MISSION MALNUTRITION FREE INDIA - 2022

National Conference on Mission Mode to address Under-nutrition

19 September 2017
New Delhi

Efficacy and Effectiveness of Food Fortification –

Addressing Micronutrient Deficiencies

Prof (Dr) Chandrakant S Pandav,

President, ICCIDD &
Former Head, Centre for Community Medicine (CCM), AIIMS, New Delhi.
Dr Kapil Yadav,
Associate Professor, CCM, AIIMS, New Delhi
Outline of Presentation

• Micronutrient Deficiencies – “Hidden Hunger”

• Strategy to address Micronutrient deficiencies

• Food Fortification

•Efficacy and Effectiveness

• Iodine

• Iron & Folate

• Vitamin A and D

•Take Home Message

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Take home message - Food Fortification : A complementary strategy
to tackle micronutrient deficiency (1)

• Hidden hunger a significant burden at global and national level

• Evidence for fortification strong, highly cost-effective strategy

• Nutrition, Health and Education are “merit goods”

(not dependent upon ability to pay)

• Food fortification complementary to food

diversification, supplementation & public health measures: access
to health care and WASH
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Take home message - Food Fortification : A complementary strategy
to tackle micronutrient deficiency (2)

• India one of the first countries globally with mandatory fortification

of Vanaspati (1953) & Salt (1962)
• Transition from voluntary to mandatory fortification

• Address “values” of target beneficiary

• Food fortification to be integrated with existing nutrition program

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 World Hidden Hunger 2014

Two billion individuals globally affected

Alarmingly high burden in India
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Micronutrient Deficiencies of Public Health Significance in India

Iodine

Folate Iron

Vitamin A Vitamin D

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Strategy to Address Micronutrient Deficiencies

Dietary Diversification

Supplementation

Food Fortification
Access to Health Care
Public Health Measures
Water, Sanitation, Hygiene (WASH)

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Adequately Iodised Salt Coverage trends in India (1985– 2015)

90
78
80 71
70
60 51
49
50
40
30
20
10 5
0

1985 1998 2005 2009 2015

Significant increase in adequately iodised salt coverage at
national level over three decades

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 Impact of Success of Salt Iodisation

• Salt Iodisation in India alone has saved -

• 4 billion IQ point since 1985
• 300 million IQ points every year
• Another 75 million IQ points can be saved annually
if USI is attained

• Estimated to contributes to 1.4% GDP growth by

preventing Brain damage in children

• And all this at cost of only 0.2 Rupees per child per
year, with a cost benefit ratio of 1: 80
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 “Panchsheel” of Partnership to Sustain USI

International, Bilateral,
Academics /
National Agencies
Universities

Private Sector
Civil Societies

Government Agencies
National/State
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The World in which Public Health Policies Were/Should be Made

1) Health Problem/Issue Values

2) Information CORE VALUES
Ideologies, Ethics
3) Institutional
structure for
decision making BELIEFS
Casual Assumptions

4) POLICIES
INTERESTS
Synthesis & Implementation of Program

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Revisiting The Policy Process: The Missing Link - Values

CORE VALUES (IDEOLOGIES)

Gandhians – Salt as a icon of the freedom struggle
Is IDD a nationwide public health problem?
Do we need compulsory iodisation?
SJM – Globalization & Liberalization
Multinational Vs National
Import of iodine
Price of Iodised salt

BELIEFS of People / Casual Assumptions –

Sea salt is impure
Traditionally used to big crystal salt
Iodine not an essential nutrient

INTERESTS –
Common and Iodised Salt manufacturers
PFA Act and its penalties, Loose Vs Packaged
Small Vs Big producers

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Iron - Flour Fortification

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Iron - Rice Fortification

35

30 29.89
27.47 26.67 Fe
25
24.18

Prevalence %
20

15 15.29 15.00

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Control
5

0
baseline 3.5 months 7 months

• Am J Clin Nutr; October 2006

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 Iodine and Iron - Double Fortified Salt

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• 8 studies have shown efficacy of DFS in
reducing anaemia after consumption of 15

DFS over 8-12 months 15

• A review of these studies showed that

both anaemia prevalence and
hemoglobin levels respond to DFS 5

consumption (review included all

formulations of DFS – ferrous
sulphate, fumarate and pyrrophosphate)

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Food Fortification – Does it work

Folic Acid- Wheat Flour Fortification

NTD before and after fortification

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 Vitamin A and D- Milk fortification

Impact of vitamin D fortified milk supplementation on vitamin D status of healthy school

children aged 10-14 years.
Khadgawat R1, Marwaha RK, Garg MK, Ramot R, Oberoi AK, Sreenivas V, Gahlot M, Mehan N, Mathur P, Gupta N

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Vitamin A - Fortification of Oils and Fats

Efficacy of vitamin A fortification

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 Cost Effectiveness of Food Fortification

Iodine Fortification Iron Supplementation Vit A Supplementation Iron Fortification

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 THANK YOU

All India Institute of Medical Sciences, New Delhi