Nutrition Solution Exchange

8/9/2019 Nutrition Solution Exchange

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Query: Use of Fortified Foods and Micronu trient Malnutritionin Children - Examples; Experiences

Compiled by Gopi Ghosh an d Joy Elamon, Resource Persons and T.N.Anuradha,Shweta Tyagi an d Meenakshi Aggarwal, Research Associates

Issue Date: 17 June 2 010

From Vanisha Nambiar, The M.S. University of Baroda, Vadodara,GujaratPosted 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 whoare 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 preventmalnutrition, food fortification has been proved to be socially acceptable, requires no change infood habits and is the most cost effective way of reaching large target populations that are at riskof micronutrient deficiency.

There are several health foods available in the Indian market claiming to be fortified withvitamins and minerals. However, food fortification is sometimes opposed for professional reasons(concern about overdoses) or on human rights grounds (consumers should be informed aboutthe 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 ChildDevelopment Services (ICDS) and Mid day Meal (MDM) Scheme in India has been initiated in theState of Gujarat via fortified wheat flour, nutri-candy, use of oil fortified with Vitamin A and D andiodized salt.


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I would request members of the Food and Nutrition Security and Maternal and Child Healthcommunity 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 tocorroborate the issue of use of fortified foods for reducing micronutrient malnutrition in children.This discussion will hopefully encourage other organizations, financing systems to introducefortified foods for strengthening the ongoing developmental programmes for childhoodmalnutrition, especially multiple micronutrient deficiencies in India.

Looking forward to a fruitful interaction.

Responses were received, with thank s, from

1. Prema Ramanchandran, Nutrit ion Foundation of India, New Delhi2. Phani Mohan, Consultant, Chennai3. Umesh Kapil, AIIM S, New Delhi (Response1, Response2)4. Nira Ramachandran, Independent Consultant, New Delhi5. Indira Chakravarty, Public Health Engineering Dept, Govt. of West Bengal, West

Bengal6. Mahtab S. Bamji, Dangoria Charitable Trust, Hyderabad7. Siddhartha Mukhopadhya, West Bengal Health Service, West Bengal (Response1,

Response2)8. Bhaskar Goswam i, Forum for Biotechnology & Food Security, New Delh i9. K V Peter, World Noni Research Foundation, Chennai10.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 M icronutrient P roject, Academy for Education

Development, New Delhi13.Uday Pathak, Mahavir Vatsalya Aspatal, Patna14.Soma Bhowmick, Pink Cascade Foundation, Shillong15.Kejal Joshi, Department of Foods and Nutrition, The M.S.University of Baroda,

Vadodara

16.Samir K, Tata CINI , Ahmedabad17.Joy Daniel, Institute for Integrated Rural Development (IIRD), Aurangabad,

Maharashtra18.Kaniz Fatima Muneeza, Aga Khan Foundation, New Delhi19.S. S. Thorat, Mahatma Phule Krishi Vidyapeeth , Rahuri, Maharashtra20.Keya Chatterjee, Ekjut, Jharkhand21.Ramit Basu, GoI-UN Joint Programme on Convergence, Programme Management

Unit, New Delhi22.Arun Gupta , Breastfeeding Promotion Netw ork of India (BPNI ), New Delhi23.Ch. Santakar, Journalist, Koraput, Orissa24.Chandrakant S Pandav and K apil Yadav, AIIMS, New Delhi25.S. Nair, Faculty of Family and Comm unity Sciences, The M. S. University of Baroda,

Vadodara, Gujarat


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26.Parimal Parya, National Institute of Health and Family Welfare (NIHFW), NewDelhi

27.Kusum Gopal, UNESCO, United Republic of Tanzania28.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 (I FPRI), New Delhi31.Kirtiman Awasthi, UNDP, New Delhi32. Anshuman Das, Development Research Communication and Services Centre

(DRCSC), West Bengal*

* Offline Contribution

Further contributions are w elcome!

Summary of ResponsesComparative Experiences

Related ResourcesResponses in Full

Summary of Responses

Fortified foods have variable but useful role in addressing micronutrient malnutrition. The effectsof micronutrient deficiency extend far beyond the known health effects with potential to affecteconomic growth and overall development of the population. Food fortification has been a viableoption compared to giving micronutrients as medicinal supplement to overcome micronutrientdeficiency. The practical approach in addressing micronutrient malnutrition though remains achallenge.

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

Salt is one of the most suitable vehicles for fortification. About 70-90% of the population in Indiaestimated 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 technologydeveloped by National Institute of Nutrition (NIN) for preparing DFS is useful for combating thisdeficiency. Though the amount of iron that it can provide is not worth comparing with amount ofiodine provided but small proportion of iron in DFS can help every child. Members suggestedtesting the effectiveness of this technology under public health conditions.

