List of Contributors
No. |
Name |
Designation |
1 |
Shifa Sanofer |
Research Officer |
2 |
Aneesh Sane |
Research Manager |
3 |
Prasad Bogam |
Director (Monitoring, Evaluation & Research) |
4 |
Joshita Lamba |
Associate Director of Partnerships |
5 |
Anthony Senanayake |
Chief Executive Officer |
Executive Summary
Iron deficiency anaemia is a prevalent public health issue in India, and food fortification, including large-scale programs for rice, wheat flour, and salt, is one of the key strategies under national programs to address anaemia. However, concerns exist around the potential risk of excessive iron intake and overload, especially when multiple fortified staples and supplements are consumed together, potentially exceeding the tolerable limits set by regulatory bodies. This study assesses total dietary iron intake using HCES 2011-12 data, which provides food consumption data across India.
Iron intake was modelled from regular diets, fortified foods, and supplements to estimate total intake levels in the top five wheat- and rice-consuming states. The analysis evaluates the risk of iron intake exceeding the Tolerable Upper Limit (TUL) by comparing wheat-consuming states, with higher intrinsic iron intake, to rice-consuming states, where intrinsic iron intake is lower. The study helps identify potential safety concerns related to iron intake exceeding the TUL, and regional variations in iron intake and offers insights applicable to regions with comparatively lower wheat consumption. The findings provide evidence-based recommendations for policymakers, millers, nutrition researchers, advisers and stakeholders to ensure that fortification strategies effectively combat iron deficiency while minimising risks.
Key findings and takeaways:
While concerns exist about excess iron intake, the risk of iron overload remains low due to several factors.
Fortification remains a safe and effective strategy for addressing iron deficiency when regionally adjusted and properly monitored. To maximise benefits and minimise risks, policies must focus on tailored fortification Strategies, better coordination with supplementation, and promoting dietary diversity. This includes adjusting fortification levels and carefully selecting the number of fortified food vehicles based on regional dietary patterns, monitoring cumulative iron intake to coordinate and align fortification and supplementation programs to avoid overlaps, and educating vulnerable groups on safe iron consumption. Strengthening these efforts will help achieve effective anaemia reduction without increasing excess iron risks.
Iron deficiency anaemia is a prevalent public health issue in India, and food fortification, including large-scale programs for rice, wheat flour, and salt, is one of the key strategies under national programs to address anaemia. However, concerns exist around the potential risk of excessive iron intake and overload, especially when multiple fortified staples and supplements are consumed together, potentially exceeding the tolerable limits set by regulatory bodies. This study assesses total dietary iron intake using HCES 2011-12 data, which provides food consumption data across India.
Iron intake was modelled from regular diets, fortified foods, and supplements to estimate total intake levels in the top five wheat- and rice-consuming states. The analysis evaluates the risk of iron intake exceeding the Tolerable Upper Limit (TUL) by comparing wheat-consuming states, with higher intrinsic iron intake, to rice-consuming states, where intrinsic iron intake is lower. The study helps identify potential safety concerns related to iron intake exceeding the TUL, and regional variations in iron intake and offers insights applicable to regions with comparatively lower wheat consumption. The findings provide evidence-based recommendations for policymakers, millers, nutrition researchers, advisers and stakeholders to ensure that fortification strategies effectively combat iron deficiency while minimising risks.
Key findings and takeaways:
- ⦿ Intrinsic Iron Intake & Fortification Impact: Regular diets alone did not provide sufficient iron intake, especially in rice-consuming states, where intrinsic iron levels were lowest. In contrast, wheat-consuming states met RDA levels due to higher intrinsic iron intake. Fortification of wheat flour and rice significantly improved iron adequacy, addressing deficiencies without exceeding safety limits.
- ⦿ Excess Intake Risks with Combined Interventions: Consumption of fortified wheat flour, rice, and salt alone with a regular diet did not lead to excessive iron intake. Excess iron intake occurred only when all fortified sources, including salt, were consumed together with supplements, while fortified staples and supplements alone did not pose a risk. When fortified salt was also consumed alongside fortified staples and supplements, the risk of exceeding the TUL increased, particularly in rural Haryana (13%) and Rajasthan (11%) among wheat-consuming states, and in Tripura (22%) and Arunachal Pradesh (13%) among rice-consuming states.
- ⦿ Regional Variations: Wheat-consuming states had higher iron intake and a greater risk of exceeding TUL while rice-consuming states benefited more from fortification. Rural populations faced a higher risk of excess intake due to greater cereal consumption, whereas urban populations generally had lower iron intake.
While concerns exist about excess iron intake, the risk of iron overload remains low due to several factors.
- ⦿ Bioavailability Limiters: Indian diets are predominantly plant-based, containing natural inhibitors like phytates, tannins, and calcium, which reduce non-heme iron absorption.
- ⦿ Self-Regulation of Iron: The body regulates iron absorption based on physiological needs, preventing excess accumulation.
- ⦿ Clear Regulatory Standards: The Fortification of staple foods contributes only 30–50% of the RDA, according to the standard regulations, further reducing concerns about excessive iron intake.
Fortification remains a safe and effective strategy for addressing iron deficiency when regionally adjusted and properly monitored. To maximise benefits and minimise risks, policies must focus on tailored fortification Strategies, better coordination with supplementation, and promoting dietary diversity. This includes adjusting fortification levels and carefully selecting the number of fortified food vehicles based on regional dietary patterns, monitoring cumulative iron intake to coordinate and align fortification and supplementation programs to avoid overlaps, and educating vulnerable groups on safe iron consumption. Strengthening these efforts will help achieve effective anaemia reduction without increasing excess iron risks.
