Micronutrient deficiency, also known as Hidden hunger is a serious health risk. It is estimated that more than two billion people suffer from ‘Hidden Hunger’ globally, with nearly half living in India.
The Global Hunger Index, 2019 has ranked India 102th out of 117 countries!!!
Hidden hunger is one of the major concerns where diets are high in calories but low in essential nutrients keeping the body undernourished. So, you might not feel it in the belly, but it strikes at the core of your health and vitality. It has usually always been discussed as a problem of the underprivileged, rural population. But in fact, it is linked to wealthier, urban populations too that rely on more of a energy dense packaged food or junk food!! Lack of consumption of a balanced diet, lack of variety foods in the diet or unavailability of food are some of the reasons for micronutrient deficiency. Often, there is considerable loss of nutrients during the processing of food as well.
An alarming 70% of Indians do not consume enough vitamins and minerals and thus suffer from micro-nutrient deficiency. According to the National Family Health Survey (NFHS-4), 58.4% of children under 5 years of age are anaemic while 35.7% are underweight. Percentage of anaemic women in the reproductive age group is also about 53.1% The silver lining is – it is preventable!!!
Micronutrient deficiencies can be addressed in three ways; by making changes in the diet, through supplementation, and by means of fortification of food with selected nutrients. While dietary modification is desirable, it is a long-term solution and may require changes in food preparation practices and social customs. Supplementation is an effective and rapid approach, but it requires appropriate medical infrastructure/administration and thus it is costly. That’s where the role of food fortification comes into play!!!
Food fortification is an attractive public health strategy and has the advantage of reaching wider at-risk population groups through existing food delivery systems, without requiring major changes in existing consumption patterns.
Food Fortification refers to the practice of deliberately increasing the content of essential micro nutrients, so as to improve the nutritional quality of the food supply and to provide a public health benefit with minimal risk to health.
It is implemented at the processing stage, and involves the addition or enhancement of one or more nutrients to a food product. Several types of fortification programs exist, covering mass, targeted, voluntary, and mandatory fortification.
Mandatory fortification applies in the case where the government makes it a regulatory requirement to fortify a given food product. The most common case of mandatory fortification is the Universal Salt Iodisation (USI) programme which requires salt to be fortified with an adequate amount of iodine (≥15 ppm).
Mass fortification involves the addition of micro-nutrients to particular food groups or products which are widely consumed across a given population, such as wheat or rice in India. This type of programme is used in addressing nutrient deficiencies which are prevalent across a large proportion of the population. In the case of India, this would include calcium, vitamin A, B12, Folate, and Lysine. However, this coverage could also be extended to a wider range of micro-nutrients, especially those such as iron and zinc where deficiency is still highly prevalent, albeit within smaller demographics.
Target Food Fortification refers to the fortification of foods designed for specific population subgroups, such as complementary weaning foods for infants. It can be either mandatory or voluntary depending on the public health significance of the problem it is seeking to address.
Market driven food fortification is always voluntary, but governed by regulatory limits to ensure that the consumption of these foods will not result in an excessive intake of micro-nutrients!! It is a business orientated initiative taken by a food manufacturer to add specific amounts of one or more micro-nutrients to processed foods to increase its market value over competition.
Home fortification involves adding multiple micro-nutrients to a semi-solid food prepared in the home. This avoids the policy and food industry involvement and allows for targeted intervention for individuals in need. It is the combination of supplementation and fortification. This is available in the form of — Soluble or crushable tablets, micro-nutrient powder, micro-nutrient-rich spreads.
Bio-fortification is a relatively new intervention that involves breeding food crops, using conventional or transgenic methods, to increase their micro-nutrient content. Plant breeders also improve yield and pest resistance, as well as consumption traits, like taste and cooking time to match or outperform conventional varieties.
In contrast to large-scale fortification, which usually reaches a greater share of urban than rural residents, bio-fortification first targets rural areas where crops are produced. Marketed surpluses of bio-fortified crops may make their way into retail outlets, reaching consumers first in rural areas, then in urban ones. Given that bio-fortified staple foods cannot deliver as high a level nor as wide a range of minerals and vitamins as supplements or industrially fortified foods can, they are not the best response to clinical deficiencies. However, they can help close the micro-nutrient intake gap and increase the daily intake of vitamins and minerals throughout a person’s life.