Some States like Uttaranchal, Chattisgarh and Himachal Pradesh have been providing DFS atsubsidized cost through Public Distribution System and to ICDS beneficiaries. In Karnataka, Dualfortification of salt with iodine and iron under controlled trial were efficacious in reducing theprevalence of anemia and iron deficiency in school children. Use of DFS in pregnant mothers dietdid not bring any significant change in iron levels, but contributory roles in iodine levels wereobserved. In children, along with dietary counseling and improved food intake, mothers said thatthey have become more active with no fatigue. At the same time, the level of iron and iodine


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currently used in double fortified salt assumes salt intake of 10 gram per day which is way abovethe current recommendation of 2 gram to prevent hypertension.

The West Bengal experiments of fortifying khichdi (a mixture of lentils and rice) with a premixfortified with iron and vitamin A demonstrated a significant positive impact. Other innovativeproducts like fortified lozenges and multiple micronutrient powders have been tried by

Micronutrient Initiative to improve the intake of vitamins and minerals by young children. Homefortification with Sprinkles containing iron, zinc, iodine, vitamins A, C, and D, and folic acid havealso been used targeting weaning children.

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

Bio-fortification of rice is of particular interest because it is more difficult and costly to fortify riceby conventional means than other grains. Feeding trials with high iron varieties of rice haveshown the iron to be bio-available and to lead to higher body iron levels. Golden rice geneticallymodified 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 wholerange of vitamins both oil-soluble and water-soluble. However, mandatory fortification is only forVitamin A for these products.

In Gujarat with the help of District Administrators, children were given Vitamin fortifiedpasteurized flavored fresh milk. It lead to significant improvement in the overall health andgrowth parameters of the beneficiary children. In Chennai, World Noni Research Foundation hasinitiated fortification of juice which facilitates the supply of nutraceuticals and somemicronutrients.

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

Government of India notification mandates eight micronutrients to an amount of 50% RDA(Recommended Dietary Allowances) in foods provided to children below six as supplementarynutrition 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 MultipleMicronutrient Powder with 5 or 15 micronutrient. Mid Day Meal (MDM) Guidelines also suggestuse 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 acountry like India where people are largely rural based, like to consume fresh foods and havesuch varied dietary habits, fortification of foods is not one of the best options except in somespecial cases. Members pointed out that at times the adverse taste of fortified food keeps peopleaway from it. Thus it is essential that the food selected for fortification is acceptable, availableand affordable to the targeted communities.


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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 villageeconomy is also low. There is a need to identify ways that will promote rural enterprises whileproviding better nutrition to children. Enough studies conclude that millets (sorghum, pearlmillets, 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, andpackaging) that suits children. Indigenous people are aware about the rich biodiversity existingaround them which holds the key to reducing malnutrition and hence the need to promote suchagro-biodiversity.

In 1970, the ICDS product for malnourished children called Hyderabad mix was immenselypopular. It was prepared using cereals along with locally available pulses and supplied nearly 600kilo 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 economiccriterion 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 arequite popular products has to be made compulsory. The intake of iodized salt in food preparationhas to be continually reinforced.

Impact on nutritional status is not a function of the product alone and it is unrealistic to expectdifferent foods to have specific impact on reduction of micronutrient malnutrition. A large numberof factors govern these including, the level of micro nutrient malnutrition, associated conditions,level of macronutrient malnutrition, morbidities, their age and overall dietary intake of thebeneficiaries. 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 tocarry out stakeholder analysis prior to development of any nutrition policy and programimplementation.

To control micronutrient malnutrition, fortification and supplementation apart from regularnutritious diet along with different approaches have to be tried together to make a difference andno single approach would ever work.

Comparative Experiences

Gujarat

Flavoured Milk Draws Children to consume milk daily, (V.R. Jani, The Panchmahal DistrictCooperative Milk Producers' Union Ltd, Godhra, Gujarat)

In various districts of Gujarat, the primary school children were provided vitamins pasteurizedtoned 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 hasbeen quite attractive for children to consume milk on a regular basis. This has led to significantimprovement in the overall health of children. Read more

Tamil Nadu


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

FromMeenakshi Aggarwal, Research Associate

Multiple States

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

Combating Moderate Malnutrit ion using Home Sprinklers

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

Related Resources

Recommended Documentation

FromUmesh Kapil, AIIMS, New Delhi

Dual Fortification of Salt with Iodine and Iron: A randomized, double-blind, controlledtrial of micronized ferric pyrophosphate and encapsulated ferrous fumarate insouthern IndiaAbstract; by Maria Andersson, Prashanth Thankachan, Sumithra Muthayya, Ramakrishna B Goud, Anura V Kurpad, Richard F Hurrell and Michael B Zimmermann; American Journal of ClinicalNutrition; November 2008Available 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 combatingmicronutrient deficiencies

The Great Vitamin A FiascoManuscript, 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 providingto children between 6 months and 5 years, regular supplements of massive medicinaldoses of vitamin A

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


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Article; by Sue Horton, American Society for Nutrition Journal of Nutrition, Volume 136, April2006Available at http://jn.nutrition.org/cgi/content/full/136/4/1068

Paper summarizes some of the literature on the cost effectiveness and cost benefit offood fortification with selected micronutrients most relevant for developing countries.

