Fortified food is not the silver bullet we need

When it comes to food, there’s a simple formula, assures Virat Kohli, the captain of the Indian cricket team, in a promotional video. One just needs to remember the plus-minus rule, he says. When buying grains, oils or milk, look out for the +F logo on the packet, which means the food is fortified with iron and vitamins. On the minus rule, Kohli very sensibly reminds consumers to cut down on oils, sugar and salt. The promotion, part of the ‘Eat Right’ campaign by the Food Safety and Standards Authority of India (FSSAI), is one of the several measures taken by government agencies to improve eating habits and nutritional standards in a country where micronutrient deficiency and hunger are at chronic levels. Fortified foods are a key part of this push.

In late 2020, FSSAI released a draft notification that proposed to make fortification of edible oils and packaged milk mandatory. Eight months later, in his Independence Day speech on 15 August, Prime Minister Narendra Modi pledged to provide iron-fortified rice by 2024 to every household that is enrolled under the food security scheme and to school children who are part of the mid-day meal programme, marking the beginning of what could soon be the world’s largest fortification drive. The idea to fortify commonly used food items appears to be a no-brainer; a low-hanging fruit. After all, over half of India’s pre-school children and women suffer from anaemia, which is caused by a shortfall in iron, vitamin B12 and folic acid in diets. Vitamin A and D deficiencies can cause childhood blindness and weak bones. So, why not add these nutrients to milk and oils? Besides, India’s experience of fortifying salt with iodine since 1962 has proved to be a cost-effective strategy to manage another type of chronic deficiency.

But a push towards large scale fortification of food also raises several discomforting questions. For instance, by looking for a low-cost quick fix—adding nutrients to mass consumption staples—are policymakers ignoring the role of dietary diversity? Fortifying staples with iron can in fact have serious health consequences since, unlike iodine, the human body has no means to release excess iron except through blood loss. Also, making fortification mandatory can push tens of thousands of small processing units such as oil and flour mills out of business, allowing big food labels to corner a larger share of the market.

What’s more, voluntary fortification of junk food—say, vitamins added to sugar-loaded juices, milk shakes or breakfast cereals—makes it easier for companies to whitewash products and fool consumers into believing that they are eating something healthy.

“The complexity of food composition means that no single nutrient is likely to work nearly so well as a diet rich in fruits and vegetables, from which that nutrient was isolated," writes Marion Nestle, professor of nutrition and public health at New York University in her book Food Politics: How the food industry influences nutrition and health.

She terms packaged food with added nutrients as “techno-food", adding that because they offer manufacturers a genuine opportunity to promote sales, food and beverage firms go to extraordinary lengths to protect the marketing environment for such products. “The development of these foods has produced at least three undesirable results: a further blurring of the distinctions between foods, supplements, and drugs; a further erosion of the ability of federal regulators to protect the public from harmful substances in foods; and, most important, a further increase in public confusion about how best to achieve recommended diets."

Fixing food

Prime Minister Modi’s independence day speech may have stirred a debate on fortification, but India had already moved swiftly towards that goal over the last few years by adding nutrients to many mass consumption products. According to FSSAI, 80 brands of edible oils (accounting for about 70% of the packaged oil market) now comes fortified with vitamin A and D. Likewise, 55 milk brands accounting for close to a third of the packaged milk sales have been fortified so far. In addition, 12 wheat flour and two rice brands (amounting to 3.4 million tonnes of packaged cereals) are fortified with iron every year. At least 16 states and union territories are also supplying fortified rice via their food safety net program.

“One should view this move to fortify staples as an affordable and complementary strategy to deliver key nutrients, (which is) in addition to diversified diets," said Tarun Vij, country director of the Global Alliance for Improved Nutrition (GAIN), which has partnered with FSSAI’s Food Fortification Resource Centre. The global non-profit counts among its donors Bill and Melinda Gates Foundation, multilateral agencies such as the World Food Program and private corporations such as Unilever Plc., Mars and Hershey.

Citing the example of milk, Vij said that the process of pasteurization takes away fat-soluble vitamins and fortification allows to replenish these nutrients. “There is no question of an overdose since the level of fortification is less than 25% of the recommended dietary allowance. The push is to ensure a threshold level of nutrition at a very low cost—just 15 paisa to fortify a litre of oil and 2 paisa for a litre of milk—to fix micronutrient deficiencies which are at an unacceptable level." According to Vij, the fears of a takeover of food supplies by large players at the cost of local level microprocessors are unfounded. Over 400 oil processors are already fortifying their products. Even small-scale processors can carry out fortification except for the village-level chakkis (flour mills), ghanis (cold presses for oil extraction) and small dairies that sell unprocessed milk, he said.

But the size of India’s unorganized food processing sector is staggering—2.8 million small chakkis supply the bulk of the wheat flour consumed within India, while there are around 150,000 oilseed crushing units, which include small and large-scale processors. It remains unclear if these micro-units will be deemed illegal once fortification is made mandatory. The policy choices could eventually make the healthiest of products—such as locally grown cold-pressed oils, which are more nutritious than solvent-extracted ones, or unpolished rice, which is healthier compared to fortified polished rice—inaccessible for many consumers.

