Against the grain
The Narendra Modi government’s grandiose plan to distribute rice fortified with iron through the public distribution system is all set to
take off despite the concerns about its efficacy, cost-effectiveness, toxicity due to excess iron, dietary diversity, and conflict of interest.
IN his Independence Day speech on August 15, Prime Minister Narendra Modi flagged malnutrition as a major impediment to the development of women and children and declared that rice would be fortified under various government schemes by 2024. The plan is to initially distribute fortified rice through the Integrated Child Development Services (ICDS) and the Mid Day Meal (MDM) scheme and later expand it to the entire public distribution system (PDS). In 2018, the Food and Safety Standards of India (FSSAI) had issued standards for fortifying five staples—wheat flour, rice, milk, oil and salt—with iron and other micronutrients.
Of late, however, the focus has shifted to iron deficiency, on the basis of a comparative study of the prevalence of anaemia in the fourth and fifth National Family Health Surveys (NFHS). As 65 per cent of the Indian population consume rice, fortification of rice with iron has taken centre stage.
Although public health experts, paediatricians and clinicians agree that anaemia poses a serious challenge to health, there are doubts as to whether iron-fortified rice is the best way to go about it. It has also been pointed out that if the decades-old iron tablet supplementation programme has not worked, there is little reason to believe that food fortification will, given the challenges involved on both demand and supply sides. Therefore, some argue that rather than mass fortification of cereals, the Anaemia Mukt Bharat programme (Anaemia-free India) and the Poshan Abhiyaan (Nutrition campaign) under the National Health Mission should focus on dietary diversity, animal protein, and easy access to affordable diet. This initiative is also expected to boost the cultivation and consumption of millets, which are richer in micronutrients and other vitamins than rice and wheat.
The grandiose plans for rice fortification are to take off despite the several concerns raised about the efficacy of its implementation, cost-effectiveness, toxicity due to excess iron, conflict of interest, and dietary diversity.
Significantly, pilot schemes for iron fortification launched by the Food and Public Distribution department were not successful. Sudhanshu Pandey, Secretary, Department of Food and Public Distribution, admitted this at a webinar organised by the Bharat Krishak Samaj, an advocacy-based farmers’ organisation, on October 25. Arun Singhal, the Chief Executive Officer of FSSAI, too, accepted that the pilots had not taken off.
PILOT STUDIES
The Centrally sponsored pilot scheme for fortification of rice and its distribution through the PDS was launched in 2019. This was for a period of three years with a budgetary outlay of Rs.174.6 crore. One district each in 15 States was identified and five States started the distribution of fortified rice. In November 2020, it was decided to scale up the programme to include all districts. The Food Corporation of India (FCI) was tasked with developing a comprehensive plan for the procurement and distribution of fortified rice in all districts under the ICDS and MDM scheme from 2021-22, with special emphasis on 112 aspirational districts.
According to a Press Information Bureau release, a meeting was held at the NITI Aayog on November 3, 2020, involving government departments and private stakeholders such as Tata Trusts, World Food Programme, PATH and Nutrition International to discuss supply chain and other logistical requirements to scale up rice fortification and distribution for the ICDS and MDM scheme in the aspirational districts.
At this meeting it was agreed that in order to achieve the goal, there was a need to increase the supply of fortified rice kernels (FRK), whose availability at that time was a meagre 15,000 metric tonnes (MT) a year.
To cover the 112 aspirational districts, nearly 130 lakh MT of fortified rice would be required; for this the FRK supply capacity in the country needed to go up to nearly 1.3 lakh MT. If the entire PDS (National Food Security Act) rice supply of about 350 lakh MT had to be fortified, an uninterrupted supply of 3.5 lakh MT of FRK was required.
According to the PIB release, nearly 28,000 rice mills in the country needed blending machines to mix FRK with normal rice. The FCI was asked to tie up with rice mills in different regions for investments in this regard. The FCI’S operational readiness was expected to help increase procurement and supply of fortified rice in a phased manner from 2021-22.
However, the pilot studies for the fortification programme, which were meant to evaluate efficacy and toxicity, were a failure. There were design issues and communication strategy gaps. Therefore, the outcomes of nutritional deficiency levels
and iron toxicity were unknown. Stating that there were fundamental problems with the pilot studies, both logistical and on the supply side, Sudhanshu Pandey said at the webinar that “one did not have the luxury of time to fix all collateral problems and then take a decision”. Many people, he said, had given advice but none had offered a solution. The government had to take a decision, he stated.