List of Abbreviations
AMB – Anemia Mukt Bharat
EAR – Estimated Average Requirement
FSSAI – Food Safety and Standards Authority of India
HCES – Household Consumption and Expenditure Survey
ICMR-NIN – Indian Council of Medical Research - National Institute of Nutrition
IFCT – Indian Food Composition Tables
LSFF – Large Scale Food Fortification
mg – Milligram
NaFeEDTA – Sodium Iron Ethylenediaminetetraacetate
NFHS – National Family Health Survey
NIPI – National Iron Plus Initiative
NNMB - National Nutrition Monitoring Bureau
NSSO – National Sample Survey Organisation
RDA – Recommended Dietary Allowance
TUL – Tolerable Upper Limit
USDA – United States Department of Agriculture
WRA – Women of Reproductive Age
EAR – Estimated Average Requirement
FSSAI – Food Safety and Standards Authority of India
HCES – Household Consumption and Expenditure Survey
ICMR-NIN – Indian Council of Medical Research - National Institute of Nutrition
IFCT – Indian Food Composition Tables
LSFF – Large Scale Food Fortification
mg – Milligram
NaFeEDTA – Sodium Iron Ethylenediaminetetraacetate
NFHS – National Family Health Survey
NIPI – National Iron Plus Initiative
NNMB - National Nutrition Monitoring Bureau
NSSO – National Sample Survey Organisation
RDA – Recommended Dietary Allowance
TUL – Tolerable Upper Limit
USDA – United States Department of Agriculture
WRA – Women of Reproductive Age
1. Excess Iron Intake from Multiple Fortified Staples: A Growing Concern in India
Anaemia and iron deficiency anaemia remain a major public health concern globally and in India, particularly among women of reproductive age, children, and adolescents. In India, according to the NFHS-5 survey, the anaemia burden is highest among children aged 6–59 months (67.1%), women aged 15–19 years (59.1%), and non-pregnant women in the reproductive age group (57.2%). Men aged 15–19 years have a lower burden of 31.1%, while pregnant women have a burden of 52.2%. Iron deficiency, said to be the leading cause of anaemia, is associated with impaired cognitive development, reduced work productivity, and adverse pregnancy outcomes. Staple food fortification is a globally proven, cost-effective intervention to address these prevalent micronutrient deficiencies in the population.
However, though iron fortification effectively addresses iron inadequacy, concerns have emerged about potential excessive iron intake due to the overlapping intake from fortified staples, dietary diversity, and supplementation programs. Iron is an essential micronutrient, but excessive intake beyond the Tolerable Upper Limit (TUL) of 45 mg/day may lead to adverse health effects. Iron overload can be potentially toxic for human cells due to its role in generating free radicals. Excess iron accumulation has been linked to gut dysbiosis, oxidative stress, and systemic inflammation (Ma et al., 2016). However, the risk of iron overload varies across populations, influenced by age, gender, genetic predisposition, and existing health conditions.
1.1 Gaps in Previous Studies on the Safety of Iron Fortification
Previous studies (Swaminathan et al., 2019; Ghosh et al., 2019; ICMR-NIN, 2023) assessed the risk of iron intake exceeding the Tolerable Upper Limit (TUL) in India but had key limitations. Swaminathan et al. (2019) faced methodological constraints, including aggregation errors due to mismatched survey sizes (NSSO and NFHS-4). These studies focused only on Women of Reproductive Age (WRA) and did not assess broader population groups. Additionally, they modelled a fixed 10 mg/day iron intake from each fortified staple, failing to capture regional dietary variations. The ICMR-NIN (2023) White Paper evaluated the safety concern of consumption of fortified rice with a regular diet; however, it did not evaluate cumulative iron intake from multiple fortified staples and supplements.
1.2 Bridging Knowledge Gaps in Iron Intake and the Safety of Iron Fortification
Given concerns about exceeding the Tolerable Upper Limit (TUL) due to overlapping dietary sources, this study is crucial for guiding safe and effective iron fortification strategies in India. Thus, this study addresses these gaps using state-wise dietary data from HCES 2011-12 to model total iron intake across the top five wheat- and rice-consuming states. Incorporating regional dietary diversity provides a comprehensive risk assessment and a streamlined framework to evaluate iron intake and the safety of fortification programs, contributing to the existing knowledge.
This document provides a comprehensive analysis of iron fortification safety in India, focusing on the potential risk of excess iron intake when multiple fortified staples are consumed concurrently alongside regular diets and supplements. The study examines regional dietary variations (wheat and rice-consuming states), iron intake levels, inadequacy, and the contribution of fortification in meeting the RDA. Additionally, it evaluates iron intake scenarios to assess potential risks of exceeding the TUL and explores mitigation strategies to ensure safe consumption. The findings provide evidence-based recommendations for regulatory bodies, policymakers, millers, and nutrition stakeholders to ensure that food fortification remains both safe and effective in combating iron deficiency in India.
Anaemia and iron deficiency anaemia remain a major public health concern globally and in India, particularly among women of reproductive age, children, and adolescents. In India, according to the NFHS-5 survey, the anaemia burden is highest among children aged 6–59 months (67.1%), women aged 15–19 years (59.1%), and non-pregnant women in the reproductive age group (57.2%). Men aged 15–19 years have a lower burden of 31.1%, while pregnant women have a burden of 52.2%. Iron deficiency, said to be the leading cause of anaemia, is associated with impaired cognitive development, reduced work productivity, and adverse pregnancy outcomes. Staple food fortification is a globally proven, cost-effective intervention to address these prevalent micronutrient deficiencies in the population.
However, though iron fortification effectively addresses iron inadequacy, concerns have emerged about potential excessive iron intake due to the overlapping intake from fortified staples, dietary diversity, and supplementation programs. Iron is an essential micronutrient, but excessive intake beyond the Tolerable Upper Limit (TUL) of 45 mg/day may lead to adverse health effects. Iron overload can be potentially toxic for human cells due to its role in generating free radicals. Excess iron accumulation has been linked to gut dysbiosis, oxidative stress, and systemic inflammation (Ma et al., 2016). However, the risk of iron overload varies across populations, influenced by age, gender, genetic predisposition, and existing health conditions.
1.1 Gaps in Previous Studies on the Safety of Iron Fortification
Previous studies (Swaminathan et al., 2019; Ghosh et al., 2019; ICMR-NIN, 2023) assessed the risk of iron intake exceeding the Tolerable Upper Limit (TUL) in India but had key limitations. Swaminathan et al. (2019) faced methodological constraints, including aggregation errors due to mismatched survey sizes (NSSO and NFHS-4). These studies focused only on Women of Reproductive Age (WRA) and did not assess broader population groups. Additionally, they modelled a fixed 10 mg/day iron intake from each fortified staple, failing to capture regional dietary variations. The ICMR-NIN (2023) White Paper evaluated the safety concern of consumption of fortified rice with a regular diet; however, it did not evaluate cumulative iron intake from multiple fortified staples and supplements.
