Despite recognizing unbalanced food intake as the main cause, the main focus is on technological adjustments for micronutrients

India is not doing well in terms of nutrition, as malnutrition (low body weight) is perceived to continue, according to report 5 of the National Family Health Survey (NFHS). Likewise, overeating (high body weight) is showing an increase. Both under and over nutrition coexist with their risks for infectious or non-communicable diseases. This is the tip of the iceberg: the truth is that India is already well into this problem, perhaps due to an inadequate response to the nutrition of those who are malnourished. If we look beyond high body weight, a massive number of Indian children (over 50%) show metabolic signs of overeating – like high blood sugar or high cholesterol or high serum triglycerides. Even in weak or stunted children. Similarly, the prevalence of anemia also appears to be stagnant. All of these events are not isolated and reflect inadequate or inadequate dietary intake, especially in nutrition programs designed to remove the population from malnutrition. Therefore, the solutions lie in prioritizing the quality of dietary intake provided in food policies and monitoring the food-based diets that are implemented. It is only in this way that it will address the underlying insufficiency without causing overeating, which single (or scanty) fortification of nutrients does not seem to address.
The BJP Manifesto in 2014 stated: “One of our main objectives will be to eradicate the curse of malnutrition. We will do this by renewing existing programs and launching a multifaceted fight against malnutrition nationwide, especially in underdeveloped areas, with the help of state governments. All resources will be provided to achieve this goal. ” Aware of the current debate over compulsory rice fortification, we want to draw the attention of the Honorable Prime Minister and his advisers to many misunderstandings about science, security, and offer solutions that will help the government keep its promises.
The motivation for rice fortification as a sustainable short-term solution to treat malnutrition comes from the NFHS findings, where anemia in women aged 15-49 has been shown to apparently increase from 2015 to date. This is in contrast to the Indian Government’s National Intensive Iron Plus Initiative, which provides pharmacological doses of iron and folic acid supplements for women and adolescent children (100 mg iron and 500 mcg folate per week) as well as younger children.
We argue that this motivation and its solution (fortification) are questionable. One, that the prevalence of anemia was stagnant should have raised at least the suspicion that the method of measuring anemia might have been part of the problem. Anemia load estimates in India are based on capillary blood. Global studies, including from India, have now shown that the use of capillary blood significantly underestimates hemoglobin; the use of the recommended venous blood sample (taken with a syringe from a vein in the arm) would halve the burden of anemia.
Second, it is incomprehensible to think that only one or two nutrients can solve the problems of a deficient diet. Only a varied diet (food) can solve the problems of many deficiencies. Deficient reductionist thinking (fortification of one or two nutrients) is reinforced by another notion, that deficiencies in the Indian diet are so great that a normal varied Indian diet cannot meet the daily requirement for nutrients. Not true! The latest nutrient requirements published by the Government of India’s National Nutrition Institute in 2020 (including iron) show that a normal, economical, vegetarian and varied diet can meet most requirements (including iron). The same institute presented a report, “What India eats”, which showed the low consumption of foods with nutritional values ​​such as fruits, vegetables, milk, legumes, meat, poultry, etc.
Three, it is also worth noting that the latest Comprehensive National Survey of Indian Child Nutrition, under the auspices of the MHFW, showed that iron deficiency was associated with less than half of the cases of anemia in the country’s children. Many other nutrients, such as vitamin B12, folate, and good protein intake are also important; their intake is achieved through a good and varied diet.
However, proponents of fortification will say that any argument against it is irresponsible and ignores the implications of nutritional deficiencies. This is also not true. Everyone agrees that the poorest 20% of the population has low quality diets. But this can and should be addressed through diversifying their diets, to include more fruits, vegetables, legumes and animal-based foods like milk or eggs. If we do not address the root cause, success may not be beneficial.
Let’s examine the scientific evidence.
A Cochrane summary of all studies on rice fortification concluded that rice fortification was unlikely to prevent anemia or iron deficiency. If one believes this, how do you expect this to eliminate anemia? The evidence used for decision-making is probably a recent study from Gujarat, which reported a reduced prevalence of anemia in school children eating their lunch meal with fortified rice. But as the authors claim, this was an almost experimental study, without randomization, which is a critical omission. Also, hemoglobin was measured with a pulse oximeter that has a high error, which the manufacturer says was intended only for adults. Other cited Indian studies make baseless claims and have not been reviewed by peers in the scientific field. Only 1 in 6 children aged 6-23 months can eat enough different foods.

Ignoring the precautionary principle, proponents of fortification say that fortification is safe — that it provides small amounts of iron — that it is unlikely to cause harmful effects. Again: not true. Fortified salt or rice can each provide an additional 10 mg of iron per day in the diet, compared to the daily requirement for iron, which for a woman is 15 mg and for a man is 11 mg. This can certainly lead to a takeover that is more than required: an overload. However, fortification suppliers will say that micronutrient overload is a “distant possibility” and that toxicity is a “myth.” There is a well-defined “risk” of chronic non-communicable diseases such as diabetes, hypertension and high cholesterol with high iron status in the body. This can happen at any age. Other damage comes from the unabsorbed iron that remains in the gut – wreaking havoc among the beneficial bacteria in the colon. We all know how important the gut microbiome is for long term health. Calling it “safe” is actually dangerous.

This leads us to the second part of malnutrition; child overweight has almost doubled in the last 5 years, and poor metabolic health stands at a dizzying 50% in children. Part of this is due to the aggressive overeating of cereals (rice and wheat) in the programs. Another important part is due to the consumption of unhealthy commercial food “products”, which are aggressively marketed through the media and supported by celebrities. India has been extremely slow in controlling the consumption and spread of ultra processed food products (UPF), usually high in salt, sugar and bad fats. India already has many chronic diseases (some call us the “diabetes capital” in the world) and we should not exaggerate this through our nutrition policies.

Food health, child development and general well-being come from eating a balanced diet rich in nutrients and agreed with by the Government of India’s policy institute and nutrition council. The difference of opinion lies in setting priorities. We believe that a transition is needed here. Providing and monitoring a varied and adequate food for all should be the first, both short-term and long-term strategies. Mandatory fortification of rice on the contrary will dilute efforts to provide various diets that are already considered expensive. The benefit derived from nutrients in whole food will always be greater than the sum of its portions. We suggest, as a process, calling for a consultation of public nutrition experts (to develop a conceptual framework to decide on technological interventions such as fortification), which takes into account the social and ecological determinants of malnutrition and is based on its risks, its benefits. and ethics. For the growing obesity we suggest the adoption of a law to urgently ban the advertising, marketing and approval of UPF celebrities, especially for children, because it is the promotion that encourages consumption. The National Nutrition Strategy 2017 mandates that policy development should be free from conflicts of interest.
What we need is adequate funding, strengthening human resources in health facilities and communities, supporting the health system for exclusive breastfeeding for the first 6 months and continuing breastfeeding for 2 years or more, universal food safety at the level family, availability of adequate different foods for babies. young children after 6 months, prevention of premature birth, strengthening primary preventive health care, skills and capacity of first line providers, increasing literacy and improving water supply and sanitation. Therefore, the end of the malnutrition game requires a plan with clear objectives; not quick short-term solutions.
Dr Arun Gupta MD FIAP is a pediatrician, nutrition advocate collector in the public interest and former member of the PM’S Nutrition Challenges Council of India.
Prof. Anura Kurpad (MD, PhD, FRCP) is Professor of Physiology and Nutrition at St John Medical College, Bengaluru.
Prof Harshpal Singh Sachdev (MD, FRCPCH) is Senior Consultant in Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute for Science and Research, New Delhi.
The views are personal