FOOD FORTIFICATION: A NUTRITIONAL MANAGEMENT STRATEGY IN INDIA
Abstract
Although the concept and implementation of food fortification are not novel in India, still since Food Safety and Standards Authority of India (FSSAI) introduced it mandatory, the paradigm of food fortification has been broadened. In the current regulation, common staple foods such as wheat flour, rice, edible oil, milk in addition to salt, and Vanaspati have been selected as food vehicle for different micronutrient fortifications. In the present review, we discussed different policies and strategies to address the public health problem associated with nutritional deficiencies with a special emphasis on food fortification. We used data and information in regard to different policies and food fortification published on governmental websites and several published scientific reports and papers were used to understand and discuss the topic. Although there are continuous efforts to mitigate nutritional deficiencies in the country, the optimum results are yet to receive. Food fortification mandate can be expected a potential tool in this context. So far, the trials conducted with fortified foods in India mostly were found having positive results to improve the nutritional status of the subjects included in the study. However, there is sufficient scope and necessity to broaden the trial design including the population of different age groups and socioeconomic status with special emphasis on female of childbearing age and geriatric population. Awareness of nutrition through continuous monitoring of the nutritional profiling of population and timely implement and revision of policies are utmost important to achieve the goal of nutritional security of the country.
References
FAO (Food and Agriculture Organization), IFAD (International Fund for Agricultural Development), WFP (World Food Program). The State of Food Insecurity in the World 2015. Meeting the 2015 International Hunger Targets: Taking Stock of Uneven Progress. Rome: FAO; 2015.
National Family Health Survey 4, 2015-2016, Government of India. Available from: http://www.rchiips.org/nfhs/NFHS-4Reposts/India. pdf. [Last accessed on 2018 Aug 10]
National Family Health Survey 3, 2005-2006, Government of India. Available from: http://www.rchiips.org/nfhs/India.pdf. [Last accessed on 2018 Aug 10]
Ritu G, Gupta A. Vitamin D deficiency in India: Prevalence, causalities and interventions. Nutrients 2011;6:729-75.
Kant S, Malhotra S, Singh AK, Haldar P, Kaur R, Misra P, et al. Prevalence of neural tube defects in a rural area of North India from 2001 to 2014: A population-based survey. Birth Defects Res 2017;109:203-10.
IFPRI (International Food Policy Research Institute) 2014. Two Billion People Suffering from Hidden Hunger According to 2014 Global Hunger Index, Even as Levels of Hunger in Many Developing Countries Decrease. Available from: http://www.ifpri.org/news-release/ two-billion-people-suffering-hidden-hunger-according-2014-global-hunger-according-2014-global-hunger-index-even. [Last accessed on 2018 Apr 24].
Dwivedi SL, Lammerts van Bueren ET, Ceccarelli S, Grando S, Upadhyaya HD, Ortiz R, et al. Diversifying food systems in the pursuit of sustainable food production and healthy diets. Trends Plant Sci 2017;22:842-56.
Barnd JC, Snow BJ, Nabhan GP, Truswell AS. Plasma glucose and insulin response to traditional pima Indian meals. Am J Clin Nutr 1990;51:416 20.
Schulz LO, Chaudhari LS. High-risk populations: The pimas of Arizona and Mexico. Curr Obes Rep 2015;4:92-8.
Kuhnlein HV. Food system sustainability for health and well-being of indigenous peoples. Public Health Nutr 2014;18:2415-24.
Ghosh S, Jung C, Meyer-Rochow VB. Snail farming: An Indian perspective of a potential for food security. Ann Aquac Res 2016;3:1024.
Chakravorty J, Ghosh S, Meyer-Rochow VB. Comparative survey of entomophagy and entomotherapeutic practices in six tribes of eastern Arunachal Pradesh (India). J Ethnobiol Ethnomed 2013;9:5.
Meyer-Rochow VB, Chakravorty J. Notes on entomophagy and entomotherapy generally and information on the situation in India in particular. Appl Entomol Zool 2013;48:105-12.
Chakravorty J, Ghosh S, Megu K, Jung C, Meyer-Rochow VB. Nutritional and anti-nutritional composition of Oecophylla smaragdina (Hymenoptera: Formicidae) and Odontotermes sp. (Isoptera: Termitidae): Two preferred edible insects of Arunachal Pradesh. J Asia Pac Entomol 2016;19:711-20.