1.2 Bridging Knowledge Gaps in Iron Intake and the Safety of Iron Fortification
Given concerns about exceeding the Tolerable Upper Limit (TUL) due to overlapping dietary sources, this study is crucial for guiding safe and effective iron fortification strategies in India. Thus, this study addresses these gaps using state-wise dietary data from HCES 2011-12 to model total iron intake across the top five wheat- and rice-consuming states. Incorporating regional dietary diversity provides a comprehensive risk assessment and a streamlined framework to evaluate iron intake and the safety of fortification programs, contributing to the existing knowledge.
This document provides a comprehensive analysis of iron fortification safety in India, focusing on the potential risk of excess iron intake when multiple fortified staples are consumed concurrently alongside regular diets and supplements. The study examines regional dietary variations (wheat and rice-consuming states), iron intake levels, inadequacy, and the contribution of fortification in meeting the RDA. Additionally, it evaluates iron intake scenarios to assess potential risks of exceeding the TUL and explores mitigation strategies to ensure safe consumption. The findings provide evidence-based recommendations for regulatory bodies, policymakers, millers, and nutrition stakeholders to ensure that food fortification remains both safe and effective in combating iron deficiency in India.
2. Current Iron Fortification Landscape in India
The World Health Organization (WHO) and Food Safety and Standards Authority of India (FSSAI) recommend fortifying wheat flour, rice, and salt mainly with iron and a few other nutrients to combat anaemia and improve public health.
The Government of India, under the National Nutrition Mission, has implemented large-scale food fortification programs as part of the Anemia Mukt Bharat (AMB) program, integrating fortified wheat flour, rice, and salt into national nutrition initiatives. Fortification is one of AMB’s six strategic interventions aimed at reducing anemia prevalence in India. To reach vulnerable populations, fortified staples are distributed through social safety net schemes, ensuring access to iron-enriched foods for high-risk groups.
The iron fortification in staples is regulated as follows by FSSAI: for salt (850–1100 ppm as Ferrous sulphate or Ferrous Fumarate), wheat flour ( 14 - 21.5 mg/kg for NaFeEDTA), rice (28 - 42.5 mg/kg for ferric pyrophosphate). The current fortification programs are designed to fill the gap between the actual intake and the requirement (Estimated Average Requirement-EAR) of the population. Despite this, concerns remain regarding the potential risk of excessive iron intake when multiple fortified staples are consumed concurrently, necessitating a comprehensive evaluation of cumulative iron intake and safety considerations.
3. Cumulative iron intake - Estimation by modelling approach
This study calculated total dietary iron intake across the top five wheat- and rice-consuming states, modelling cumulative average intake from intrinsic sources from regular diet, fortified staples (wheat, rice, salt), and supplements to evaluate the risk of excess iron intake. Household Consumption and Expenditure Survey (HCES) 2011-12 data provides the average per capita consumption quantity for all the states. This data was used as gender-wise breakdowns were unavailable and TUL for iron remains uniform across age groups. For micronutrient intake estimations, the study used the Indian Food Composition Tables (ICMR-NIN, 2017) and ICMR-NIN, RDA 2024.
The mid-point of FSSAI fortification standards was used as the target iron fortification level in salt, wheat flour, and rice for calculation. Iron intake from supplementation was calculated by considering the National Iron Plus Initiative (NIPI) dosage of 60 mg/week, which was converted to a daily equivalent of 8.6 mg elemental iron and factored into the analysis. The analysis considered major food groups, including wheat, rice, salt, pulses, vegetables, green leafy vegetables, fruits, meat, and fish, to calculate total dietary iron intake. Certain food sources, such as tea, coffee, spices, and processed foods, were excluded due to the comparatively negligible amount of iron content received from their consumption. Spices and condiments had minimal consumption data, while tea and coffee intake was reported in cups/millilitres, making iron estimation difficult.
The study team adopted specific assumptions and considerations for the modelling exercise apart from the average per capita consumption and the selection of food sources. Iron intake estimates were based on raw food sources, without adjusting for cooking losses, nutrient interactions or dietary inhibitors, which could overestimate actual iron intake. Absorption factors were not separately considered, as they are already accounted for in the ICMR-NIN RDA calculations. Wheat has a higher intrinsic iron content (4.1mg/100g) compared to rice (0.65mg/100g), contributing significantly to dietary iron intake. Given this difference, the study assessed total iron intake in the top five wheat-consuming states (Haryana, Rajasthan, Punjab, Madhya Pradesh, Uttar Pradesh), where wheat is a major staple food. Intake in these states remains below the TUL; other states with lower wheat consumption are also likely within safe limits. A similar analysis was conducted for the top five rice-consuming states (Manipur, Nagaland, Tripura, Mizoram, and Arunachal Pradesh) to compare nutritional gaps and excess intake risks.
4. Iron intake from diet, fortification and supplementation
This section presents dietary iron intake estimates for the All India average and state-specific data, evaluating iron intake and incremental intake scenarios from intrinsic dietary sources, fortified staples, and supplements. It analyses total intake levels in the top five wheat- and rice-consuming states, covering both rural and urban regions, and compares them to the Recommended Dietary Allowance (RDA) and discusses the impact of staple food fortification on iron adequacy.
4.1. Cumulative Iron Intake - All India Average
Intrinsic iron intake from the regular diet for all India average ranged from 20.19 mg/day (Rural) to 20.87 mg/day (Urban), which is ~20 mg/day and falls below the RDA (26–30 mg/day) for vulnerable populations, particularly women of reproductive age (WRA) and adolescent girls. Consumption of fortified atta and rice increased intake modestly, reaching 29.7 mg/day (Rural) and 28.5 mg/day (Urban), adding ~9.5 mg/day and ~ 7.5 mg/day in rural and urban regions, respectively. When iron supplements (8.6 mg/day) were included along with fortified wheat and rice, the total intake increased to 38.3 mg/day (Rural) and 37.6 mg/day (Urban). However, Further consumption of fortified salt incrementally added ~8 mg/day, further raising the intake to 46.6 mg/day (rural) and 44.8 mg/day (Urban). Without fortification or supplementation, a large portion of the population remains at risk of iron deficiency. However, with fortified wheat and rice or iron supplements, the intake meets RDA requirements for vulnerable groups, including pregnant women (Table 1, Annexure).
