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Fortification to tackle iron deficient anemia – Evidence from a community-based nutrition program in Gujarat

Iron-deficiency anemia (IDA) is
one of the most frequent nutritional disorders, affecting up to 1.6 billion people
worldwide [i].
Bioavailable iron is essential to synthesize
hemoglobin, the oxygen-transporting protein. The shortage of iron depletes
hemoglobin, resulting in various detrimental health outcomes, such as impaired
cognitive function and delayed physical growth in children, weakness, reduced
working capacity, and many other manifestations that affect the quality of
life.

In India,
anemia affects over 80% of children below the age of three, 58% of expectant
mothers, 50% of non-pregnant and non-lactating women, and over 56% of
adolescent girls[ii].
Although other factors may cause anemia, iron
deficiency accounts for over 60% of anemia cases[iii].
IDA has been associated with 24% of
maternal mortality in India, and indirectly another 50% of maternal mortality[iv].
The economic implications of IDA in India are also severe, accounting for 5%
gross domestic product (GDP) loss[v].

National
surveys have shown that, except for staples, the consumption of other
nutritionally dense commodities, such as pulses, milk, fruits, and vegetables,
falls far below the recommended dietary allowances (RDA)[vi].
With meat consumption among the lowest worldwide, IDA incidence is high in
India[vii].
In such areas, fortification has been considered as a successful and
cost-effective public health approach to compensate for nutritional iron
inadequacy. Thus, ideal iron sources that can be effectively utilized in food
products to improve iron nutrition remain elusive.

Fortification in food systems

Fortification is a process by which micronutrients are added to foods to increase their nutritional value. In
1833, French chemist Boussingault was the first to recommend the addition of
iodine in salt to combat goiter in South America. In the 20th
century, fortification of milk with vitamin A and vitamin D in milk and
margarine became common practices to prevent rickets in children in both Europe
and the United States. In India, food fortification was mandated in salt (with
iodine) in the 1950s and and hydrogenated oil (with vitamin A) in the 1980s, promoted through public-private partnerships and international agencies.
Currently, 91% of households in India have access to iodised salt, and 71% of them consume adequate amounts. [viii]

Fortification of
the staple grains that are most widely and abundantly consumed can have great
benefits and prove to be an essential tool in the fight against malnutrition.
However, implementing and sustaining fortification programs faces significant
constraints, including: technical, socio-economic, infrastructural and
political issues.  The technical
difficulties arise from identifying a fortificant that is adequately
bioavailable for the body to absorb and also does not change the appearance and
color of the food. Socio-economic challenges are usually related to inadequate
information regarding the benefits of fortified foods and the ability to source
and access foods for consumption. Infrastructural constraints emerge due to the
absence of mechanisms to implement programs, make fortified foods readily available
and distribute them to the target population. The major political obstacles are
about getting the attention of policymakers to back such initiatives and help
scale up programs to benefit the larger society.

In the remainder of this article,
we will look at an example of a community-based fortification program locally
called “Sfurti,” which means healthy in
Gujarati and also stands for the Sustainable Flour Fortification Initiative (SFurtI) instigated by the Tata-Cornell
Institute for Agriculture and Nutrition
. We present the
significant lessons learned in implementing and sustaining community-based
fortification programs, the constraints that were addressed and some that
remain.

image

Sustainable
Flour Fortification Initiative: SFurtI for a healthier life

Since 2016, the
Tata-Cornell Institute has overseen the implementation of the Sustainable Flour
Fortification Initiative (aka, SFurtI). SFurtI was designed to leverage both
the social capital created through women’s empowerment and the entrepreneurial
aspirations of these women to target micronutrient malnutrition in
marginalized, tribal communities in rural Gujarat. The program covers approximately
5,600 households in 15 tribal villages in Songadh Block of Tapi
District, in the State of Gujarat. Each micronutrient sachet contains 1.25
grams of fortificant consisting of iron, folic acid, vitamin B12, and vitamin
A, adequate for up to 5 kg of wheat or rice or jowar (sorghum) flour, which are
distributed to households through women members of community Self Help Groups
(SHGs).

Lesson 1: Reliable community-based and institutional
partners are essential to tackle technical and infrastructural problems

This program is implemented through the Women’s Federation of Self-Help
Groups (SHGs), a field team staff from the Tata-Cornell Institute, and with
support from the BAIF Development Research Foundation. Technical assistance is
provided by Maharaja Sayajirao (MS) University of Baroda and by Sight and Life,
the think tank of DSM, a well-known manufacturer of
micronutrients. MSU Baroda is a knowledge
partner that has been involved in community based public health advocacy and
provided the knowledge support to the program. DSM supplied the sachets of
micronutrient powder, ensuring that the fortificant had adequate amounts of
bioavailable iron and did not change the color and taste of the food that was
prepared. As they had worked with them for many years, BAIF, the local NGO,
helped in mobilizing the SHGs. The SHG members were instrumental in sensitizing
the community to the legitimacy of the program and encouraged community
participation.