Bishai D, Nalubola R. The history of food fortification in the United States: Its relevance for current fortification efforts in developing countries. Econ Dev Cult Change 2002;51:37-53.
Dary O, Mora JO. Food fortification to reduce Vitamin A consultative group recommendations. J Nutr 2002;132:2927S-33.
Pandav CS, Yadav K, Srivastava R, Pandav R, Karmakar MG. Iodine deficiency disorders (IDD) control in India. Indian J Med Res 2013;138:418-33.
FAO (Food and Agricultural Organization of the United Nations).FAOSTAT 2009. Food Consumption Tables. Available from: http://www.faostat.fao.org/site/609/DesktopDefault.aspx?PageID=609#ancor. [Last accessed on 2018 Aug 10]
Muthayya S, Hall J, Bagriansky J, Sugimoto J, Grundy D, Matthias D, et al. Rice fortification: An emerging opportunity to contribute to the elimination of vitamin and mineral deficiency worldwide. Food Nutr Bull 2012;33:296-307.
Steiger G, Müller-Fischer N, Cori H, Conde-Petit B. Fortification of rice: Technologies and nutrients. Ann N Y Acad Sci 2014;2014:1-11.
Nomura RM, Igai AM, Francisco RP, Zugaib M. Anemia, roux-en-Y gastric bypass and conception. In: Hollins-Martin C, van den Akker O, Martin C, Preedy VR, editors. Handbook of Diet and Nutrition in the Menstrual Cycle, Periconception and Fertility. Metherland: Wageningen Academic Publishers; 2014. p. 376.
Hallberg L, Brune M, Rossander L. The role of Vitamin C in iron absorption. Int J Vitam Nutr Res Suppl 1989;30:103-8.
Fisher AE, Naughton DP. Iron supplements: The quick fix with long-term consequences. Nutr J 2004;3:2.
Dabbagh AJ, Lynch S, Mannion T, Frei B. The effect of iron overload on rat plasma and liver oxidant status in vivo. Biochem J 1994;300:799 803.
Aranda N, Fernandez-Cao JC, Tous M, Arija V. Increased iron levels and lipid peroxidation in a Mediterranean population of Spain. Eur J Clin Invest 2016;46:520-6.
Faga CG, Oteiza PI. Iron toxicity and antioxidant nutrients. Toxicol 2002;180:23-32.
Blunden RW, Lloyd JV, Rudzki Z, Kimber RJ. Changes in serum ferritin levels after intravenous iron. Ann Clin Biochem 1981;18:215-17.
Kim JY, Kang HT, Lee YJ, Kim JY, Kim TJ, Lim HJ, et al. Serum ferritin levels are associated with the higher risk of diabetes mellitus in men and post-menopausal women, based on the 2010-2012 KNHANES. Korean J Health Promot 2017;17:47-53.
Kim MK, Baek KH, Song KH, Kang MI, Choi JH, Bae JC, et al. Increased serum ferritin predicts the development of hypertension among middle-aged men. Am J Hypertens 2012;25:492-97.
Hurrell RF. Bioavailability of different iron compounds used to fortify formulas and cereals: Technological problems. In: Stekel A, editor. Iron Nutrition in Infancy and Childhood. New York: Vevey/Raven Press; 1984. p. 147-78.
Palacios S. The management of iron deficiency inmenometrorrhagia. Gynecol Endocrinol 2011;27(Suppl1):1126-30.
Akhtar S. Zinc status in South Asian populations-an update. J Health Popul Nutr 2013;31:139-49.
Brown KH, Hambidge KM, Ranum P, Zinc Fortification Working Group. Zinc fortification of cereal flours: Current recommendations and research needs. Food Nutr Bull 2010;31:S62-74.
Hess SY, Brown KH. Impact of zinc fortification on zinc nutrition. Food Nutr Bull 2009;30:S79-107.
Shah D, Sachdev HS, Gera T, De-Regil LM, Peña-Rosas JP. Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population. Cochrane Database Syst Rev 2016;6:CD010697.
Hettiarachchi M, Hilmers DC, Liyanage C, Abrams SA. Na2EDTA enhances the absorption of iron and zinc from fortified rice flour in Sri Lankan children. J Nutr 2004;134:3031-6.
