Food Fortification or Diverse Diet?

A default policy tool widely used in India for resolving the problem of undernutrition is large-scale food fortification of grains, oil, salt, and other staples. The approach dates back to 1950s with fortification of Vanaspati oil with vitamin A, and salt with iodine. It has gained momentum over the years with the universal distribution of fortified rice through Public Distribution System, mid-day meals and the Integrated Child Development Scheme. In addition to this, state governments are also implementing fortification projects for other staples in collaboration with various international NGOs. As a result, thousands of crores of public money is spent on fortification.

But, is this is an efficient response to the issue of undernutrition? A recent EAC-PM paper by Mudit Kapoor et al. (2024), using data from Household Consumption Expenditure Survey 2022-23 and NFHS 5 (2019-21), found that irrespective of the consumption of fortified cereals, anaemia prevalence was higher in states with lower dietary diversity of iron-rich foods among both children and women. For example, the average iron intake was the highest among Rajasthan households owing to the consumption of fortified cereals but the prevalence of anaemia was also very high. The study found that the state had the lowest dietary diversity for sources of iron, and the poorest average iron intake when fortified cereals when excluded (since 84% of iron was from the fortified cereals). In other words, a diverse diet rather than fortified foods is a better way to reduce anaemia.

In view of this finding, we revisited some of the scientific evidence from a decade ago that was used to justify the ramping up of rice fortification programmes by the central government. Interestingly, of the 18 studies on the impact of rice fortification on anaemia, only 4 studies were from India. The results too showed ambiguous results. For instance, the study by Radhika et al. (2011) among primary school children in Andhra Pradesh found that the provision of fortified rice over 8 months improved serum ferritin (another measure of iron deficiency) in the treated group. However, the increase in Haemoglobin (Hb) levels was the same among children who were given fortified rice vis-à-vis those given unfortified rice. The study concluded that other factors, apart from iron intake, explained Hb concentration.

More recent studies also show similarly ambiguous results. A case-control study by Mahapatra et al. 2021 was conducted among 973 school children in Gujarat, divided roughly equally into intervention and control groups. It found that improvements in severity of anaemia of children given fortified rice was marginally better than those given unfortified rice over a span of 8 months: “Within the intervention group, 30.9% of children improved their anaemia status from moderate to mild anaemia, mild anaemia to healthy, or moderate anaemia to a healthy status. Within the control group, 24.3% of children improved their anaemia status from moderate to mild anaemia, mild anaemia to healthy, or moderate anaemia to a healthy status.”

While fortification seems to have an impact, surely the more interesting question is why the control group saw such a large improvement without fortification. The study itself mentions that it did not account for dietary diversity. The presumption in favour of fortification is so strong that the study still concluded: “Rice fortification can help address anaemia in settings where rice is a staple food.”

Members of the medical fraternity have also expressed their concerns about the fortification heavy strategy. A group of eighteen doctors and nutrition experts have cautioned about the low impact of fortification on lowering anaemia levels and have advocated reconsideration of mandatory universal fortification in an article by Kurpad et al. 2021.

The issue seems to be that the human body does not absorb micro-nutrients from fortified sources as easily as from natural food. This explains why the recent EAC-PM study found that diversified diets were a better response to undernourishment. This issue is in addition to the serious problems with the measurement of public health parameters as highlighted by us elsewhere (see “Anaemia, a weak case”, Sanjeev Sanyal & Chirag Dudani, ET 13th April, 2023).

Our investigation found that an important driver of the fortification-heavy strategy is advocacy by international donors and NGOs. However, a recent comment by Bill Gates suggests that at least one large donor may be having second thoughts: “There's still a lot to be done, but the recognition is there that it's very important to diversify the diet.”

Let it be clear that we are not advocating a blanket withdrawal of fortification but merely pointing out that we need much stronger evidence supporting different kinds of fortification. Moreover, given the large sums being devoted to such schemes, there is need for an honest cost-benefit analysis between chemical-enhancement and natural dietary diversity.

(Sanyal is Member and Chauhan is Young Professional, Economic Advisory Council to the Prime Minister (EAC-PM)