Another plus is that bio-fortified crops are sustainable, climate-resilient and inexpensive. To date, effective bio-fortification of crops with iron, zinc, and vitamin-A has been proven, with distribution via the HarvestPlus Programme. In India, this includes zinc wheat, iron pearl millet, and “golden rice” (vitamin-A enriched rice). In the next five years, we are likely to see bio-fortified foods on the shelves.
One of the key processes in the development of a successful fortification is selecting an appropriate Food Vehicle and identifying the Fortificant.
Food Vehicle is the specific food to which the process of fortification is done. This requires specific knowledge of specific food patterns of who is eating what food among the groups at greatest risk of deficiency. Overall, staples have been the primary choice as they are widely consumed by the population, whereas processed foods and cereals have been chosen when infants were the target population.
Fortificant is the specific nutrient that is being added to the food vehicle. The micronutrient added should have a good bio-availability, affordable cost, should have acceptable color, taste, solubility and particle size and it should be commercially available.
Dry mixing, Dissolution in water and oil, Spraying, Coating, Pelleting are some of the common food fortification techniques which will be discussed in detail in second part of this article, Industrial food fortification techniques.
Being a food-based approach, food fortification offers a number of advantages over other interventions aimed at preventing and controlling micro-nutrient deficiencies. Most importantly it is a socio-culturally acceptable way to deliver nutrients that does not require any changes to be made in existing food patterns. With the type of food technology & distribution system in hand, it is most cost effective and feasible way to fortify foods with several micro-nutrients simultaneously without altering food characteristics. Fortification of widely distributed and widely consumed foods such as staples, has the potential to improve the nutritional status of a large proportion of the population, both poor and wealthy. If consumed on a regular and frequent basis, fortified foods will maintain body stores of nutrients more efficiently and more effectively than will intermittent supplements.
Food fortification is currently experiencing a revolution in India.
The Food Safety and Standards Authority of India (FSSAI) released the Standards for fortification of wheat flour, rice, oil, milk and double fortified salt in October 2016 and have also released a logo for fortified foods. The +F logo can only be used, if the staple is fortified as per the regulations. The recently established Food Fortification Resource Centre (FFRC) is working with all stakeholders – development partners, government, industry, academia and civil society organizations to promote large scale food fortification across India. It is a resource hub which provides information and inputs on standards and food safety, technology and processes, premix, equipment procurement, manufacture, quality assurance and quality control for fortification of foods.
Fortification, however, has a number of shortcomings!!!
Fortified foods often fail to reach the poorest segments of the general population who are at the greatest risk of micro-nutrient deficiency. This is because such groups often have restricted access to fortified foods due to low purchasing power and an underdeveloped distribution channel. To reach those most in need, fortification must be subsidized or mandatory; otherwise people may buy cheaper non fortified alternatives.
Technological issues relating to food fortification have yet to be fully resolved, especially with regard to appropriate levels of nutrients, stability of fortificants, nutrient interactions, physical properties, as well as acceptability by consumers including cooking properties and taste.
Although often more cost-effective than other strategies, there are nevertheless significant costs associated with the food fortification process, which might limit the implementation and effectiveness of food fortification programmes. These typically include start-up costs, the expense of conducting trials for micronutrient levels, physical qualities and taste, a realistic analysis of the purchasing power of the expected beneficiaries, the recurrent costs involved in creating and maintaining the demand for these products, as well as the cost of an effective national surveillance system to ensure that fortification is both effective and safe.
Eliminating hidden hunger will not be easy. Food fortification will continue to be an important tool, not only to treat or prevent specific nutritional deficiencies, but also to promote a general state of well-being in different populations, and possibly to prevent certain chronic diseases.
However, pan-India public education programmes are required to inform the public about the benefits of fortification and encourage them to consume fortified food. The right polices also must be in place to ensure health services, including fortification programs, are made available to the most at-risk communities. With more concerted efforts from all stakeholders, these challenges will be overcome more easily in the coming months and improve the nutrition profile of the population.
So, next time when you visit the nearest grocery store, remember to opt for fortified food products to ensure the health and nutrition for your family.
References:
Book: Guidelines on Food Fortification with Micronutrients