Harinarayan CV, Ramalakshmi T, Prasad UV, Sudhakar D, Srinivasrao PV, Sarma KV, et al. High prevalence of low dietary calcium, high phytate consumption, and Vitamin D deficiency in healthy South Indians. Am J Clin Nutr 2007;85:1062-7.
Khadilkar A, Crabtree NJ, Ward KA, Khadilkar V, Shaw NJ, Mughal MZ, et al. Bone status of adolescent girls in Pune (India) compared to age-matched South Asian and white Caucasian girls in the UK. Osteoporos Int 2010;21:1155-60.
Aggarwal V, Seth A, Aneja S, Sharma B, Sonkar P, Singh S, et al. Role of calcium deficiency in development of nutritional rickets in Indian children: A case control study. J Clin Endocrinol Metab 2012;97:3461 6.
Raj JP, Oommen AM, Paul TV. Dietary calcium intake and physical activity levels among urban South Indian postmenopausal women. J Fam Med Prim Care 2015;4:461-4.
Teotia SP, Teotia M. Nutritional bone disease in India population. Indian J Med Res 2008;127:219-28.
Rafferty K, Heaney RP. Nutrient effects on the calcium economy: Emphasizing the potassium controversy. J Nutr 2008;138:166S-71S.
Weaver CM, Heaney RP, Nickel KP, Packard PI. Calcium bioavailability from high oxalate vegetables: Chinese vegetables, sweet potatoes and rhubarb. J Food Sci 1997;62:524-5.
Pansu D, Bellaton C, Bronner F. The effect of calcium intake on the saturable and non-saturable components of duodenal calcium transport. Am J Physiol 1981;240:G32-7.
Pansu D, Bronner F. Nutritional aspects of calcium absorption. J Nutr 1999;129:9-12.
Gue´guen L, Pointillart A. The bioavailability of dietary calcium. J Am Coll Nutr 2000;19:119S-36S.
Crider KS, Bailey LB, Berry RJ. Folic acid food fortification-its history, effect, concerns, and future directions. Nutrients 2011;3:370-84.
Green R. Is it time for Vitamin B-12 fortification? What are the questions? Am J Clin Nutr 2009;89:712S-16S.
Allen LH. Pros and cons of increasing folic acid and Vitamin B12 intake by fortification. In: Bhutta ZA, Hurrell RF, Rosenberg IH, editors. Meeting Micronutrient Requirements for Health and Development. Vol. 70. Basel: Nestle Nutrition Institute Workshop Ser, Nestec Ltd., Vevey/S. KargerAG; 2012. p. 175-83.
Honein MA, Paulozzi LJ, Mathews TJ, Erickson JD, Wong LY. Impact of folic acid fortification of the US food supply on the occurrence of neural tube defects. JAMA 2001;285:2981-6.
Williams LJ, Mai CT, Edmonds LD, Shaw GM, Kirby RS, Hobbs CA, et al. Prevalence of spina bifida and anencephaly during the transition to mandatory folic acid fortification in the United States. Teratology 2002;66:33-9.
De Wals P, Tairou F, Van Allen MI, Uh SH, Lowry RB, Sibbald B, et al. Reduction in neural-tube defects after folic acid fortification in Canada. N Eng J Med 2007;357:135-42.
Morris MS, Jacques PF, Rosenberg IH, Selhub J. Folate and Vitamin B-12 status in relation to anemia, macrocytosis, and cognitive impairment in older Americans in the age of folic acid fortification. Am J Clin Nutr 2007;85:193-200.
Selhub J, Morris MS, Jacques PF, Rosenberg IH. Folate-Vitamin B-12 interaction in relation to cognitive impairment, anemia, and biochemical indicators of Vitamin B-12 deficiency. Am J Clin Nutr 2009;89:702S 6S.
McLean E, de Benoist B, Allen LH. Review of the magnitude of folate and Vitamin B12 deficiencies worldwide. Food Nutr Bull 2008;29:S38 51.
National Nutrition Monitoring Bureau (NNMB). Prevalence of Micronutrient Deficiencies. Hyderabad, India: National Institute of Nutrition; 2003.
