contributions.

Parimal Parya, NIHFW, New Delhi

The ICDS programme has been going on for more than three decades and mid day meals
scheme has also been there for so many years. India is a food sufficient country. The average
per capita consumption of food has been increased and nobody is starving in our country. Why
do we need to fortify foods for improving the nutritional status?

Do we need to introduce another programme when all the programmes / Schemes are poorly
running? It is not better to give attention to the quality of foods which are being provided to
children. Even if we are able to maintain the quality, it will automatically improve the nutritional
status of our children. How would we assure that the micro nutrient enrich quality supplement
foods will reach the children who need it most?

Kusum Gopal, UNESCO, United Republic of Tanzania

I agree with the views expressed by Mr Ramit Basu. We need to encourage and invest in local
agricultural products and particularly learn from indigenous traditions that are pre-colonial such
as Gur (Jaggery) production as indeed, use of unpolished rice and fresh vegetables and fruits
from the forests.

Kitchen gardens must be made a priority and where land is scarce allotments can be provided
along with water and seeds. Some lessons can be learnt from pooling of resources and spirit of
cooperation such as the rich langar (free meals to community) tradition and common kitchens for
two meals a day provided.

S. Murali Mohan, Visakhapatnam

For wheat eaters, Atta (Wheat Flour) fortified with minerals and vitamins is a good choice and
can be implemented as part of the mid-day meal program for school children. This can also be a
part of the supplementary food supplied to pregnant mother under the Government scheme.

The availability of various vitamins and micro minerals at reasonably low prices in our country
may be made use of by the Government and fortification may be made compulsory for branded
Atta (Wheat Flour) and Maida (Refined Wheat Flour) both of which are quite popular products.

Another new entrant in Indian consumer market is table margarine and spreads. Mandatory
fortification is only for Vitamin A for these products. These actually are excellently suited for
fortification with a whole range of vitamins both oil-soluble and water-soluble. Only a small cost
increase will be incurred but the benefits obtainable are immense.

When considering nutrition policy matters one should not be overly concerned with affordability
and funding alone. Mandating fortification with essential (as seen in the surveys) micronutrients
will help our health standards improve to decent levels.

V.R. Jani, The Panchmahal District Cooperative Milk Producers' Union Ltd, Godhra,
Gujarat
The discussions on this query have been quite interesting. Lots of views and suggestions on the
matter have been presented by the learned forum members. We have successfully tried to
combat this issue in tribal/malnourished pockets of Panchmahal and Dahod districts of eastern
Gujarat.

The Mid day meal programme is being implemented since many years now. The issues of
malnutrition and stunted growth in children are yet to seek the suitable and satisfactory
solutions. With the help of District Administrators, under various schemes of TASPs and DRDAs
supply of Vitamin’s fortified pasteurized flavored fresh milk to the children has been successfully
tried. Initially, all the primary school children of 2 selected tehsils were provided 200 ml of
pasteurized toned flavored milk daily - about 100000 pouches. The insulated boxes have been
specially designed to ensure the desired quality of milk till it reaches to children. The periodic
change in flavors like rose, kesar, strawberry, eliachi etc has been attractive enough for children
to consume milk regularly. The funds for this project are made available by Govt. of Gujarat,
under ambitious Vanbandhu Project. Some other pockets in South and North Gujarat also have
the similar projects in operation.

Getting the desired success, since last year the similar project is being implemented for
Aanganwadi children with the help of ICDS. These small kids are provided the pasteurized
fortified flavored double toned milk having low fat. There has been significant improvement in
the overall health and growth parameters of the beneficiary children. After all, Milk being the
complete food, it takes care of many useful nutrients required by the growing children. The
propagation of such projects can be the real solution of the issue in question.

Ravishwar Sinha, Independent Consutant, New Delhi (response 2)

I appreciate the feelings expressed by Mr Basu. I do not believe that there is any doubt that a lot
has been and is being done to increase the nutrient content of the foods on the Indian plate. The
agriculture efforts are remarkable and these should enhance. However nowhere in the near
future do we see the problem being solved in its entirety.

The question is what we do for the people till then? When every second child is malnourished
every thing possible should be done. The challenging fact is that the nutrient and micronutrient
content of the Indian plate is very deficient, specially, if we focus on the not so privileged. Indian
studies be it of NIN, ICMR or NFHS, the scenario is the same. The reasons are well known and
need not be repeated. To meet the challenge of malnutrition, food quality and quantity have to
improve and so has many other things that need to happen simultaneously.

Food fortification is one of these activities and in no way exclusive or singular. It is and shall be a
supplementary activity to food. Secondly it needs to be appreciated that even in the nutritionally
better of countries food fortification is an ongoing activity. Do we deny our people the benefit of
scientific knowledge?

