27 November 2016
Fortification: It's a bit more complicated than "add, stir and distribute"
Surprisingly, one of the new things I am learning about is fortification. Surprising to me, because if you are not an expert it is easy to think of fortification as "add fortificant, stir and distribute".
A recent PLOS One paper (including two of my new GAIN colleagues) shows how misguided such simplistic thinking is.
The paper contains two pieces of analysis, both from the Indian state of Telangana (36 million people, containing the city of Hyderabad). Both analyses are drawn from a survey of children 0-35 months of age residing in the catchment areas of all the ICDS centres in the state. The survey found that 79% of all salt samples from the households of the selected children were adequately iodised. BUT, the level of adequate iodisation varied significantly by District within the State and by iodised salt brand. So even in one of the most easy to fortify substances, fortification is variable. Work is needed just to maintain effective iodisation levels.
The second piece of analysis aims to examine the prospects for effective fortification of rice. As I have written in an earlier gung-ho blog, I thought: rice fortification--its a no-brainer. Well, its a little bit more complicated than that!
First, do the groups in the population that are micronutrient deficient actually consume rice? Second, do they get rice from sources that can actually fortify rice? Third, can the rice be fortified in a cost effective way? Overall, the answers for Telangana are not encouraging. First, no recent deficiency data exist for Telegana. Second, if rice could be fortified it would make a big difference to the % of children and women meeting the RDA for various micronutrients (so this indicates the potential). But, third, a quarter of households consume rice they produced themselves and the households that do buy rice buy it from markets that are served by over 600 millers--a complex context for cost-effective fortification.
Of course the rice situation will likely change over time as more people buy rice from market sources and as rice milling and distribution becomes more concentrated, but for now the fortification of rice in Telegana does not look to be a promising solution to reducing micronutrient malnutrition in the state. The authors examine if the government's Public Distribution System could be a viable delivery channel, but only 6% of households surveyed access rice from this source. Still, 6% is not bad if the cost-effectiveness ratios look reasonable.
The rice fortification story just reinforces the need for policymakers in the State to look at their food systems to see what they can do to encourage the demand for and supply of affordable foods that are rich in nutrients.
Fortification: its not just "add, stir and distribute" -- but you already knew that!