4.2 Cumulative Iron Intake In The Top Five Wheat-Consuming States In India
The intrinsic iron intake in the top five wheat-consuming states ranged between 22.2 mg/day (Rural Madhya Pradesh) to 29.7 mg/day (Rural Haryana). Figures 1 and 2 and Table 1 (Annexure) show the incremental rise in iron intake across different dietary scenarios in the top five wheat-consuming states. The study found that Haryana and Rajasthan, the top wheat-consuming states, had a higher intrinsic iron intake, meeting RDA levels across all age groups. Fortified wheat flour contributed an additional 3.83–5.44 mg/day of iron, with an average intake of 4.65 mg/day, significantly improving adequacy, particularly for WRA and adolescent girls, and ensuring sufficient intake across all top five wheat-consuming states. When fortified wheat, rice and salt are consumed, the iron intake increases and ranges between 37.4 mg/day (Urban Punjab) and 42.1 mg/day (rural Haryana), cumulatively adding ~14 mg/day on average to the regular diet, with ~1.8 mg/day from fortified rice and ~7.5 mg/day from fortified salt. Further intake of supplements increased the total iron intake between 46.2 mg/day (rural MP) to 50.6 mg/day (rural Haryana). However, without fortified salt alone, the total intake remained between 38.3 mg/day (rural MP) to 43.1 mg/day (rural Haryana).
4.3 Cumulative Iron Intake In The Top Five Rice-Consuming States In India
The intrinsic iron intake in the top five rice-consuming states ranged from 9.49 mg/day (Urban Manipur) to 19.18 mg/day (Urban Tripura), averaging 14.86 mg/day, which is well below the Recommended Dietary Allowance (RDA). Many rural areas had intake below the Estimated Average Requirement (EAR) (<15 mg/day), failing to meet RDA levels. Figures 3 and 4 and Table 2 (Annexure) show the incremental rise in iron intake across different dietary scenarios in the top five rice-consuming states. However, fortified rice contributed an additional ~14–17 mg/day, significantly closing the dietary gap and ensuring adequate iron intake across all age groups, particularly benefiting WRA and children. Including fortified rice and wheat flour significantly increased total iron intake to an average of 29.55 mg/day, meeting RDA levels in all states. The addition of fortified wheat flour contributed only ~0.15 mg/day on average, making a minimal impact on iron adequacy. Further, with the intake of fortified rice, wheat and salt, the iron intake ranged from 32.97 mg/day (urban Manipur) to 46.52 mg/day (rural Tripura) and with the addition of supplements it further increased to an average of ~47.5 to 48.5 mg/day, with the highest intake of 55.12 mg/day observed in rural Tripura.
The World Health Organization (WHO) and Food Safety and Standards Authority of India (FSSAI) recommend fortifying wheat flour, rice, and salt mainly with iron and a few other nutrients to combat anaemia and improve public health.
The Government of India, under the National Nutrition Mission, has implemented large-scale food fortification programs as part of the Anemia Mukt Bharat (AMB) program, integrating fortified wheat flour, rice, and salt into national nutrition initiatives. Fortification is one of AMB’s six strategic interventions aimed at reducing anemia prevalence in India. To reach vulnerable populations, fortified staples are distributed through social safety net schemes, ensuring access to iron-enriched foods for high-risk groups.
The iron fortification in staples is regulated as follows by FSSAI: for salt (850–1100 ppm as Ferrous sulphate or Ferrous Fumarate), wheat flour ( 14 - 21.5 mg/kg for NaFeEDTA), rice (28 - 42.5 mg/kg for ferric pyrophosphate). The current fortification programs are designed to fill the gap between the actual intake and the requirement (Estimated Average Requirement-EAR) of the population. Despite this, concerns remain regarding the potential risk of excessive iron intake when multiple fortified staples are consumed concurrently, necessitating a comprehensive evaluation of cumulative iron intake and safety considerations.
3. Cumulative iron intake - Estimation by modelling approach
This study calculated total dietary iron intake across the top five wheat- and rice-consuming states, modelling cumulative average intake from intrinsic sources from regular diet, fortified staples (wheat, rice, salt), and supplements to evaluate the risk of excess iron intake. Household Consumption and Expenditure Survey (HCES) 2011-12 data provides the average per capita consumption quantity for all the states. This data was used as gender-wise breakdowns were unavailable and TUL for iron remains uniform across age groups. For micronutrient intake estimations, the study used the Indian Food Composition Tables (ICMR-NIN, 2017) and ICMR-NIN, RDA 2024.
The mid-point of FSSAI fortification standards was used as the target iron fortification level in salt, wheat flour, and rice for calculation. Iron intake from supplementation was calculated by considering the National Iron Plus Initiative (NIPI) dosage of 60 mg/week, which was converted to a daily equivalent of 8.6 mg elemental iron and factored into the analysis. The analysis considered major food groups, including wheat, rice, salt, pulses, vegetables, green leafy vegetables, fruits, meat, and fish, to calculate total dietary iron intake. Certain food sources, such as tea, coffee, spices, and processed foods, were excluded due to the comparatively negligible amount of iron content received from their consumption. Spices and condiments had minimal consumption data, while tea and coffee intake was reported in cups/millilitres, making iron estimation difficult.
The study team adopted specific assumptions and considerations for the modelling exercise apart from the average per capita consumption and the selection of food sources. Iron intake estimates were based on raw food sources, without adjusting for cooking losses, nutrient interactions or dietary inhibitors, which could overestimate actual iron intake. Absorption factors were not separately considered, as they are already accounted for in the ICMR-NIN RDA calculations. Wheat has a higher intrinsic iron content (4.1mg/100g) compared to rice (0.65mg/100g), contributing significantly to dietary iron intake. Given this difference, the study assessed total iron intake in the top five wheat-consuming states (Haryana, Rajasthan, Punjab, Madhya Pradesh, Uttar Pradesh), where wheat is a major staple food. Intake in these states remains below the TUL; other states with lower wheat consumption are also likely within safe limits. A similar analysis was conducted for the top five rice-consuming states (Manipur, Nagaland, Tripura, Mizoram, and Arunachal Pradesh) to compare nutritional gaps and excess intake risks.
4. Iron intake from diet, fortification and supplementation
This section presents dietary iron intake estimates for the All India average and state-specific data, evaluating iron intake and incremental intake scenarios from intrinsic dietary sources, fortified staples, and supplements. It analyses total intake levels in the top five wheat- and rice-consuming states, covering both rural and urban regions, and compares them to the Recommended Dietary Allowance (RDA) and discusses the impact of staple food fortification on iron adequacy.
