Rice fortification isn’t the way to fight iron deficiency

Large-scale, mandatory food fortification has often been thought to be a cost-effective intervention to address micronutrient inadequacy. But this is only true with rampant dietary micronutrient inadequacy in all segments of the population, including men. India has now moved well beyond florid micronutrient deficiencies, which were prevalent decades ago.

Is the Indian diet deeply inadequate in iron, which is the prime focus of the mandatory rice fortification initiative? No. In 2020, the Indian Council of Medical Research (Icmr)-national Institute of Nutrition (NIN) published the latest Nutrient Requirements of Indians. These are about 40-50% lower for iron than the earlier 2010 estimates also from the ICMR-NIN.

Evaluating diets with these latest estimates of iron requirements reveals no rampant deficiency. Indian diets already have native iron, and it is important to absorb it efficiently. This is facilitated by avoiding tea near mealtime and consuming diverse diets, including fruits and vegetables. Simply adding more chemical iron to diets through fortification is unnecessary. It also raises the spectre of excess intake.

Regarding excess intake, if half the cases of anaemia are due to iron deficiency, what happens to the remaining half, which does not need the extra iron? They will be at risk of excess iron intake. It is crucial to not trivialise this risk, by saying “fortification carries no risk of toxicity”. Toxicity is the appearance of toxic symptoms, such as stomach pain and nausea. But more importantly, we are seeing a different type of risk — of chronic diseases such as diabetes.

As iron stores in the body increase with dietary fortification or supplementation, the risk for diabetes increases. This risk has not been evaluated in food fortification trials. In addition, studies on children in Africa showed that their gut bacteria changed towards more dangerous types with fortification. The long-term drain on personal and state finances from these risks must be factored into any cost-effectiveness exercise. The cost of the mandatory rice fortification — just of the fortificant and not of the rice — for the public distribution system (PDS) alone is not trivial: While the cost per kg appears small (0.60-0.80 per kg), the overall national cost is substantial (₹2,600 crore per annum).

However, the total cost, including that of the risks, might be far more than we can imagine.

Scientific studies reported to support iron fortification are selective and quasiexperimental (which are not entirely scientific), or unrelated to anaemia (in Karnataka). The routine way to evaluate scientific studies is to perform a systematic review. Here, a combined analysis is performed, of all the relevant, high-quality scientific studies that have been conducted. Indeed, this analysis, published as a Cochrane Review (2019) reported: “We are uncertain if fortification of rice with iron… reduces the risk of having anemia or iron deficiency.”

There is no case for universal rice fortification, as this will reach even those not in need, including men whose needs are the lowest. Men have no means to excrete iron and are most at risk of excess intake. In addition, adding iron through fortification on top of existing iron tablet supplementation programmes (as an extra layer) to women and children is redundant, wasteful, and potentially dangerous. Overeating rice (and there is no control for this) means even more risk of excess.

It then raises a question on ethics: What if one knew the risks and did not want the rice? That option is not possible with mandatory fortification. This lack of autonomy will get institutionalised over time. Therefore, if fortified rice must be given, it should only be given to those in need or iron-deficient, and certainly not layered on existing iron supplementation. For instance, not all the poor have greater iron deficiency. They may have more anaemia due to other causes.

Anura Kurpad is professor of physiology and nutrition, St John’s Medical College. Harshpal Singh Sachdev is senior consultant in paediatrics and clinical epidemiology, Sitaram Bhartia Institute of Science and Research The views expressed are personal