Strategies for Children under Six (FromArun Gupta, BPNI, New Delhi)Paper; by Arun Gupta, Biraj Patnaik, Devika Singh, Dipa Sinha, Jean Drze, Radha Holla, SamirGarg, 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 tocombat micronutrient malnutrition in this age group

Delhi Fortified Wheat Flour Scheme A Big Hit (fromKirtiman Awasthi, UNDP, New Delhi)Article; by Gaurav Vivek Bhatnagar; The Hindu; 1 January 2010Available at http://beta.thehindu.com/news/cities/Delhi/article74013.ece

Reports the Delhi Governments scheme to sell reasonably priced fortified wheat flour atRs.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, WestBengal (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 (PDFSize: 2.25 MB)

The Hyderabad mix provides 9 g of protein and 260 kcal with 500 mg sulphur aminoacids and 400 mg lysine per meal.

FromT N Anuradha, Research Associate

Community-level Micronutrient Fortif ication of a Food Supplement in India: AControlled Trial in Preschool children aged 36-66 mon thsAbstract; by Jessica L Varma, Soumita Das, Rajan Sankar, Marthi G Venkatesh Mannar, F JamesLevinson and Davidson H Hamer; American Journal of Clinical Nutrition, Vol. 85, No. 4, 1127-1133, April 2007Available 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 thecommunity level to prepared khichdi in increasing iron and vitamin A stores

Home Fortif ication with Multiple Micronutrients: Effectively Preventing IronDeficiency Anaemia in Infants and Young ChildrenJoint Statement; by Micronutrient Initiative, International Nutrition Foundation and the SprinklesGlobal Health Initiative at Sick KidsAvailable at: http://www.sghi.org/resource_centre/MISGHIIDPAS.pdf(PDF, Size: 111 KB)

Elaborates on the Sprinkles Global Health Initiative doing home Fortification with MultipleMicronutrients

Acceptability of Double-Fortified Salt in Foods (Table 5)Food and Nutrition Bulletin Vol. 17, No. 1; UN University Press; March 1996Available at: http://www.unu.edu/unupress/food/8f171e/8F171E0e.htm

Article gives information about organo-leptic properties of DFS in various food items andtrials on loss of iron and iodine on transportation.


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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 forMicronutrient Interventions; May 1995Available at: http://www.jsi.com/intl/omni/fe_ch13.htm

A review article on iron deficiency anemia in children and information on pilot project inRajasthan, where DFS will be given to children

New Weapon in War on M icronutrient DeficienciesBy Michael Boulet; International Development Research Centre; July 1996Available at: http://archive.idrc.ca/books/reports/1996/17-01e.html

Article on breakthrough in food-fortification technology allowing iodine and iron to beadded to salt, represents major advance in efforts to prevent micronutrient deficiencies

FromShweta Tyagi, Research Associate

Development of a New Tapioca Product with Tropical Fruit Pulp and Soy ExtractArticle; 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 productsthat can be used for the same

Micronu trient Fortification of Foods- Rationale, Application and ImpactPaper; by M G Venkatesh Mannar and R Shankar; Indian Journal of Pediatrics; Ottawa;November 2004Available 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 andminimize malnutrition

Nutrit ionAnnual Report; by National Institute of Nutrition; 2000-2001Available 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 inIndia

Mid Day Meal Scheme (fromMeenakshi Aggarwal, Research Associate)Guidelines; Department of Elementary Education and Literacy, Ministry of Human ResourceDevelopment Available at http://education.nic.in/mdm/FINAL_Guidelines_MDM_19_sept.pdf (PDF, Size: 200KB)

Provides information on the national feeding programme providing nutritional support toprimary school children, covering nearly 12 crore children

Recomm ended Organizations and Programmes

National Institute of Nu trit ion (NIN), Hyderabad (fromPrema Ramanchandran , NutritionFoundation of India, New Delhi)Jamai-Osmania, Hyderabad 500007, Andhra Pradesh; Tel: 91-40-2719-7200; Fax: 91-40-2701-9074; [email protected]; http://www.ninindia.org/nin.htm;


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Has developed various technologies for food fortification, especially for iodine and ironfortification of salt

National Iodine Deficiency Disorder Control Programme, New Delhi (fromUmesh 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.htmWorking towards the iodine deficiency in the country, also has specific guidelinesconcerning the iodine fortification

World Noni Research Foundation, Chennai (from K V Peter , World Noni ResearchFoundation, Chennai)No. 12, Rajive Gandhi Road, Old Mahabalipuram Road, Perungudi, Chennai 600096, Tamil Nadu;Fax : 91-44-2442-3601; [email protected]; www.nonifamily.net

Working towards the goal of creating a healthy population in a world of wellness andwellbeing, also developing fortified juices and other products

FromRavishwar 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; [email protected];http://www.icmr.nic.in/

Has been working on formulation and promotion of biomedical research in India, carryingout research on malnutrition and food fortification