4.1. Cumulative Iron Intake - All India Average
Intrinsic iron intake from the regular diet for all India average ranged from 20.19 mg/day (Rural) to 20.87 mg/day (Urban), which is ~20 mg/day and falls below the RDA (26–30 mg/day) for vulnerable populations, particularly women of reproductive age (WRA) and adolescent girls. Consumption of fortified atta and rice increased intake modestly, reaching 29.7 mg/day (Rural) and 28.5 mg/day (Urban), adding ~9.5 mg/day and ~ 7.5 mg/day in rural and urban regions, respectively. When iron supplements (8.6 mg/day) were included along with fortified wheat and rice, the total intake increased to 38.3 mg/day (Rural) and 37.6 mg/day (Urban). However, Further consumption of fortified salt incrementally added ~8 mg/day, further raising the intake to 46.6 mg/day (rural) and 44.8 mg/day (Urban). Without fortification or supplementation, a large portion of the population remains at risk of iron deficiency. However, with fortified wheat and rice or iron supplements, the intake meets RDA requirements for vulnerable groups, including pregnant women (Table 1, Annexure).
4.2 Cumulative Iron Intake In The Top Five Wheat-Consuming States In India
The intrinsic iron intake in the top five wheat-consuming states ranged between 22.2 mg/day (Rural Madhya Pradesh) to 29.7 mg/day (Rural Haryana). Figures 1 and 2 and Table 1 (Annexure) show the incremental rise in iron intake across different dietary scenarios in the top five wheat-consuming states. The study found that Haryana and Rajasthan, the top wheat-consuming states, had a higher intrinsic iron intake, meeting RDA levels across all age groups. Fortified wheat flour contributed an additional 3.83–5.44 mg/day of iron, with an average intake of 4.65 mg/day, significantly improving adequacy, particularly for WRA and adolescent girls, and ensuring sufficient intake across all top five wheat-consuming states. When fortified wheat, rice and salt are consumed, the iron intake increases and ranges between 37.4 mg/day (Urban Punjab) and 42.1 mg/day (rural Haryana), cumulatively adding ~14 mg/day on average to the regular diet, with ~1.8 mg/day from fortified rice and ~7.5 mg/day from fortified salt. Further intake of supplements increased the total iron intake between 46.2 mg/day (rural MP) to 50.6 mg/day (rural Haryana). However, without fortified salt alone, the total intake remained between 38.3 mg/day (rural MP) to 43.1 mg/day (rural Haryana).
4.3 Cumulative Iron Intake In The Top Five Rice-Consuming States In India
The intrinsic iron intake in the top five rice-consuming states ranged from 9.49 mg/day (Urban Manipur) to 19.18 mg/day (Urban Tripura), averaging 14.86 mg/day, which is well below the Recommended Dietary Allowance (RDA). Many rural areas had intake below the Estimated Average Requirement (EAR) (<15 mg/day), failing to meet RDA levels. Figures 3 and 4 and Table 2 (Annexure) show the incremental rise in iron intake across different dietary scenarios in the top five rice-consuming states. However, fortified rice contributed an additional ~14–17 mg/day, significantly closing the dietary gap and ensuring adequate iron intake across all age groups, particularly benefiting WRA and children. Including fortified rice and wheat flour significantly increased total iron intake to an average of 29.55 mg/day, meeting RDA levels in all states. The addition of fortified wheat flour contributed only ~0.15 mg/day on average, making a minimal impact on iron adequacy. Further, with the intake of fortified rice, wheat and salt, the iron intake ranged from 32.97 mg/day (urban Manipur) to 46.52 mg/day (rural Tripura) and with the addition of supplements it further increased to an average of ~47.5 to 48.5 mg/day, with the highest intake of 55.12 mg/day observed in rural Tripura.
5. Potential Risk of Excess Iron Intake and Safety Analysis
Fortification has effectively improved iron adequacy, but ensuring safe and balanced interventions is critical to maximising impact while mitigating excess intake risks. This section discusses the excess risks observed with the concurrent consumption of multiple fortified staples along with supplements and highlights regional intake disparities.
5.1 Combined interventions, risk concerns and Iron Intake Variability
Excess iron intake emerged only when all fortified sources, including salt and supplements, were consumed together, while fortified staples and supplements alone did not pose a risk. The analysis of dietary iron intake for All India (rural and urban) revealed no risk of exceeding the Tolerable Upper Limit (TUL) of 45 mg/day in most scenarios (Table 1, Annexure). Still, when fortified staples, salt and supplements were taken concurrently along with a regular diet, the intake exceeded the TUL with a 4% risk of excess iron intake.
In the top five wheat-consuming states, none exceeded the Tolerable Upper Limit (TUL) of 45 mg/day from the regular diet alone. Even with fortified wheat and rice, total iron intake remained within safe levels (<35 mg/day). However, the addition of fortified salt raised total intake to an average of 39.3 mg/day, nearing the TUL in Rural Haryana (42.09 mg/day) and Rural Rajasthan (41.39 mg/day). When iron supplements were included, total intake exceeded the TUL in all states, averaging 47.89 mg/day, with the highest excess risk in Rural Haryana (13%) and Rural Rajasthan (11%), while urban areas showed a lower but notable risk (9-10%) (Figures 1 & 2 & Table 1 - Annexure). If only fortified wheat, rice, and supplements were consumed alongside the regular diet, iron intake remained below TUL but within the cautionary range (40–44.5 mg/day). Haryana and Rajasthan had the highest risk (9–13%) of exceeding TUL, primarily due to high intrinsic iron intake from wheat and the cumulative effect of fortified staples, salt, and supplements.
Similarly, in the top five rice-consuming states, iron intake remained below the TUL when only fortified wheat, rice, and supplements were included with the regular diet, staying within critical caution limits. However, fortified salt consumption alongside fortified staples increased total iron intake, bringing Tripura (rural and urban) to the TUL threshold and pushing Rural Arunachal Pradesh into the caution range (Table 2 - Annexure, Figures 3 & 4). When iron supplements were included, total intake exceeded the TUL in all five states, with Rural Tripura reaching 55.12 mg/day (22.5% excess risk), followed by Urban Tripura (21.31%) and Arunachal Pradesh (13.37%), while Urban Manipur and Nagaland remained within the caution zone. In rice-consuming states, where intrinsic iron intake is lower, risks emerged only when fortified staples, salt, and supplements were consumed together.