The pilot programme, which began in 15 districts of 15 States, was eventually scaled down to 11 districts in 11 States. He said an ecosystem was necessary for the supply of micronutrient mix and the production of FRK. Besides this, the equipment for fortification and blending had to be standardised. Moreover, the fortified kernels had to look as natural as the local rice; otherwise it would be identified as a foreign element and removed while cleaning the rice before cooking.
If FRK manufacturing had gone up from 15,000 MT a year ago to 1.6
According to Arun Singhal, there was no evidence of diet improving despite rising incomes. Supplementation, he argued, was targeted and had a limited reach, whereas fortification was short term but had a wider impact; and dietary diversity was long term but it was the most sustainable. “We cannot give up fortification as an approach,” he said categorically. He said the FSSAI had been advocating fortification of cereals in the ICDS and MDM programmes. It was also the Women and Child Development Ministry’s goal to make fortification mandatory in both schemes by March 2022.
WHAT INDIANS EAT
The general assumption was that Indians were not eating right and not eating enough and the only way to address this problem was to fortify rice with iron and possibly with other micronutrients such as zinc and selenium. Dietary diversity was at the bottom of the solution pyramid.
However, no comparative studies have been done to determine the difference in efficacy between those who consumed fortified rice and those who did not. Nor were there any toxicity studies. The only evidence was that anaemic levels were worsening.
The National Nutrition Monitoring Bureaux, with their extensive networks across the country, had been done away with several years ago. Therefore, policymakers had little idea of what or how much India ate except that they thought undernutrition and over-nutrition were the two sides of what they knew as malnutrition.
Speaking to Frontline, Ajay Jakhar, chairperson of the Bharat Krishak Samaj, said: “It needs a wider range of consultation not only to get the counter-views but also to decide the transition. The science is still grey, there are two points to consider. If the government is of the opinion that it is a transition, then what is the design to ending the transition? Whether it should be targeted or universal also needs to be discussed.”
According to T. Nand Kumar, former Secretary to the Government of India and ex-chairperson of the National Dairy Development Board (NDDB), fortification could be one of the options. The ICDS and MDM schemes were probably more appropriate instruments to address child nutrition, he said, but then it could be addressed in the form of dietary diversity. “The logical thing would be to look at impact studies. This will tell us whether the intervention was correct or not. It is only rational to look at the results of the pilot, not to reject them, but to improve the design,” he told Frontline.
The primary commodities distributed through the PDS are rice and wheat. Wheat flour or atta can be fortified, but there are logistic issues as the entire quantity of wheat has to first go through chakkis (flour mills). Storage is also an issue. Said Nand Kumar: “Many people prefer to grind the wheat themselves. Rice then becomes the typical candidate for fortification. If one looks at the poverty profile of States, you will see most of them are rice-eating States. There is a colour difference also between varieties of rice. The Odisha variety is not like that of Punjab. If people see rice of different colour, it will most likely be regarded as foreign matter and thrown out. I do have reservations both on the science and the efficacy of implementation.”
He also expressed concern about the usage of the term “continuity of business” in fortification discussions. “We keep hearing this now and then. If this is the case, one will not wait for pilot studies to come through. But this should not be a matter of weightage as one is addressing an issue of under-nutrition. I am against mandatory fortification though am sure we are heading towards that,” he said. In his opinion, mandatory and large-scale fortification would ultimately be irreversible.
In Nand Kumar’s opinion, the fortification of milk and edible oils would also be problematic because it would eventually lead to branded products, and most poor people, the intended beneficiaries of the fortification, did not buy branded milk or packaged oil. He said the government could reintroduce pulses and edible oils in the PDS in order to ensure dietary diversity. “Pulses can be given [through the PDS] or a cash subsidy, just as the gas subsidy,” he said.
DOCTORS’ OBJECTIONS
H.P.S. Sachdev, a leading pediatrician, disagrees with the government’s push for rice fortification. The biggest myth, he said, was to equate under-size with under-nutrition. Some countries use cast iron utensils to reduce anaemia, he said. Extra iron, he claims, will only harm the vulnerable poor who are already at risk because of their elevated serum ferritin levels. “As a clinician I will not prescribe iron to those suffering from haemoglobinopathy, infections or thalassemia. The sub-clinical harm of fortified rice has to be looked at,” he said.