Indian Academy of Pediatrics (IAP), MumbaiKailas Darshan, Kennedy Bridge, Mumbai 400007, Maharashtra; Tel: 91-22-2388-9565, 22-2388-7922, 22-2388-7906; Fax: 91-22-2385-1713; [email protected]; http://www.iapindia.org

Has been committed to the improvement of the health and well being of all childrenespecially regarding the micronutrient malnutrition

Micronutrient Initiative (MI), New Delhi11, Zamroodpur Community Centre, Kailash Colony Extension, New Delhi 110048, Delhi; Tel: 91-11-4100-9801, 4100-9807; Fax: 91-11-4100-9808; [email protected];http://www.micronutrient.org/english/View.asp?x=603

Contributing to initiate awareness on micronutrient malnutrition and devising ways andmethods to combat the same

From Ravishwar Sinha , Independent Consultant, New Delhi andPrakash V Kotecha , A2Z, theUSAID Micronutrient Project, Academy for Education Development, New Delhi

United Nations Childrens Fund (UNICEF), New Delhi73 Lodi Estate, New Delhi 110003, Delhi; Tel: 91-11-2469-0401, 2469-1410; Fax: 91-11-2462-

7521, 2469-1410; [email protected]; http://www.unicef.org/india/children_2356.htmActively working for safeguarding health of children and working on issues ofmalnutrition

World Health Organization (WH O), New Delhi537, 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; [email protected];http://www.who.int/nutrition/publications/anaemia_iron_pub/en/index.html


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Has been working for improving public health and implementing programmes to tacklemicronutrient malnutrition

United States Agency for International Development (USAID), New DelhiAmerican 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 thehealth status of people around the globe

International Food Policy Research Institute (IFPRI), New Delhi (fromPurnima 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;[email protected]; 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 assessingthe micronutrient malnutrition in children

Panchm ahal District Cooperative Milk Producers' Union Ltd., Godhra, Gujarat(fromV RJani)

Panchmahal District Cooperative Milk, Producers' Union Ltd. Godhra, Dist. Panchmahals, Gujarat-389001; Tel: 91-02672-261782; Fax: 91-02672-260327; [email protected]://www.panchamrutdairy.org/sgsy/about_projects_cattle.html

Provide fortified milk to school children and aanganwadi centres helping them improvetheir nutritional status

World Food Programme, New Delhi (fromMeenakshi Aggarwal, Research Associate)2, Poorvi Marg, Vasant Vihar, New Delhi 110057, Tel: 91-11-26150000, 46554000; Fax: 91-11-26150019, 4655405; [email protected]; http://www.wfp.org/nutrition/special-nutritional-products

Undertaking various programme on improving the nutritional value of food products likefortified blended foods and ready to eat foods.

Related Portals and Information Bases

Golden Rice Project (FromBhaskar Goswami, Forum for Biotechnology & Food Security, NewDelhi)

http://www.goldenrice.org/The portal provides information on the project based on the need for a sustainablebiofortification approach to contribute to alleviating the scourge of micronutrientdeficiencies worldwide

Integrated Child Development Services Scheme (from Meenakshi Aggarwal , ResearchAssociate)http://wcd.nic.in/icds.htm

Portal provides the details of the ICDS scheme and the supplementary nutrition providedto the beneficiaries.

Related Consolidated Replies

Iron Fortification of Millet Flours, Priya Naik, Poverty Action Lab MIT, Cambridge (Advice), Food and Nutrition Security Comm unity, Solution Exchange, IndiaIssued 2 March 2006. Available at: ftp://ftp.solutionexchange.net.in/public/food/cr/cr-se-food-02030601-public.pdf (PDF; Size: 196 KB)


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Deals with causative factors of anaemia and various coping strategies including the prosand cons of food fortification, dietary diversification and iron supplementation

Double Fortified Salt for Combating Anaemia, Rita Patnaik, NFI, New Delhi(Experiences) , Food and Nutrit ion Security and Maternal and Child HealthCommunity, 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, alsoexplores the utility of DFS and appropriateness of employing it in national programs.

Combating Iodine Deficiency Disorders (IDD) in India, Anna Somos, ColumbiaUniversity, New York (Experiences), Food and Nutrition Security and Maternal andChild 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, providessuggestions for improving iodine consumption.

Responses in Full

Prema Ramanchandran, Nutrit ion Foundation of India, New Delhi

Salt is consumed by all segments of the population. It is inexpensive and therefore one of themost suitable vehicles for fortification if the micronutrient deficiency is wide spread. In Indiaabout 70-90 % of the population is estimated to be iron deficient and majority of the populationare anaemic. Under these conditions salt fortification with iron (in addition to the mandatoryfortification 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 byNational 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 (PublicDistribution System). Himachal Pradesh has been providing DFS to the ICDS beneficiaries. MidDay meal (MDM) guidelines suggest use of DFS for MDM. However, the supply constraints havecome in the way of its wider use.