Notably, without fortified salt, all states remained within safe limits, highlighting its significant role in pushing intake beyond recommended thresholds and the need for strategic fortification adjustments. Additionally, concerns about excess iron intake from supplementation do not apply to the general population, as these programs are primarily targeted at pregnant women, who generally have lower baseline iron intake, and with poor adherence to iron supplementation in the population, further reducing the overall risk. The ICMR-NIN (2023) White Paper supports these findings, emphasising that fortified rice alone does not pose an excess risk and recommending that fortification efforts focus on regions with <10 mg/day iron intake to ensure both effectiveness and safety. Also, urban populations had lower iron intake than rural populations, reducing their risk of exceeding the TUL, especially in wheat-consuming states (Table 1 & 2 - Annexure). Rural populations, relying heavily on cereals (50–84% of dietary iron intake - EAC-PM, 2024), were more likely to breach TUL when fortified staples and supplements were combined.
These findings reinforce that fortification is safe when limited to one or two staples (wheat and rice) but exceeds safety limits when fortified wheat, rice, and salt are combined with supplements.
5.2 Insights from Other Studies on Iron Intake in India
A nationwide analysis of dietary iron intake (HCES 2022-23) revealed significant disparities, with 18 states reporting <10 mg/day iron intake for adult females. Rajasthan was the only state meeting the EAR (15 mg/day) due to high cereal consumption (EAC-PM Working Paper, 2024). The data suggest lower-than-expected iron intake, reinforcing that excess iron intake risk is unlikely. Among wheat-consuming states, rural iron intake ranged from 16.5 mg (Rajasthan) to 11.7 mg (Uttar Pradesh), while rice-consuming states had an even lower intake, with rural Arunachal Pradesh (7 mg), Manipur (5.5 mg), and Mizoram (6.1 mg) reporting the lowest levels.
Urban areas consistently had lower iron intake than rural counterparts. However, higher milk consumption in rural areas may reduce iron absorption, while urban populations benefit from diverse iron sources like fruits, vegetables, and animal products. Kerala derives 40% of its iron from fruits, compared to just 1–2% in Rajasthan and Uttar Pradesh, highlighting the need to improve non-cereal iron intake (EAC-PM, 2024)
5.3 Limitations of the safety analysis
While this study provides a comprehensive assessment of iron intake and potential safety risks from fortified staples and supplements, it has methodological limitations that should be considered when interpreting the findings.
Fortification has effectively improved iron adequacy, but ensuring safe and balanced interventions is critical to maximising impact while mitigating excess intake risks. This section discusses the excess risks observed with the concurrent consumption of multiple fortified staples along with supplements and highlights regional intake disparities.
5.1 Combined interventions, risk concerns and Iron Intake Variability
Excess iron intake emerged only when all fortified sources, including salt and supplements, were consumed together, while fortified staples and supplements alone did not pose a risk. The analysis of dietary iron intake for All India (rural and urban) revealed no risk of exceeding the Tolerable Upper Limit (TUL) of 45 mg/day in most scenarios (Table 1, Annexure). Still, when fortified staples, salt and supplements were taken concurrently along with a regular diet, the intake exceeded the TUL with a 4% risk of excess iron intake.
In the top five wheat-consuming states, none exceeded the Tolerable Upper Limit (TUL) of 45 mg/day from the regular diet alone. Even with fortified wheat and rice, total iron intake remained within safe levels (<35 mg/day). However, the addition of fortified salt raised total intake to an average of 39.3 mg/day, nearing the TUL in Rural Haryana (42.09 mg/day) and Rural Rajasthan (41.39 mg/day). When iron supplements were included, total intake exceeded the TUL in all states, averaging 47.89 mg/day, with the highest excess risk in Rural Haryana (13%) and Rural Rajasthan (11%), while urban areas showed a lower but notable risk (9-10%) (Figures 1 & 2 & Table 1 - Annexure). If only fortified wheat, rice, and supplements were consumed alongside the regular diet, iron intake remained below TUL but within the cautionary range (40–44.5 mg/day). Haryana and Rajasthan had the highest risk (9–13%) of exceeding TUL, primarily due to high intrinsic iron intake from wheat and the cumulative effect of fortified staples, salt, and supplements.
Similarly, in the top five rice-consuming states, iron intake remained below the TUL when only fortified wheat, rice, and supplements were included with the regular diet, staying within critical caution limits. However, fortified salt consumption alongside fortified staples increased total iron intake, bringing Tripura (rural and urban) to the TUL threshold and pushing Rural Arunachal Pradesh into the caution range (Table 2 - Annexure, Figures 3 & 4). When iron supplements were included, total intake exceeded the TUL in all five states, with Rural Tripura reaching 55.12 mg/day (22.5% excess risk), followed by Urban Tripura (21.31%) and Arunachal Pradesh (13.37%), while Urban Manipur and Nagaland remained within the caution zone. In rice-consuming states, where intrinsic iron intake is lower, risks emerged only when fortified staples, salt, and supplements were consumed together.
Notably, without fortified salt, all states remained within safe limits, highlighting its significant role in pushing intake beyond recommended thresholds and the need for strategic fortification adjustments. Additionally, concerns about excess iron intake from supplementation do not apply to the general population, as these programs are primarily targeted at pregnant women, who generally have lower baseline iron intake, and with poor adherence to iron supplementation in the population, further reducing the overall risk. The ICMR-NIN (2023) White Paper supports these findings, emphasising that fortified rice alone does not pose an excess risk and recommending that fortification efforts focus on regions with <10 mg/day iron intake to ensure both effectiveness and safety. Also, urban populations had lower iron intake than rural populations, reducing their risk of exceeding the TUL, especially in wheat-consuming states (Table 1 & 2 - Annexure). Rural populations, relying heavily on cereals (50–84% of dietary iron intake - EAC-PM, 2024), were more likely to breach TUL when fortified staples and supplements were combined.
These findings reinforce that fortification is safe when limited to one or two staples (wheat and rice) but exceeds safety limits when fortified wheat, rice, and salt are combined with supplements.
