Mandatory iron Fortification of Cereals – Treatment of anemia, or the road to a new epidemic of Chronic Diseases?

Dr. Veena Shatrugna, Deputy Director (retd), National Institute of Nutrition and Steering Committee Member, Right to Food Campaign

It is well known that the nutritional status of Indians is far from satisfactory. Because of the largely cereal pulse diet there are multiple vitamin and mineral deficiencies due to the absence or poor intakes of fruits, fresh vegetables, eggs, milk, nuts, to name a few. Not surprisingly 35-70% of the population has multiple micronutrient deficiencies. A large number of people from poor backgrounds have body and muscle aches, tingling numbness, general aches and pains and even dizziness and blackouts. Children may have night blindness due to Vitamin A deficiency.

The clinical pictures of many of these deficiencies have been established, but one major result of the poor intakes is Anemia, present in over 60% of pregnant women and 30-45% in children, and even men. It was found that Iron deficiency was the major reason for the severe anaemias resulting in high MMRs, due to bleeding during pregnancy. Its impact on low birth weights and premature deliveries has also been demonstrated.

In 1970, the Govt. of India initiated a universal iron and folic acid supplementation program in the last 100 days of pregnancy to address the problem. Severely anemic women were however admitted and treated with injectable iron or even blood transfusions.

There have been many problems in the implementation of this program, such as the quality of formulation, side effects, regularity of distribution and intake and supervision. But it has sent a message to the whole country that pregnant women need iron tablets. The private sector has also played its role in popularizing iron supplementation. Despite a poor absorption of oral iron on plant based diets, (3-5% in the non pregnant state, and about 8-10% in pregnancy) the Anemia Prophylaxis program with Antenatal care has been an important intervention in pregnancy.

Despite regular iron intakes, hemoglobin levels rarely reach the desired 11gm levels in pregnancy. This is because of the poor quality of diets. Even if there is an excess of iron, Haemoglobin synthesis plateaus when it hits the next level of deficiency such as Vitamin B12, Vitamin C, folic acid, Vitamin A, Copper and other nutrients.

Another less acknowledged but important reason for anemia is the absence of quality proteins in the diet for the globin synthesis of the haemoglobin molecule. Plant proteins are unfortunately inefficient for the synthesis of this fraction. Quality proteins (abundantly found in milk and egg) are also required for the synthesis of the transport and storage proteins like Transferrin and Ferritin. The enzymes needed for all the above reactions are also dependent on quality proteins.

Because of the persistence of anemia, the Government of India now plans to fortify rice and many other foods with iron. This mandatory exercise has long-term consequences. The diets will still be devoid of other nutrients like calories, proteins and vitamins and minerals, but men and women will receive iron from multiple sources such as the supplementation program, rice and wheat fortification, and other processed foods. This iron will raise the Ferritin levels with little effect on anemia. High Ferritin levels are shown to be associated with chronic diseases like Diabetes and Blood pressure. The impact of excess iron in the absence of food may result in oxidative damage in malnourished children and vulnerable populations.

Other serious repercussions of high iron intakes are the worsening of Malaria, and other acute viral or bacterial infections. Iron also has the potential of TB flare up when given before the anti TB drugs start working. In addition, it is known that those who have sickle cell anemia or Thalassemia should not consume iron supplements.

This is an important phase in the life of a nation when mandatory iron fortification will lead to large scale food processing and change the way we eat in India. Instead of diet diversity, we will get our nutrients from one food i.e. rice. The basic tenet of Nutrition is that every food must provide many nutrients, and every nutrient must come from many foods.

This will also result in many changes in the way food is procured, stored, fortified and distributed in bulk. Only big players can enter this market, and small chakkiwalas and oil Ghanis, who operate in villages, will have to wind up.

A discussion on this topic is therefore urgently required.

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