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

Fortifying multiple products with multiple nutrients may result in some segments of thepopulation 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 whatproduct 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, itsfortification has been a subject under study of Sugar technologists but has not moved much, but


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is really worthy consideration and enforcement by GOI which some how has not been theenforcing 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 theeffectiveness 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 DrKamala Krishnaswamy, former director NIN Hyderabad - DFS developed by NIN will provide only1 mg/gram of salt and with low iron absorption; it will take a long time to demonstrate a rise inHemoglobin. Over a period of time (2-5 years), the Hemoglobin curve is likely to shift to theright.

Do we have studies on DFS under public health conditions to demonstrate its effectivenessleading to improvement on haemoglobin and iodine status? If yes then I would request membersto 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 andDFS is one such promising intervention.

The problem of iron and iodine deficiency is so common that the state governments adopt theintervention strategies recommended by the scientists in the states. In Chhattisgarh state ironand 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 inTamil Nadu also, DFS made by an Industry under the State Government is producing anddistributing DFS.

There are many private manufacturers, which are producing and selling DFS. It will be useful toknow 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 addressedare:

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 inthe programme. This approach will help us to meaningfully evaluate the DFS programme after aspecific number of years of implementation. We do have specific guidelines under National IodineDeficiency 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 strongone. Even in purely economic terms, studies have revealed that the benefits of investments inmicronutrient fortification far outweigh the costs (the costs tend to be a few cents per person peryear). Horton S makes very rough estimates of the annual potential costs attributable to iodine


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deficiency in the developing world - $35.7 billion prior to widespread salt iodization, as comparedwith an estimated $ 0.5 billion annual cost for salt iodization, i.e., a 70:1 benefit : cost ratio. Amore 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 ifcognitive benefits are also included.

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

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

Estimates for Sprinkles for Pakistan, when primarily targeted to children 612 months, suggestthat cost per disability adjusted life year (DALY) saved could be as low as $12 (based on theeffects of zinc on averting diarrhea), and the benefit : cost could be 37:1 (based on the effects ofiron 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-scaleprogram, but could be useful as similar conditions prevail in India.

In regions where rice is the preferred staple, bio-fortification may be considered, whereby highermicronutrient 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 riceby conventional means than the other grains. Preliminary work suggests this could be very costeffective. For rice, high iron varieties have been identified and feeding trials have shown the ironto be bio-available and to lead to higher body iron levels. Golden rice genetically modified tocontain a high beta carotene content aims at providing the recommended daily allowance ofvitamin A (in the form of beta carotene) per 100-200 grams of rice, which is the daily riceconsumption of children in rice eating countries, including India.

References: Horton S, The Economics of Food Fortification accessed athttp://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 notneed them. The other fortification methods implemented through various programmes, mostlysupported 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 avehicle. Other options which are rather enrichments and not fortification in the true sense couldbe products like skimmed milk.

For a country like India where people are largely rural based, like to consume fresh foods andhave such varied dietary habits, fortification of foods is not one of the best options excepting insome special cases.


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Finally, trying out different methods through Government programs or otherwise on populationgroups, which can be withdrawn after a period, is not at all recommended, as till date we haveno report what so ever on the withdrawal effects of these so called innovative products. It ismost unethical.

Mahtab S. Bamji, Dangoria Charitable Trust, Hyderabad

Food fortification is a good method of supplying micronutrients, provided the vehicle is consumedby those who need the supplements. The level of iron and iodine fortification currently used indouble fortified salt assumes salt intake of 10gram per day. This is way above the currentrecommendation of 2 gram to prevent hypertension. The issue needs to be re-visited and thelevel 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 carefullystudied.

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 asVitamin A, C, D if it is possible and supply the salt in the Public Distribution System (PDS) to thepoor.

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

Bhaskar Goswam i, Forum for Biotechnology & Food Security, New Delh iThe potential of Genetically Engineered (GE) foods to combat malnutrition in children is usuallyoverestimated - 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 oldchildren and 12.5-18.7% of those in the four-six years age group. Similarly, back in 2003 GEPotato was touted as the answer to meet protein requirements of children by the Department ofBiotechnology. 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, ChennaiMother natures complete food for children below 3 years is mothers milk. Lactating mothersneeds balanced diet and at least 2-3 litre of pure water and good air. Exposure to sunlight atsunrise 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 JuiceConcentrate which facilitates supply of nutraceuticals and micronutrients. Noni (Morindacitrifolia L.) is called Indian Mulberry and used by polynesians for energizing the body. Details areavailable in www.nonifamily.net

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


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

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

Thank you for the very interesting discussions on food fortification. It is very educative andbrings out differing concerns, which I respect. Sharing the deep concerns, I believe, of thedifferent 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 foodfortification 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 andwithin states are common in food intake and habits. There are solutions well in reach throughresearch and local adaptation. There are many examples. I believe the genius of the caringdevelopment experts can find the solutions and have been doing so. This is not the situation tolet up but to enforce efforts. Sprinkles is a good option for reaching the un-reached withmicronutrient 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 regulatorsare strict. Some incidents that have been cited have other issues of adulteration, found to be thecause. However strict quality control and training is a must for the care givers and the users.