Lesson
2:  Active community participation is
essential to address socio-economic constraints – Women SHGs played a pivotal
role in enabling uptake  

Once the SHGs
became partners in the project, outreach was carried out through a network of Sfurti Bens and Sfurti Sakhis (SHG members responsible for promoting and selling fortificants). Sfurti Bens, with support from the Anganwadi and the ASHA worker, were responsible for
creating awareness about micronutrient malnutrition and Sfurti as a possible
solution. Outreach programs targeted women in the household and the Sfurti
Bens
were able to reach ~70% of households within a span of one year.

Social networks play a vital role in the sale
of the product. This is evident from the fact that sales numbers were higher in
villages where the Federation (and its SHGs) had a strong presence. We found
that the likelihood of purchase by a household could increase by 55% depending
on the intensity of its interaction with the SHG and other social networks. Villages
where the Sfurti Ben had a secure
network and connection also showed higher sales. Motivated Sfurti Bens went out of their way to build and leverage upon their
social networks, which converted to higher sales in such villages. Villages
will complex social structures and a low-on-motivation Sfurti Ben, however, continued to show poor sales.

According to the SHGs,
the critical factors for success were:

  • Purchasing decisions are often consultative with men
    (rather than solely with women), Engaging men in the marketing of Sfurti is key
    to household purchasing decisions.
  • It is easy to reach the conveniently-located people,
    but going beyond the “low-hanging fruit” to reach geographically distant
    communities takes intentionality, planning, and effort.
  • Be mindful of women’s time demands and heavy workloads.
    – Women did complain about the additional work of mixing
    the flour and fortificant in the right
    proportions.

The
Sfurti micronutrient product reached out to 3,821 households in year one, while
the outreach in year two was 3,501 households.
However, the regularity of consumption (i.e., households who consumed
the product for five months and above) was higher in year two. This has been a significant achievement of the
project in year two.

image

Figure 1 shows the shift in the regularity of consumption during the second year of the program, with a higher number of households consuming Sfurti for five months or more in year 2 than in year 1.

Lesson
3: Scaling up requires the active involvement of the state and policymakers
need to be convinced

Programs such as Sfurti will remain
important especially for subsistence and semi-subsistence households that rely
on their production of grain for their daily consumption rather than rely on
the markets and the Public Distribution System (PDS). For this group, the
option of fortifying flour at home will have nutrition implications. Government,
Industry and CSR support for these programs is essential to implement them more
widely in regions where markets and safety nets are thin.

Through extant social safety net
programs, micronutrients could become more widely available across India. The
most widespread impact will come from the distribution of fortified foods in
the PDS. The PDS currently does distribute fortified cooking oils; diversifying
to fortified staples would ensure adequate outreach. Similarly, the Mid-Day
Meal Scheme (MDMS) could enhance the nutritional status of children with the
presence of fortified foods in school meals. Promotion of fortified foods in
the Integrated Child and Development Services (ICDS), which targets children
below the age of 6 as well as expecting and lactating mothers, would also
benefit from fortification.

Active involvement of the state has been an integral aspect of widely
implemented fortification initiatives in India. For example, public-private
partnerships for the promotion of iodine fortified salt and the distribution of
fortified oil through the PDS has been essential in making fortified foods more
widely available. In 2016, the national Food Safety and Standards Authority
of India (FSSAI) operationalized standards for fortification of five staples –
wheat flour and rice with iron, vitamin B12, folic acid and zinc, edible oils
and milk with vitamin A and D, and salt with iodine and iron. The ‘+F’ logo on
foods will be used to identify these foods in the marketplace. While this helps
promote nutritious foods available in the open market, the need to promote
fortified foods through safety net programs is an ongoing requirement. For this,
significant state-level intervention through policy is essential.

By the Tata-Cornell Institute

REFERENCES:

[i] McLean
E, Cogswell M, Egli I, Wojdyla D, de Benoist B 2009. Worldwide prevalence
of anaemia, WHO Vitamin and Mineral Nutrition Information System,
1993–2005. Public Health Nutr 12: 444–454. Available here.

[ii] Kapil,
U., et al. National Iron-plus initiative guidelines for control of iron
deficiency anaemia in India. Natl. Med.
J. India
(2014); 27(1): 27-9.

[iii] Black,
R.E., et al. Maternal and child undernutrition: global and regional exposures
and health consequences. Lancet
(2008); 371: 243-60.

[iv] Anand
T., et al. Issues in prevention of iron deficiency anemia in India. Nutrition (2014) 30: 764-70.

[v] Sharma,
K.K. “Improving Bioavailability of Iron in Indian Diets through Food-based
Approaches for the Control of Iron Deficiency Anaemia.” (2003). In Albert, J.,
and C. Probart (eds). Food, Nutrition and Agriculture. FAO.

[vi] NIN
(National Institute of Nutrition). Dietary Guidelines for Indians – A Manual
(2011), NIN, Indian Council of Medical Research, Hyderabad. Accessed Sept. 16,
2017. Available at: http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf

[vii] Delgado,
C.L. Rising consumption of meat and milk in developing countries has created a
new food revolution. J. Nutr. (2003);
133(11): 3907S-10S.

[viii]
Pandav CS, Yadav K, Srivastava R, Pandav R, Karmarkar MG. Iodine deficiency
disorders (IDD) control in India. Indian J Med Res. 2013;138(3):418-33.