Brainstorming Session on ‘Food Fortification Issues and Way Forward’ (Convener: Dr K. Madhavan Nair, former Deputy Director, ICMR-NIN, and Fellow, NAAS)

A brainstorming session on ‘Food Fortification Issues and Way Forward’ was organized on  March 11, 2022 to deliberate on the issues emerging out of the new nutrient requirements and recommended dietary allowances by the ICMR-NIN, 2020, nationwide study on the status of micronutrients (anemia, iron, vitamin A and D, folic acid and vitamin B12, and iodine) among 1-19 years old children and adolescents (CNNS 2019) and urban diet and nutrient survey (NNMB 2017). The meeting was chaired by Dr Ramesh Chand, Member, NITI Aayog. Dr P K Joshi, Secretary, NAAS welcomed the participants.

In his opening remarks, Dr Ramesh Chand stated that the national policy on food and nutrition takes into consideration the ground realities. He raised the concern that despite improvements in food supply, the level of malnutrition remains static. He flagged the debate on voluntary vs mandatory fortification of foods.

Dr K. Madhavan Nair presented the base paper highlighting the existing fortification strategies,  current status of micronutrient deficiency  and the ICMR-NIN (2020) Nutrient requirements which enables the provision of three reference values for nutrients viz. EAR (Estimated Average Requirements), RDA (Recommended Dietary Allowances) and TUL (Tolerable Upper Limits). He made detailed presentation on the prevalence of nutrient inadequacy, modeling to compute standards for iron, folic acid, vitamin B12, vitamin A and vitamin D fortification of foods, and deliberated on the likely impact of layering of interventions with single vs multiple vehicles. He suggested that adoption of ICMR-NIN 2020 reference values and methodological framework to shift the population nutrient adequacy to their requirements distribution should form the basis for setting the fortification standards to safely address the micronutrient deficiencies in our country.

Dr N Bhaskar, Advisor (Science and Standards), FSSAI presented views on these issues. He briefly presented the basis of existing set of fortification standards and stressed the need for robust monitoring mechanism for science based policy changes. He has raised concerns of amending RDA to EAR in the FSS Act-2006.

The views of the ICMR-National Institute of Nutrition were presented by Dr A. Laxmaiah, Scientist G. The main highlights were (i) NIN does not recommend universal fortification (ii) not in favour of fortification of multiple staple foods (for example, rice and salt) with the same nutrient (iii) suggests assessing inadequacies from NNMB data across all age and gender groups and arriving at fortification standards through modeling to shift the intake distribution close to the requirement distribution, while minimizing the risk of exposure beyond tolerable upper levels as specified in ICMR-2020.

This was followed by a panel discussion chaired by Dr M S Bamji, INSA Honorary Scientist.  The panel members included Dr V. Prakash, former Director, CFTRI; Dr Rajan Shankar, Senior Advisor - Nutrition, TATA Trust ; Dr Anura Kurpad, Professor, Physiology, St. John's Medical College, Bengaluru; Dr Kapil Yadav, Associate Professor,  Centre for Community Medicine, AIIMS, New Delhi; Dr Sheila Vir, Public Health Nutrition Consultant Director, Public Health Nutrition and Development Centre; Major General Dr R.K. Marwaha, former Additional Director, INMAS, DRDO and  Dr Prema Ramachandran , Director NFI.

The following recommendations emerged from the deliberations of this brainstorming session.

• Dietary diversification is a sustainable strategy to address holistically the problem of malnutrition, including micronutrient deficiencies. Better strategies, for educating the public, particularly women and children, through behavioural change communication  are needed to get the best results despite economic constraints.
• India needs to implement micronutrient fortification, based on evidence from dietary inadequacies, as a complimentary strategy along with dietary diversification.
• Deal with fortification of each micronutrient separately and contextually (vitamin A for poor children, vitamin D for upper SLI).
• Fortification needs to be discouraged if there is an ongoing universal supplementation programme of specific nutrients (i.e.,  iron and anemia mukth bharath).
•  Restrict to the fortification of one vehicle rather than layering of multiple vehicles as this may pose safety issue, particularly with respect to iron and vitamin A.
• Use oil as a vehicle for vitamins A  and D, and salt for iron.
• Close monitoring for addressing risk and benefit in the context of evidence for rise in biomarkers of iron and NCD is needed.
• Short and long term monitoring mechanisms of food fortification on health and toxicity needs to be established.
• There is a need for contemporary and representative data on dietary intakes and prevalence of functional/biochemical deficiency across all age groups