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LETTERS TO EDITOR
Year : 2022  |  Volume : 66  |  Issue : 4  |  Page : 534-535  

Advocacy for large-scale food fortification ignores pertinent evidence and safety concerns


1 Professor, Department of Physiology, St John's Medical College, Bengaluru, Karnataka, India
2 Assistant Professor, Department of Biostatistics, St John's Medical College, Bengaluru, Karnataka, India
3 Professor, Department of Biostatistics, St John's Medical College, Bengaluru, Karnataka, India
4 Senior Consultant, Department of Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi, India

Date of Submission28-Sep-2022
Date of Decision19-Oct-2022
Date of Acceptance20-Oct-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Harshpal Singh Sachdev
Sitaram Bhartia Institute of Science and Research, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1306_22

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How to cite this article:
Kurpad AV, Ghosh S, Thomas T, Sachdev HS. Advocacy for large-scale food fortification ignores pertinent evidence and safety concerns. Indian J Public Health 2022;66:534-5

How to cite this URL:
Kurpad AV, Ghosh S, Thomas T, Sachdev HS. Advocacy for large-scale food fortification ignores pertinent evidence and safety concerns. Indian J Public Health [serial online] 2022 [cited 2023 Feb 1];66:534-5. Available from: https://www.ijph.in/text.asp?2022/66/4/534/366563



Dear Editor,

We read the “critical review” on the purported benefits of large-scale staple food fortification (LSFF)[1] with skepticism. This “critical review” failed to meet the standards of either systematic reviews or an overview of systematic reviews, cherry-picking studies with questionable methods to illustrate their points.

There are many glaring mistakes and omissions. A systematic review of micronutrient deficiencies[2] is quoted to show that these are high in India. In that review,[2] a B12 study (Srinivasan et al., 2017) is misquoted as showing 97.3% deficiency prevalence; we know that this is wrong as two of us (TT and AVK) were coauthors on that paper. This lack of rigor should have been checked. There is also no indication that selected iron-deficiency estimates were corrected for inflammation.[2] This is simply “crying wolf.” We direct their attention to our recent paper on how to correctly interpret micronutrient biomarkers.[3] A further striking omission is their quoting WHO,[4] thus “…fortified rice may reduce the risk of iron deficiency by 35% and increase the average concentration of hemoglobin by almost 2 g/L.” The rest of the complete WHO[5] sentence is carefully omitted, which continues, “(fortified rice)…may not make a difference to the risk of anemia in the general population of those aged over 2 years”. Another omission is when they state, “Iron overload does not occur in genetic carriers with normal phenotypes.”[1] It has been shown, by accurate stable isotope methods, that heterozygotes for thalassemia do not downregulate their iron absorption, rendering some risk of excess intake with universal iron fortification.

They quote the FSSAI process to set standards for fortification, but forget that when these were set, there were no standards for the EAR or tolerable upper limits (TUL) in India (only the recommended dietary allowance was available); these became available in 2020. We direct their attention to a recent paper on how to correctly set fortification standards that uses the EAR and TUL[5] and considers the distribution of intakes, rather than averages, as well as the TUL. There is a sting in the (distribution) tail, as the right-hand tail can exceed the TUL with unfettered universal fortification, rendering talk of “reducing the nutrient gap” much too simplistic. We would ask them: is there an acceptable proportion of the population that can have a chronic nutrient intake that exceeds its TUL? From their tables,[1] it appears that they only see a problem when the average intake (50% of the population) exceeds the TUL. That is far too much, and they must reconsider their analyses.

LSFF will actually reduce dietary diversification, contrarily resulting in a monotonous food dystopian desert. Increasingly in public health nutrition, we sadly note that advocacy is being prioritized and prevails over good science and evidence. The invariable focus is on specific products and simple solutions (silver bullets) being offered to the complexity of human nutrition and health. To quote HL Mencken, “For every complex problem there is an answer that is clear, simple, …and wrong.” Apt and true. Ironically, these alternatives to deliver nutrients are becoming “sole solutions”, which eventually acquire permanence.

Acknowledgment

AVK, TT, and HSS are recipients of the Wellcome Trust/Department of Biotechnology India Alliance Clinical/Public Health Research Centre Grant # IA/CRC/19/1/610006.

Financial support and sponsorship

Nil.

Conflicts of interest

AVK was the Chair of the FSSAI Scientific Panel on Fortification and Nutrition, and is presently a member of the FSSAI Scientific Committee. He was also the co-Chair of the ICMR Committee to set Nutrient Requirements of Indians. HSS is a member of the FSSAI Scientific Panel on Fortification and Nutrition and was a member of the ICMR Committee to set Nutrient Requirements of Indians. Both AVK and HSS views are personal.



 
   References Top

1.
Duggal M, Sesikeran B, Arlappa N, Nair S, Shekhar V, Sabharwal V. Large-scale staple food fortification as a complementary strategy to address vitamin and mineral vulnerabilities in India: A critical review. Indian J Public Health 2022;66:313-20.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Venkatesh U, Sharma A, Ananthan VA, Subbiah P, Durga R, CSIR Summer Research training team. Micronutrient's deficiency in India: A systematic review and meta-analysis. J Nutr Sci 2021;10:e110.  Back to cited text no. 2
    
3.
Ghosh S, Kurpad AV, Sachdev HS, Thomas T. A risk-based approach to measuring population micronutrient status from blood biomarker concentrations. Front Nutr 2022;9:991707.  Back to cited text no. 3
    
4.
World Health Organization. Guideline: Fortification of Rice with Vitamins and Minerals as a Public Health Strategy. Geneva: World Health Organization; 2018.  Back to cited text no. 4
    
5.
Ghosh S, Thomas T, Pullakhandam R, Nair KM, Sachdev HS, Kurpad AV. A proposed method for defining the required fortification level of micronutrients in foods: An example using iron. Eur J Clin Nutr. 2022 Sep 8. doi: 10.1038/s41430-022-01204-4.  Back to cited text no. 5
    




 

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