Micronutrient malnutrition, also known as hidden hunger, affects at least
1 in 2 children under 5 years old worldwide (UNICEF 2019).
Iron deficiency anaemia and neural tube defects are two widespread, preventable health conditions caused by deficiencies of essential micronutrients. These conditions primarily contribute to the suffering of women and children. Poverty predisposes people to anaemia and neural tube defects for a variety of reasons, including inadequate nutrition, weak health systems, infectious/parasitic disease, and limited access to fortified foods.
The problems we are tackling
Iron deficiency anaemia
Iron deficiency anaemia (IDA) occurs when the body does not have enough iron to produce haemoglobin and cannot carry sufficient levels of oxygen around the body. IDA is responsible for roughly half of the 2.36 billion cases of anemia globally, and accounts for 4% of all years lived with disability. Anaemia can cause chronic tiredness/fatigue, impaired cognitive development in children, low moods and low productivity in adults, and even increase risk for depressive symptoms and heart disease. Women with severe anaemia have double the risk of dying during or shortly after childbirth (UNICEF 2019).
Neural tube defects
Neural tube defects (NTDs) are developmental abnormalities affecting the spine, spinal cord, and brain, largely due to folic acid deficiency within the first month of pregnancy. NTDs account for over 5 million DALYs and over 40 thousand deaths annually.
The India context
Anaemia in India
Across India, 38.3% of the population suffers from iron deficiency anaemia (compared to 2.3% in the US). Anaemia affects 55.3% of women and 69.5% of children in India (considering all causes, including anaemia resulting from iron deficiency, intestinal worms, etc.).
NTDs in India
Nearly 100,000 children are thought to be born with neural tube defects each year in India.
How can fortifying food help to tackle
widespread micronutrient malnutrition?
Fortification of staple foods is an evidence-based means of improving nutritional status at population scale. There are several benefits to food fortification including: 1) cost and the cost:benefit ratio; 2) how it is implemented through the private sector; 3) limited requirement for behavior change, and; 4) the fact that fortified foods, consumed on a regular and frequent basis, maintain body stores of nutrients more efficiently and effectively than occasional, high-dose supplementation (Rowe et al 2014). There is ample evidence globally and within India that points to health improvements as a result of fortified wheat flour specifically:
In India, a randomised control trial in Karnataka and Maharashtra (Muthyya et al, 2012) finds that fortifying wheat flour with iron from NaFeEDTA sources for seven months reduces iron deficiency anaemia (IDA) from 62% to 21% in school age children. The most recent systematic review (Imhoff-Kunsch et al 2019) found that iron fortification can, on average, reduce anaemia by 34% if the anaemia is due to a lack of iron in the diet.
Neural tube defects
Fortification with folic acid has repeatedly demonstrated that it leads to significant reductions in NTDs. This is illustrated in this graph, which shows that at least 12 countries have documented a lower number of neural tube defects after initiation of mandatory flour fortification with folic acid using pre-post cross-sectional surveys (Food Fortification Initiative 2018). Pre-fortification values are illustrated in orange and post-fortification values in green.
Economic implications to fortification
Fortification has been found to yield US$84 for every US$1 spent on reducing iron deficiency anaemia prevalence (Hunt 2002). Specifically in India, the Food Fortification Resource Center (FFRC) has found that it costs 10 paisa to fortify 1 kg of atta flour.