Interestingly, Amul, the largest food and dairy brand in India, has declined to fortify milk and milk products that it supplies across the country. “A handful of global nutrient suppliers are pushing for mass fortification of food," said R.S. Sodhi, managing director of Amul. “Adding vitamins to flavoured milk is just a marketing gimmick."

How likely is the mandatory fortification of edible oils and milk? According to FSSAI chief executive officer Arun Singhal, the agency has received comments on the draft proposal and a scientific panel is looking into them. Several factors such as deficiency levels, existing supplementation programmes and the ease of adding nutrients will determine if fortification will be made mandatory. For instance, Vitamin D deficiency is widespread and overdose is not a concern. But recent surveys show that Vitamin A deficiency is no longer endemic. So, if the health ministry continues with its existing supplementation programmes, it may weaken the case for adding vitamin A to staples. What about food firms voluntarily adding vitamins in processed food to make them appear healthier? “We can only provide information to the consumer in a transparent manner. The information on sugar content is also there on the packet… but what one chooses to eat is their business," Singhal said.

But the vitamin labels mostly appear on front-of-the-pack and are displayed prominently in order to draw attention, while the nutritional information on salt, sugars and fat are always displayed back-of-pack. This might change if FSSAI decides to make front-of-pack warning labels mandatory. According to Singhal, an empirical study is underway and a decision might be taken in less than six months.

Shrinking diversity

Even as India pushes for fortification, the best strategy to address undernutrition and micronutrient deficiency, most experts agree, is to increase the diversity of food on an average person’s plate. But that is easier said than done.

The share of Indian households consuming above recommended levels of cereals was a staggering 97% in rural areas and 69% in urban regions, found a 2017 study titled What India Eats by the Indian Council of Medical Research and the National Institute of Nutrition. Over 65% of the calories consumed in rural parts came from cereals compared to the recommendation of 45%.

Overall, most families were consuming lower than recommended levels of pulses, legumes, milk, nuts and vegetables, and instead filling up their stomachs with calorie-dense cereal products.

The report said that increased availability of cheap cereals has reduced hunger, but at the expense of dietary diversity and the replacement of local foods. While not everyone is able to access (or afford) a diverse micronutrient-rich diet, foods that are high in salt, sugars, saturated and trans fats have become cheaper and are more widely available.

“For the elimination of all forms of malnutrition, there is an urgent need to create awareness among households for inculcating healthy dietary practices and improve (the) consumption of locally grown and available protective foods," the study suggested, contradicting Kohli’s prescription that fortified packaged food ensures wholesome nutrition.

According to Anura Kurpad, former chair of FSSAI’s scientific panel and head of physiology and nutrition at St John’s Medical College, Bengaluru, the advice to eat fortified foods while also opting for a diversified diet is a bit contradictory. The single-nutrient focus of fortification pushes consumers to eat more of the same food, while a diversified diet mandates exactly the opposite—rely on a variety of food items to ensure the intake of the required essential nutrients.

Kurpad added that the 2010 National Institute of Nutrition dietary guidelines that formed the basis for fortification standards for daily intake of iron and vitamins was revised down sharply in 2020, meaning these deficiencies can be met through a normal diet.

The iron puzzle

Only one in four men in India is estimated to be anaemic and it makes little sense to push iron into their diets.

Massive doses of iron from fortified food will put men at a higher risk of diabetes, Kurpad said.

Each nutrient has to be derived from different types of food and each food item should provide many types of nutrients, said Veena Shatrugna, former deputy director at the National Institute of Nutrition. “Of course, carrots provide a range of nutrients, including vitamin A, but one can’t just keep eating carrots. Your face will turn orange."

According to Shatrugna, mass fortification of cereals with iron is akin to medicating an entire nation. Ideally, iron is best used as a supplement under medical supervision to targeted groups such as pregnant women and children. She warned that iron-fortified food increases the severity of infection in tuberculosis and malaria patients.

Most importantly, Shatrugna said, haemoglobin is not formed just by iron, but being a dense molecule, it requires proteins, copper, and magnesium, among others. And it’s not just about the synthesis of haemoglobin.

Even before iron reaches the bone marrow or the liver, absorption is a challenge, and this can only be improved by the consumption of animal or haem proteins (organ meats) or if an iron-rich diet is complemented with vitamin C rich fruits and vegetables, which can aid absorption. To push iron into the body without this additional dietary support is a futile exercise. “The hope that nutritional indicators will improve by adding iron to rice is making a mockery of science… the solution lies in food diversity and addressing the question as to why a large number of people are unable to afford a diversified diet," Shatrugna added.

Do the potential benefits of fortification outweigh the many risks? “For product manufacturers, the answer is an unequivocal yes," Marion Nestle wrote in her book. “They need only look at the greatly increased sales of calcium-fortified juices and fruit drinks to women (who are) concerned about osteoporosis."

She added that the nutrients used in fortification make up only a small fraction of the nutrients that are essential to a good diet.

“These missing ingredients make fortification a techno-fix with inherently limited impact, because this method fails to address (the) fundamental causes of inadequate dietary intake, such as poverty or insufficient education."