Prakash V Kotecha, A2Z, the USAID M icronutrient P roject, Academy for EducationDevelopment, 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 malnutritionissue remains a challenge and fortification has been more often found resistance both byGovernment 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 notworth comparing with amount of iodine it provides since 100% RDA (Recommended DailyAllowance) of iodine can be given and we have no fear of toxicity. For iron we can provide smallfraction of RDA for number of reasons and theoretical but fear of toxicity remains. But smallproportion 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, similarlyin 85% anemic child population small fraction of hemoglobin would improve with additional irongone in DFS.


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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 atftp://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/UNICEFhas two formulae for Multiple Micronutrient Powder and they have either 5 or 15micronutrient while GOI has 8 micronutrients.

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

Micronutrient to be fortified to foods with the objective of reducing micronutrient malnutrition ispurview of Drugs Control or Food Control is not clear as of today to the best of my knowledgeand 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 factorsthat include, the level of micro nutrient malnutrition present, associated conditions in thechildren, level of other malnutrition, other morbidities, their age and overall dietary intake of thebeneficiaries

We need to learn however from the global experience that to control micronutrient malnutritionfortification, supplementation and other approaches will all have to be tried together to make adifference 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 athttp://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 itcan be used, how do we determine toxicity levels? Please share if there are any studies.Soma Bhowmick, Pink Cascade Foundation, ShillongIntake of iodized salt is definitely prescribed however its use in food preparation should becontinually reinforced. The distribution through the PDS (Public Distribution System) needs to bedone with a lot of caution coupled with scrutiny given the public perception about the efficacyand 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) supplementationamongst school children in rural areas. During our work its been observed that the ruralpopulation is reluctant to consume any other food item which we supply as supplement other


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than their daily foods due to negligence and limited resources. In such a situation salt can workas 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 thechildren 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, mostothers 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 extremelyor widely popular - maybe because of potential side effects or because the population in large isnot yet prepared to buy fortified food products which give positive health benefits rather than lowfat food or more healthy food stuffs.

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

For addressing malnutrition issues in resource poor areas, fortified food could be a combatingsolution right away. But specific and customized approach needs to be undertaken. Areas whichreally require iodine should be supplied with it. Today almost every household in urban area usesiodized salt (whereas it is unnecessary in many areas). Similarly micro nutrient study needs to beundertaken 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 tapinto 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 ruraleconomy. We have to identify ways that will promote rural enterprises while at the same timebring 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 (whichare incidentally the most backward and driest regions), it would be better to introduce millets tothe mid-day meals. The policy makers and civil society organizations would do better to identify


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ways for value addition of millets (for improved taste, shelf life, and packaging) that suitschildren. This value addition and marketing if done in the respective villages will have positiveimpact 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 consumedin almost equal quantity by all segment of the population in all socioeconomic groups. Iunderstand that in Karnataka state DFS (Double Fortified Salt) developed by an internationalagency, has been utilized for effectiveness trial. Kindly see the article mentioned below.

Dual fortification of salt with iodine and iron: a randomized, double-blind, controlledtrial of micronized ferric pyrophosphate and encapsulated ferrous fumarate insouthern India by M Andersson, Prashanth Thankachan, Sumithra Muthayya, Ramakrishna BGoud, Anura V Kurpad, Richard F Hurrell and Michael B Zimmermann; American Journal ofClinical 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 proposedcontrasting formulasone fortifying with iron as micronized ground ferric pyrophosphate(MGFePP) and the other with iron as encapsulated ferrous fumarate (EFF)with the efficacy ofiodized salt (IS) in schoolchildren in rural southern India.

Design: After stability and acceptability testing, a double-blind, household-based interventionwas conducted in 515-y-old children (n = 458) randomly assigned into 3 groups to receive IS orDFS with iron as MGFePP or EFF, both at 2 mg/g salt. We measured hemoglobin, iron status, andurinary 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% inthe MGFePP group (P < 0.05) and from 15.1% to 5.0% in the EFF group (P < 0.01). The medianurinary iodine concentration increased significantly in the IS and EFF groups (P < 0.001) but notin 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 localfoods.

Conclusions: Both DFSs were efficacious in reducing the prevalence of anemia and irondeficiency in school-age children. Local salt characteristics should be taken into considerationwhen 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 presentin all parts of the country. However, we need to have hard scientific data to select a particularDFS, otherwise it will be like any routine fortified food available in the market, which increasesthe intake of micronutrient but do not claim any health benefits.

Kaniz Fatima Muneeza, Aga Khan Foundation, New DelhiThe 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)


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also has to be taken into account with the problem of under nutrition. Here are a fewsuggestions:

1. Given the agricultural diversity of the country, a mix of locally available food grains andat times other foods available outside have to be judiciously mixed to be provided tochildren.

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, MaharashtraFor 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 thevulnerable groups.