5.2 Insights from Other Studies on Iron Intake in India
A nationwide analysis of dietary iron intake (HCES 2022-23) revealed significant disparities, with 18 states reporting <10 mg/day iron intake for adult females. Rajasthan was the only state meeting the EAR (15 mg/day) due to high cereal consumption (EAC-PM Working Paper, 2024). The data suggest lower-than-expected iron intake, reinforcing that excess iron intake risk is unlikely. Among wheat-consuming states, rural iron intake ranged from 16.5 mg (Rajasthan) to 11.7 mg (Uttar Pradesh), while rice-consuming states had an even lower intake, with rural Arunachal Pradesh (7 mg), Manipur (5.5 mg), and Mizoram (6.1 mg) reporting the lowest levels.
Urban areas consistently had lower iron intake than rural counterparts. However, higher milk consumption in rural areas may reduce iron absorption, while urban populations benefit from diverse iron sources like fruits, vegetables, and animal products. Kerala derives 40% of its iron from fruits, compared to just 1–2% in Rajasthan and Uttar Pradesh, highlighting the need to improve non-cereal iron intake (EAC-PM, 2024)
5.3 Limitations of the safety analysis
While this study provides a comprehensive assessment of iron intake and potential safety risks from fortified staples and supplements, it has methodological limitations that should be considered when interpreting the findings.
- ⦿ Reliance on HCES 2011-12 data, which may not fully reflect current dietary patterns or regional variations. However, HCES 2022-23 shows lower cereal consumption, reducing iron intake from major sources and keeping it within safety limits.
- ⦿ Use of average per capita consumption data limits insights into age, gender, and physiological variations, particularly for children, adolescents, and women of reproductive age, restricting group-specific risk assessment.
- ⦿ Assumption of uniform adherence to the National Iron Plus Initiative (NIPI), without accounting for variability in supplementation compliance, particularly among vulnerable populations.
- ⦿ Analysis restricted to the top five wheat- and rice-consuming states, which may not represent dietary patterns in regions with lower staple consumption or higher dietary diversity.
- ⦿ Exclusion of hemoglobinopathies (e.g., sickle cell anaemia, thalassemia), which alter iron metabolism and may lead to iron overload despite dietary deficiencies, limits applicability to these populations.
- ⦿ Fortification calculations assumed consistent implementation, without accounting for storage conditions, cooking losses, or compliance variability
6. Strategies to Mitigate the Risk of Iron Overload
6.1 Factors Influencing Iron Intake & Safety Risk
Iron absorption and overload risks depend on fortificant types, dietary inhibitors (phytates, calcium), and nutrient interactions. Phytates in wheat and rice, calcium in dairy, and tannins in tea reduce non-heme iron absorption, counterbalancing high dietary intake. ICMR-NIN (2020) states that the body absorbs only 0.8–2 mg of iron daily, preventing excess accumulation. Despite high iron intake in some states, actual absorption is lower due to inhibitors, making theoretical iron overload unlikely. Ghosh et al. (2019) found wheat-consuming states had higher intrinsic iron but lower bioavailability due to phytate-rich diets. Additionally, fortification levels as per the national regulations only contribute around 30-50% of the RDA based on average per capita consumption, aiming to bridge the nutrient gap without risk of overload. This also reduces concerns about excess iron intake. However, more research is needed to understand dietary factors influencing absorption and strategies to mitigate potential excess intake risks.
6.2 Need for Coordinated & Region-Specific Micronutrient Interventions
Fortification and supplementation programs play a critical role in addressing iron deficiency, but their impact depends on effective coordination and region-specific adaptation. When interventions are not aligned, overlapping fortification and supplementation efforts can lead to excess iron intake in some regions while failing to address deficiencies in others (Bourassa et al., 2023). A one-size-fits-all approach is ineffective due to variations in regional dietary iron intake. Instead, precision programming is needed - regions with low iron intake (<10 mg/day) should be prioritised for fortification, while areas with naturally high iron intake should focus on dietary diversification instead of additional iron fortification.
6.3 Key Recommendations
To balance the benefits of fortification with the safety risks of excess iron, particularly in scenarios where multiple fortified staples, fortified salt, and supplements are consumed simultaneously, the following measures can help optimise iron intake.
6.1 Factors Influencing Iron Intake & Safety Risk
Iron absorption and overload risks depend on fortificant types, dietary inhibitors (phytates, calcium), and nutrient interactions. Phytates in wheat and rice, calcium in dairy, and tannins in tea reduce non-heme iron absorption, counterbalancing high dietary intake. ICMR-NIN (2020) states that the body absorbs only 0.8–2 mg of iron daily, preventing excess accumulation. Despite high iron intake in some states, actual absorption is lower due to inhibitors, making theoretical iron overload unlikely. Ghosh et al. (2019) found wheat-consuming states had higher intrinsic iron but lower bioavailability due to phytate-rich diets. Additionally, fortification levels as per the national regulations only contribute around 30-50% of the RDA based on average per capita consumption, aiming to bridge the nutrient gap without risk of overload. This also reduces concerns about excess iron intake. However, more research is needed to understand dietary factors influencing absorption and strategies to mitigate potential excess intake risks.
6.2 Need for Coordinated & Region-Specific Micronutrient Interventions
Fortification and supplementation programs play a critical role in addressing iron deficiency, but their impact depends on effective coordination and region-specific adaptation. When interventions are not aligned, overlapping fortification and supplementation efforts can lead to excess iron intake in some regions while failing to address deficiencies in others (Bourassa et al., 2023). A one-size-fits-all approach is ineffective due to variations in regional dietary iron intake. Instead, precision programming is needed - regions with low iron intake (<10 mg/day) should be prioritised for fortification, while areas with naturally high iron intake should focus on dietary diversification instead of additional iron fortification.
6.3 Key Recommendations
To balance the benefits of fortification with the safety risks of excess iron, particularly in scenarios where multiple fortified staples, fortified salt, and supplements are consumed simultaneously, the following measures can help optimise iron intake.
- ⦿ Optimising Fortification Strategies Based on Regional Needs - for example
- ⦿ In high iron intake states like Haryana and Rajasthan, limiting fortified salt intake can prevent exceeding the TUL.
⦿ In low iron intake states like Tripura and Manipur, continued fortification of rice is essential to meet RDA levels, while limiting simultaneous consumption of fortified salt can prevent exceeding the TUL.
- ⦿ In high iron intake states like Haryana and Rajasthan, limiting fortified salt intake can prevent exceeding the TUL.