Purnima Menon, International Food Policy Research Institute (IFPRI), New Delhi
The issue of whether or not to fortify, what to fortify, with what, and for whom, must be
evidence-based. The fact remains that in India, micronutrient deficiencies are sky-high,
particularly deficiencies of micronutrients that are critical for cognitive and brain development of
infants, immune functioning, fetal development, and work performance of adults. It is in fact,
almost utopian, to expect that all nutrient needs of all population groups can be met through only
unfortified foods, or without the use of some kinds of supplements.

No developed country has removed folate deficiency and iron deficiency in the population without
the use of fortified foods. If 65% of children even in the highest wealth quintile (NFHS-3 data)
are anemic, surely this is something that should make us sit up and introspect/analyze the
situation. Additionally, there are vulnerable groups, such as young infants (6-24 months) whose
nutrient needs for iron and zinc cannot be met even if they are consuming red meats (we have
published work on this issue). Identifying creative solutions, including fortification, bio-
fortification, diet diversification, etc., in concert with each other, is beyond critical to address the
problems that India faces. This should not be an either-or discussion, but rather, a discussion of
what information can and should be used to decide what solutions are useful in different
contexts. India is, if anything, a country of contrasts and context-specific solutions are needed.
Fortifying the foods in ICDS, mid day meals, and other large programs can have substantial
benefits, and this can be done without introducing corruption. West Bengal's experiments with
centre-based fortification of khichdi and the evidence of that on addressing anemia are a good
example; many other exist.
Again, the main point here is that one has to take an analytical view of the situation, and identify
solutions that are context-specific and context-appropriate, rather than advocate for one thing or
the other without full consideration either of the magnitude of the need, or the
constraints/facilitating factors in the context.

I hope this helps the discussion. Warm regards to all.

Kirtiman Awasthi, UNDP, New Delhi

I am no expert on food and nutrition issues. However I would like to share my experience on
micronutrient supplementation through food fortification based on my desk research to find out
suitable food supplement for my three year old child.

The effects of micronutrient deficiency extend far beyond the known effects like anaemia, goitre
etc. It has potential to affect economic growth and over all development as affected populations
are unable to achieve full mental and physical growth, have low work capacity and are prone to
infections.

Food fortification has been a cost-effective and sustainable solution compared to giving
micronutrients as medicinal supplement to overcome micronutrient deficiency. Iodized salt is a
successful, cost-effective and sustainable solution of food fortification. In India food fortification
however has to go beyond iodine in salt. Even for salt, the technology for double fortification of
salt with iron and iodine was developed way back in India, but I do not see such product in the
market.

Flour fortification has been done in many Latin American countries. In Chile and Venezuela, iron
fortification helped in overcoming iron deficiency to a large extent. Food fortification in Denmark
helped overcome high incidences of night blindness due to Vitamin A deficiency in children. There
margarine was fortified with vitamin A. Similarly, milk was fortified in Europe and North America
to overcome Vitamin D deficiency. In some countries even noodles and sauce are fortified with
micronutrients. Fortifying flour with iron and vitamin A has been mandatory in the Philippines
since 2004. So far technologies to fortify rice are limited.

Our choice of food vehicles would depend on their local availability. Rice and wheat are staple
food, locally available and can be fortified. Delhi began fortifying flour in November last year
through a program jointly initiated by the Delhi Government and the Delhi Roller Flour Mills
Association, where wheat flour is being fortified with iron and folic acid. However, in most other
parts of the country wheat/ rice is grown, processed and consumed locally. Is safe and
standardize fortification possible at that level? And also how many of these food items are
intended to address micronutrient deficiency in infants?

Anshuman Das, DRCSC, West Bengal*

National feeding programme, specifically ICDS and midday meal scheme, created opportunity for
creating linkages with
• local farmers'/producers' group
• gardeners' group
• local SHGs who are doing food processing
• parent's group which can contribute, as participation, in the programmes etc.

However, we overlooked the scope of creating such linkages, motivating people to take part in
the government programme.
When we are thinking about fortified food, we are inviting companies who will again use this for
making their own profit and inviting other problems. Why do we have to always think about ex-
situ external synthetic food products when we think about tackling malnutrition.

A simple nutrition garden with locally available leafy vegetable/fruits and one egg daily can make
a sea change in nutrition status of the children. We, DRCSC (www.drcsc.org), through our school
garden programme have tried this in tribal area with very good result.

We are underestimating our natural resources while proposing such fortified food and
micronutrient.

Many thanks to all who contributed to this query!

If you have further information to share on this topic, please send it to Solution Exchange for the
Food and Nutrition Security Community in India at se-food@solutionexchange-un.net.in or
Solution Exchange for the Maternal and Child Health Community in India at se-
mch@solutionexchange-un.net.in with the subject heading “Re: [se-food] [se-mch] Query: Use of
Fortified Foods and Micronutrient Malnutrition in Children - Examples; Experiences. Additional
Reply.”

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