By doing so we can improve the nutritional value and also farmers can get remunerative pricesfor 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 ManagementUnit, New Delhi

I would take a very different view to this entire issue of using fortified foods to combatmalnutrition as if we are left with no other option. This is just like advocating for GM (GeneticallyModified) crops to meet the rising food grain demand in our country without having done acomprehensive assessment of the potential of current agricultural system as to whether it is ableto 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 locallyavailable food materials (with high nutrient content) is not at all a viable proposition - both fromthe social as well as economic view points.

Using fortified foods as a supplement will take away the opportunity or rather will put much lessemphasis on the local agricultural system to be improved which answers most of the nutritionrelated 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 thekey 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 smalland marginal farming communities and will most importantly move towards a degree of selfreliance thus reducing the dependency on external food products. It will in a way strengthen theinternal money circulation.

This will also be socially and culturally acceptable as against fortified foods and I think all ofthese can be achieved by converging existing government programmes like NREGA, RKVY, NFSMwhich focuses on rejuvenation of the natural resources and giving impetus to improvedagricultural systems at decentralized levels.


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Once we achieve the above which is certainly do-able, only then we should consider mapping thegaps 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. Theseproducts do not look at the underlying factors at all. What should we do to tackle is acomprehensive set of strategies, for convenience put together by the Working Group of ChildrenUnder 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 onemay 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 wasprepared by the cereals along with locally available pulses. It was immensely popular and wasable 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 poorundernourished children.Ch. Santakar, Journalist, Koraput, Orissa

Rather than fortification of food items, more suitable option could be to promote the concept ofhaving a balanced diet in the rural families. This is because even if the fortified food was madeavailable for its richness and the promises of well being, the poor who are the really deprived ofqualitative food select their items on the basis of easy accessibility which very often is not thefortified food. Hence once they are sensitized on the importance of a balanced diet, it is possiblethat 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 costbenefit ratio not only amongst available health interventions but even amongst all developmentrelated interventions. Based on our experience with salt iodine fortification we have realized thatonly economic criterion is not sufficient to translate any policy into a successful program.

The dynamic evolution of National Iodine Deficiency Disorders Control Program (NIDDCP) inIndia provides a unique opportunity to study the interaction between research, programme policyand decision making and identify solutions for the future. The sudden lifting of ban on sale ofnon-iodized ban in India in year 2000 was a shock for academician and researchers engaged inIDD research. The arguments forwarded by the proponents advocating removal of banhighlighted the importance of values in influencing the formulation of policies in a democraticsetup like India. The academicians and researchers realized, though in hindsight, that the lack offocus in previous years on influencing the Values of different stakeholders and community atlarge was one of the major failures of NIDDCP in India.


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Lessons Learnt From NIDDCP:Values in form of core values, beliefs, interests have an importantbearing on implementation and sustainability of policies. Implementation of policy based only onscientific evidence will not only achieve less than optimum results but more seriously may alsolead to a retrograde step as seen in the case study of NIDDCP. In an ideal scenario valuesshould 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 andprogram implementation. Stakeholder analysis is a process of systematically gathering andanalyzing qualitative information to determine whose interests should be taken into accountwhen developing and/or implementing a policy or program. Stakeholders include persons ororganizations, who have a vested interest in the policy that is being promoted are consideredstakeholders in the process. These stakeholders or interested parties can usually be groupedinto the following categories: international, public, national political, commercial/private,nongovernmental organization (NGO)/civil society, labor, and users/ consumers. Knowing whothe key actors are, their knowledge, interests, positions, alliances, and importance related to thepolicy 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 implementinga 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 orprogram 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 Comm unity Sciences, The M. S. University of Baroda,Vadodara, Gujarat

All the contributors worded meaningfully from own areas and perspectives. My experiences withfortification are suggestive that, it is highly beneficial in urban as well as rural scenario. Majorsuccess 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 changesare playing a contributory role when it is used in long term strategies and programmes mainlybecause of sustained release of Iron and Iodine.

Using it in a pregnant mothers diet did not bring any significant change in iron, but contributoryroles in Iodine levels were observed. In children, along with dietary counseling and improvedfood intake, mothers opined that they have become more active and fatigue is not seen. This issuggestive that we need to promote consumer education before introducing the fortificant. Itwould 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 mealsscheme has also been there for so many years. India is a food sufficient country. The averageper capita consumption of food has been increased and nobody is starving in our country. Whydo we need to fortify foods for improving the nutritional status?

Do we need to introduce another programme when all the programmes / Schemes are poorlyrunning? It is not better to give attention to the quality of foods which are being provided to


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children. Even if we are able to maintain the quality, it will automatically improve the nutritionalstatus of our children. How would we assure that the micro nutrient enrich quality supplementfoods 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 localagricultural products and particularly learn from indigenous traditions that are pre-colonial suchas Gur (Jaggery) production as indeed, use of unpolished rice and fresh vegetables and fruitsfrom the forests.