- ⦿ Improving Monitoring and Coordination
- ⦿ Assess cumulative iron intake from all sources (regular diet, fortified staples, supplements) to prevent excessive intake in high-risk regions.
⦿ Better coordination between supplementation programs and food fortification efforts is necessary to avoid unintentional overlaps.
- ⦿ Assess cumulative iron intake from all sources (regular diet, fortified staples, supplements) to prevent excessive intake in high-risk regions.
- ⦿ Enhancing Awareness & Dietary Education
- ⦿ Educate vulnerable populations (pregnant women, adolescents) on appropriate iron intake and supplement use to prevent both deficiency and excess and encourage diversified dietary practices.
7. Conclusion & Future Research Directions
This study underscores the critical role of wheat and rice fortification in addressing iron deficiency while highlighting regional variations in intake and safety risks. Intrinsic iron intake alone remains insufficient to meet the RDA (19–32 mg/day) for most populations, particularly for women of reproductive age (26–32 mg/day), especially in rice-consuming states where dietary iron intake is lower. In contrast, wheat-consuming states like Haryana and Rajasthan exhibited higher dietary iron intake and greater risk percentages, largely due to greater reliance on wheat-based staples. However, excess iron intake risk is observed only when all fortified sources, including salt, were consumed together, while fortified staples and supplements alone did not pose a risk.
Fortification effectively bridges dietary iron gaps, ensuring adequacy, particularly in regions with low intrinsic iron intake. However, concurrent consumption of multiple fortified staples (wheat, rice), fortified salt, and supplements may push iron intake over the TUL in some states, necessitating careful regulation and monitoring. Despite these concerns, iron overconsumption remains a lesser risk, as Indian diets contain natural inhibitors like phytates, tannins, and calcium, and physiological regulation prevents excessive accumulation. To ensure both efficacy and safety, a region-specific fortification strategy, improved program coordination, and dietary diversification efforts are essential to maximise benefits while minimising risks.
To strengthen these findings to address the excess iron intake concerns, further research will focus on:
This study underscores the critical role of wheat and rice fortification in addressing iron deficiency while highlighting regional variations in intake and safety risks. Intrinsic iron intake alone remains insufficient to meet the RDA (19–32 mg/day) for most populations, particularly for women of reproductive age (26–32 mg/day), especially in rice-consuming states where dietary iron intake is lower. In contrast, wheat-consuming states like Haryana and Rajasthan exhibited higher dietary iron intake and greater risk percentages, largely due to greater reliance on wheat-based staples. However, excess iron intake risk is observed only when all fortified sources, including salt, were consumed together, while fortified staples and supplements alone did not pose a risk.
Fortification effectively bridges dietary iron gaps, ensuring adequacy, particularly in regions with low intrinsic iron intake. However, concurrent consumption of multiple fortified staples (wheat, rice), fortified salt, and supplements may push iron intake over the TUL in some states, necessitating careful regulation and monitoring. Despite these concerns, iron overconsumption remains a lesser risk, as Indian diets contain natural inhibitors like phytates, tannins, and calcium, and physiological regulation prevents excessive accumulation. To ensure both efficacy and safety, a region-specific fortification strategy, improved program coordination, and dietary diversification efforts are essential to maximise benefits while minimising risks.
To strengthen these findings to address the excess iron intake concerns, further research will focus on:
- ⦿ Incorporating Updated Consumption Data – Refining analysis using HCES 2022-23 data to reflect current dietary patterns, ensuring more accurate assessments of iron intake adequacy and safety risks.
- ⦿ Conducting Gender- and Age-Specific Analysis – Examining demographic-specific iron intake to provide better insights into the adequacy and excess risks, particularly for vulnerable populations.
- ⦿ Analysing State-Level RDA and EAR – Evaluating state-wise EAR and RDA for iron to enhance understanding of regional intake variations, strengthening insights from the EAC-PM Nationwide Analysis Report (2024).
References
- 1. HCES 2011-2012
- 2. HCES 2022-2023
- 3. Revised Short Summary Report-2024, ICMR-NIN Expert Group on Nutrient Requirements for Indians, Recommended Dietary Allowances (RDA) and Estimated Average Requirements (EAR)-2020.
- 4. ICMR-NIN Expert Group on Nutrient Requirement for Indians, Recommended Dietary Allowances (RDA) and Estimated Average Requirements (EAR) - 2020.
- 5. Indian Food Composition Table - 2017
- 6. Bourassa, M. W., Atkin, R., Gorstein, J., & Osendarp, S. (2023). Aligning the Epidemiology of Malnutrition with Food Fortification: Grasp Versus Reach. Nutrients, 15(9), 2021. https://doi.org/10.3390/nu15092021
- 7. Swaminathan, S., Ghosh, S., Varghese, J. S., Sachdev, H. S., Kurpad, A. V., & Thomas, T. (2019). Dietary Iron Intake and Anemia Are Weakly Associated, Limiting Effective Iron Fortification Strategies in India. The Journal of Nutrition, 149(5), 831-839. https://doi.org/10.1093/jn/nxz009
- 8. Ghosh, S., Sinha, S., Thomas, T., Sachdev, H. S., & Kurpad, A. V. (2018). Revisiting dietary iron requirement and deficiency in Indian women: Implications for food iron fortification and supplementation. Journal of Nutrition, 149(3), 366–371. https://doi.org/10.1093/jn/nxy283
- 9. Efficacy and safety of iron-fortified rice in India - A white paper, ICMR-National Institute of Nutrition, Hyderabad,2023. Hemalatha R, Samara Simha Reddy N, Sairam Challa, Venkatesh K, Raghu Pullakhandam, Nandeep ER, Teena D, Mahesh Kumar M, Raghavendra P.
- 10. Dietary Iron Intake - Nationwide Analysis. A complementary analysis to the “Changes in India’s Food Consumption and Policy Implications: A Comprehensive Analysis of Household Consumption Expenditure Survey 2022-23 and 2011-12”. EAC-PM Working Paper Series. EAC-PM/WP/30/2024.
- 11. Ma, J., Sun, Q., Liu, J., Hu, Y., Liu, S., Zhang, J., Sheng, X., & Hambidge, K. M. (2016). The Effect of Iron Fortification on Iron (Fe) Status and Inflammation: A Randomized Controlled Trial. PLOS ONE, 11(12), e0167458. https://doi.org/10.1371/journal.pone.0167458.
Annexure