National Nutrition Monitoring Bureau (NNMB). Prevalence of Vitamin A Deficiency among Rural Pre-School Children. Hyderabad, India: Indian Institute of Nutrition; 2006.
Rahamathullah L, Raj MS, Chandravathi TS. A etiology of severe Vitamin A deficiency in children. Natl Med J India 1997;10:62-5.
Shaikh S, Mahalanabis D. Prevalence of Vitamin A deficiency is a greater concern in children in India. Nutr Food Sci Int J 2018;5. DOI: 10.19080/NFSIJ.2018.05.555655.
Andarwulan N, Gitapratiwi D, Laillou A, Fitriani D, Hariyadi P, Moench-Pfanner R, et al. Quality of vegetable oil prior to fortification is an important criteria to achieve a health impact. Nutrients 2014;6:5051 60.
Laillou A, Hafez SA, Mahmoud AH, Mansour M, Rohner F, Fortin S, et al. Vegetable oil of poor quality is limiting the success of fortification with Vitamin A in Egypt. Food Nutr Bull 2012;33:186-93.
Silalahi DK, Yuliyanti D, ds Silva M, Christianti I, Mulyono K, Wassell P. The stability of Vitamin A in fortified palm olein during extended storage and thermal treatment. Int J Food Sci Technol 2017;52:1869-77.
Moretti D, Zimmermann MB, Muthayya S, Thankachan P, Lee TC, Kurpad AV, et al. Extruded rice fortified with micronized ground ferric pyrophosphate reduces iron deficiency in Indian schoolchildren: A double-blind randomized controlled trial. Am J Clin Nutr 2006;84:822-9.
Zimmermann MB, Muthayya S, Moretti D, Kurpad A, Hurrell RF. Iron fortification reduces blood lead levels in children in Bangalore, India. Pediatrics 2006;117:2014-21.
Varma JL, Das S, Sarkar R, Mannar MG, Levinson FJ, Hamer DH. Community-level micronutrient fortification of a food supplement in India: A controlled trial in preschool children aged 36-66 mo. Am J Clin Nutr 2007;85:1127-33.
Radhika MS, Nair KM, Kumar RH, Rao MV, Ravinder P, Reddy CG, et al. Micronized ferric pyrophosphate supplied through extruded rice kernels improves body iron stores in children: A double-blind, randomized, place-controlled midday meal feeding trial in Indian school children. Am J Clin Nutr 2011;94:1202-10.
Thankachan P, Rah JH, Thomas T, Selvam S, Amalrajan V, Srinivasan K, et al. Multiple micronutrient-fortified rice affects physical performance and plasma Vitamin B-12 and homocysteine concentration of Indian school children. J Nutr 2012;142:846-52.
WEP (World Food Pragram). 2017. A Case for Fortified Rice. www.wfp.org/sites/default/files/FINALPrintBook%20%28007%29.pdf [Last accessed on 2018 Aug 15].
Muthayya S, Thankachan P, Hirve S, Amalrajan V, Thomas T, Lubree H, et al. Iron fortification of whole wheat flour reduces iron deficiency and iron deficiency anemia and increases body iron stores in Indian school-aged children. J Nutr 2012;142:1997-2003.
Anderson M, Thankachan P, Muthayya S, Goud RB, Kurpad AV, Hurrell RF, et al. Dual fortification of salt with iodine and iron: A randomized double-blind, controlled trial of micronized ferric pyrophosphate and encapsulated ferrous fumarate in Southern India. Am J Clin Nutr 2008;88:1378-87.
Haas JD, Rahn M, Venkatramanan S, Marquis GS, Wenger MJ, Murray-Kolb LE, et al. Double-fortified salt is efficacious in improving indicators of iron deficiency in female tea pickers. J Nutr 2014;144:957 64.
Ekbote VH, Khadilkar AV, Chiplonkar SA, Hanumante NM, Khadilkar VV, Mughal MZ. A pilot randomized controlled trial of oral calcium and Vitamin D supplementation using fortified laddoos in underprivileged Indian toddlers. Eur J Clin Nutr 2011;65:440-6.
Khadgawat R, Marwaha RK, Garg MK, Ramot R, Oberoi AK, Sreenivas V, et al. Impact of Vitamin D fortified milk supplementation on Vitamin D status of healthy school children aged 10-14 year. Osteoporos Int 2013;24:2335-43.