Kitchen gardens must be made a priority and where land is scarce allotments can be providedalong with water and seeds. Some lessons can be learnt from pooling of resources and spirit ofcooperation such as the rich langar (free meals to community) tradition and common kitchens fortwo meals a day provided.S. Murali Mohan, Visakhapatnam

For wheat eaters, Atta (Wheat Flour) fortified with minerals and vitamins is a good choice andcan be implemented as part of the mid-day meal program for school children. This can also be apart 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 countrymay be made use of by the Government and fortification may be made compulsory for brandedAtta (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. Mandatoryfortification is only for Vitamin A for these products. These actually are excellently suited forfortification with a whole range of vitamins both oil-soluble and water-soluble. Only a small costincrease will be incurred but the benefits obtainable are immense.

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

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

The Mid day meal programme is being implemented since many years now. The issues ofmalnutrition and stunted growth in children are yet to seek the suitable and satisfactorysolutions. With the help of District Administrators, under various schemes of TASPs and DRDAssupply of Vitamins fortified pasteurized flavored fresh milk to the children has been successfullytried. Initially, all the primary school children of 2 selected tehsils were provided 200 ml ofpasteurized toned flavored milk daily - about 100000 pouches. The insulated boxes have beenspecially designed to ensure the desired quality of milk till it reaches to children. The periodicchange in flavors like rose, kesar, strawberry, eliachi etc has been attractive enough for childrento consume milk regularly. The funds for this project are made available by Govt. of Gujarat,


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under ambitiousVanbandhu Project. Some other pockets in South and North Gujarat also havethe 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 pasteurizedfortified 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 thecomplete food, it takes care of many useful nutrients required by the growing children. Thepropagation 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 lothas been and is being done to increase the nutrient content of the foods on the Indian plate. Theagriculture efforts are remarkable and these should enhance. However nowhere in the nearfuture 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 micronutrientcontent of the Indian plate is very deficient, specially, if we focus on the not so privileged. Indianstudies be it of NIN, ICMR or NFHS, the scenario is the same. The reasons are well known andneed not be repeated. To meet the challenge of malnutrition, food quality and quantity have toimprove 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 asupplementary activity to food. Secondly it needs to be appreciated that even in the nutritionallybetter of countries food fortification is an ongoing activity. Do we deny our people the benefit ofscientific 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 beevidence-based. The fact remains that in India, micronutrient deficiencies are sky-high,particularly deficiencies of micronutrients that are critical for cognitive and brain development ofinfants, 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 onlyunfortified foods, or without the use of some kinds of supplements.

No developed country has removed folate deficiency and iron deficiency in the population withoutthe 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 thesituation. Additionally, there are vulnerable groups, such as young infants (6-24 months) whosenutrient needs for iron and zinc cannot be met even if they are consuming red meats (we havepublished work on this issue). Identifying creative solutions, including fortification, bio-fortification, diet diversification, etc., in concert with each other, is beyond critical to address theproblems that India faces. This should not be an either-or discussion, but rather, a discussion ofwhat information can and should be used to decide what solutions are useful in differentcontexts. 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 substantialbenefits, and this can be done without introducing corruption. West Bengal's experiments withcentre-based fortification of khichdi and the evidence of that on addressing anemia are a goodexample; many other exist.


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Again, the main point here is that one has to take an analytical view of the situation, and identifysolutions that are context-specific and context-appropriate, rather than advocate for one thing orthe other without full consideration either of the magnitude of the need, or theconstraints/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 onmicronutrient supplementation through food fortification based on my desk research to find outsuitable food supplement for my three year old child.

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

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

Flour fortification has been done in many Latin American countries. In Chile and Venezuela, ironfortification helped in overcoming iron deficiency to a large extent. Food fortification in Denmarkhelped overcome high incidences of night blindness due to Vitamin A deficiency in children. Theremargarine was fortified with vitamin A. Similarly, milk was fortified in Europe and North Americato overcome Vitamin D deficiency. In some countries even noodles and sauce are fortified withmicronutrients. 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 staplefood, locally available and can be fortified. Delhi began fortifying flour in November last yearthrough a program jointly initiated by the Delhi Government and the Delhi Roller Flour MillsAssociation, where wheat flour is being fortified with iron and folic acid. However, in most otherparts of the country wheat/ rice is grown, processed and consumed locally. Is safe andstandardize fortification possible at that level? And also how many of these food items areintended to address micronutrient deficiency in infants?

Anshuman Das, DRCSC, West Bengal*National feeding programme, specifically ICDS and midday meal scheme, created opportunity forcreating 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 inthe government programme.


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When we are thinking about fortified food, we are inviting companies who will again use this formaking 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 makea 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 andmicronutrient.

Many thanks to all w ho contributed to this query!

If you have further information to share on this topic, please send it to Solution Exchange for theFood and Nutrition Security Community in India [email protected] orSolution Exchange for the Maternal and Child Health Community in India [email protected] the subject heading Re: [se-food] [se-mch] Query: Use ofFortified Foods and Micronutrient Malnutrition in Children - Examples; Experiences. Additional

Reply.

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