According to the Comprehensive National Nutrition Survey, he said, children in the 5-19 age group had shown biomarkers indicative of early non-communicable diseases. In an article titled “When the cure might become the malady”, which was published in the American Journal of Clinical Nutrition in July 2021, Sachdev, along with Anura V. Kurpad of the St. John’s National Academy of Health Sciences, Bengaluru, Arun Gupta, a leading paediatrician, and others, argues that while food fortification has its place in alleviating specific nutrition deficiencies, it may be overdone in response to the apparent failure of other interventions. The authors contend that nutrients, like medicines, can be harmful if ingested in excess. Before supplying more iron, it was important to understand why the iron supplementation programme had not worked, he said.
According to the authors, the layering of multiple intervention programmes may emerge from incorrect measurements of the risk of nutrient inadequacy in the population or incorrect biomarker cut-offs used to evaluate the extent of such deficiencies. For example, using potentially higher universal haemoglobin cutoffs to diagnose anaemia among In
dian children and adolescents may not be the correct marker as it could be much lower than the level recommended by the World Health Organisation (WHO). With the proposed cut-off, they say, anaemia prevalence among children would fall from the current 30 per cent to 11 per cent. Capillary or finger-prick blood samples to estimate anaemia could underestimate HB levels compared with venous blood samples. This, they argue, explained the wide difference between the anaemia prevalence rates (in children 1-4 years) between the NFHS 4 and the Comprehensive National Nutrition Survey (CNNS), which was 56 and 44 per cent respectively. Both Sachdev and Kurpad are members of the NITI Aayog’s National Technical Board on Nutrition and on FSSAI expert committees.
According to the researchers, the lack of response of anaemia to iron fortification was not uniform and could be because of other nutrient deficiencies and inflammation. The study also estimated the cost of iron fortification to be around $350 million a year which was in addition to the $130 million per fiscal for the Anaemia Mukt Bharat programme. The authors argue for a dietary diversity programme with high-quality foods along with limited fortification if a supplementation programme did not exist concurrently. They warn of three dangers: one, a fixation with a nutrient rather than a broader appraisal of the entire food system; two, an urge to simplify coverage operations and make fortification mandatory and universal; and three, a lack of will to roll back interventions when things improve.
COCHRANE REVIEWS
The WHO guidelines on rice fortification with minerals and vitamins as a public health strategy viewed it as a challenge because most iron powders used in food fortification were coloured, resulting in differences between fortified kernels and unfortified ones. According to a Cochrane systematic review of 16 studies, conducted from 2012 to 2017, and cited in the WHO guidelines, rice fortified with iron and other minerals increased iron content but had no effect on anaemia in the general population of those over the age of two. Cochrane reviews, Sachdev said, were recognised internationally as the gold standard for high quality and trustworthiness.
The proponents of fortification argue that as most of India cannot afford a healthy diet and a good number of the population a nutrientadequate one, fortification of cereals was the only way out to arrest anaemia. At the webinar, a World Food Programme representative, citing the State of Food Insecurity Report 2020, argued that the cost of a healthy diet was 60 per cent higher than a nutrient-adequate diet and five times the cost of an energy-sufficient diet. Around 78 per cent of India’s population could not afford a healthy diet and 39 per cent a nutrient-adequate one. There were, she said, “huge affordability issues”.
Across the globe, mandatory rice fortification is prevalent in eight countries and in ten it is voluntary; mandatory wheat fortification is prevalent in 19 countries while in 11 it is voluntary. As many as 67 countries fortify more than three commodities. No public health policy was set in stone, she said, and implementation should begin.
It is well known that there is no recent data on dietary intake. The last dietary intake survey was conducted by the National Nutrition Monitoring Bureau (NNMB) in 2012. The rice fortification pilot studies were unsuccessful, yet the implementation for the programme is being pushed, more so perhaps because the Prime Minister made the clarion announcement.
Given a range of unresolved issues, it is unclear why the FSSAI and the government were keen to push rice fortification. The FSSAI has a Food Fortification Resource Centre which works with donor and partner organisations. According to Arun Gupta, a paediatrician by training and convener of Nutrition Advocacy in Public Interest, some of the donors and partners of those organisations had links with the food and nutrients industry.
It is evident that there is nothing short term about the rice fortification plan. It simply cannot be short term given the huge investments that would be made by units preparing the pre-mix and those manufacturing blenders to mix the fortified rice kernels and regular rice. One of the big questions therefore in the fortification debate is “Cui Bono”, or who benefits, the answers to which will emerge gradually. m
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