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Tackling malnutrition – a simple solution

Multiple micronutrient fortified salt provides a simple and elegant solution to tackle widely prevalent anaemia and malnutrition in pregnant women and young children. Salt being universally used in about the same quantity every day, is an ideal medium for fortification. Tamil Nadu that pioneered the noon meal programme can further enhance the nutrition content by switching to multinutrient fortified salt. The initiative can be bolstered by CSR funds. 

Anaemia in pregnant women and young kids has been a major health issue. Low birth weight (LBW) babies and anaemia are estimated to impact more than a third of children in India. These are the result of micronutrient deficiencies, notably iron, zinc, and vitamins, described as hidden hunger. This impacts severely on the growth of the child, its attention, memory, concentration and cognition, and results in poor productivity; impairs immune functions leading to susceptibility to diseases. Cumulatively, hidden hunger results in a humongous loss of national production.

Tamil Nadu was the earliest state to identify the problem: in the 1950s, the then Chief Minister Kamaraj introduced a programme to provide food to needy school children. In 1982, then Chief Minister MG Ramachandran gave full form to this brilliant concept by introducing the free mid-day meal programme for all poor school children. This was found effective in arresting school dropouts and ensuring one good meal daily. Nutritional aspects were addressed by introducing salt fortified with iodine and iron. The scheme was adopted as an important component of child welfare and implemented nationwide.

While the mid-day meal programme addresses one part of mitigating hunger, it needs a stronger focus on eradicating anaemia by meeting the deficiencies of vitamins and minerals like zinc.

Sundar Serendipity Foundation through years of research and development has perfected the technique for fortifying salt with not just iodine and iron but also with other essential vitamins and minerals.

This important work needs to be reached to millions of children by policymakers, philanthropists, and business leaders with a high degree of social consciousness. The effort appears an extremely fit case for spending from the Corporate Social Responsibility (CSR) budgets. Can one think of a more noble act of philanthropy or social purpose than helping the child blossom to its full potential?

Anaemia, malnutrition widely prevalent

Maternal anaemia is responsible for 20-22 per cent of maternal deaths due to complications during pregnancy. 50 per cent of the women and children and 25 per cent of men in India are anaemic. Anaemia is also one of the reasons for LBW babies of less than 2500 grams.

In Tamil Nadu, the prevalence of anaemia in percentages is 50.7 in young children, 55.1 in women and 20.4 in men; central and northern India being the worst contributors. The overall picture is bleak.

NFHS data only gives information on the prevalence of anaemia and does not give details on the other micronutrient deficiencies like vitamin A, zinc, B12, folic acid and iodine. We have seen that all these deficiencies exist substantially.

Multiple micronutrient fortification of salt

Multiple micronutrient fortified salt provides one of the solutions to this massive problem.

Salt being universally used by everyone in about the same quantities every day is an ideal vehicle for fortification. But multiple micronutrient fortification of salt is very difficult because the multiple micronutrients interact with each other and destroy themselves. All the micronutrients have to be micro-encapsulated so that these micronutrients are stable in environments most suitable for them to ensure they are not in contact with themselves. We have achieved multiple micronutrient fortification of common cooking salt withVitamin A, B12, folic acid, iron, iodine, and zinc. It is white in colour and does not cause changes in the taste or colour of the food cooked. It is ensured that micronutrients are stable in the salt and absorbed by the body. It has been accepted in the cuisines of Tamil Nadu, Karnataka, West Bengal, Andhra Pradesh, Gujarat, and Madhya Pradesh as found in our studies.

The poor, however, use only crystal salt. Therefore, it has to be enriched with iron, iodine, B12, folic acid, and zinc. This was a great challenge, but we did this because this was the only way to reach these micronutrients to the poor all over the country.

Low birth weight babies

A normal birth weight is 2500 grams or more in every human being. Unfortunately, nearly 30 per cent of the new-borns in India do not get this basic birth weight. We are referring to the full-term new-borns with LBW due to growth retardation in the womb. This is one of the cruellest things, as a child with LBW starts off in life on a negative scale, for basically no fault of the child. LBW children have deficiencies in cognition and lower developmental test scores than children with normal birth weight.

The child being of a lower birth weight to aid an easy delivery is a part of the widespread belief among rural India – they reason that the child can always grow well later. So women eat less and continue to do hard physical work in the crucial third trimester, the time for the maximal growth of the fetus. This is a myth, as the growth curve of a LBW child is lower than a normal child and it is a battle for the child from day one, as the child suffers deficiencies in cognition and lower development test scores. Even survival is closely associated with birth weight. That is why we call LBW children as children who have lost their childhood.

The Iron irony…

Another myth is the rural people associating their black stool when iron tablets are taken, to think that the iron tablets will similarly produce dark-coloured babies! Hence women are discouraged from taking iron tablets during pregnancy and are encouraged to consume costly saffron. Further evidence suggests that thin children are usually the issue of thin mothers and both are caught up in an inter-generational cycle of poverty and malnutrition.

Underweight or very thin children, suffering from macro and micronutrient deficiencies, are much more susceptible to chronic diseases in mid-life, including cardiovascular diseases, hypertension and diabetes which, combined with poor adult diets, predispose for adult obesity. Thus, poor children risk a ‘double burden of disease.’ Proper nutrition for the mother and infant will avert a substantial disease burden across the life cycle of the new generation.

Neglect in the most crucial months

Neglect of the pregnant mother’s nutrition leading to growth retardation of the fetus in her womb is one of the major causes of LBW babies.

The first three years of life form the most critical period of brain development with proper nutrition being the critical factor. Adequate health and nutrition during prenatal phase and infancy can prevent many learning disabilities.

Role of Vitamin A and zinc

Rajesh is an auto driver. He cannot see well when it gets dark in the evening. He almost met with an accident because of this. He is the sole breadwinner of his family, and he has to work at night also. He does not realise that he is suffering from night blindness due to Vitamin A deficiency. Severe vitamin A deficiency can even result in blindness. Vitamin A is also responsible for the proper functioning of the immune system.

Prakash who is 12 years old, is shorter than his 8-year-old cousin. Prakash does not realise that he is suffering from zinc deficiency contributing to his short stature. Zinc is necessary for normal growth and short and stunted features are a result of zinc deficiency. Proper functioning of the immune system is also dependent on zinc. Vitamin A reduces infant deaths and sickness. Children with diarrhoea receive zinc along with oral rehydration therapy. Zinc reduces the incidence of diarrhoea in children. Zinc might significantly contribute to increase in the heights and weights of children.

Vitamin B12, folic acid and iodine

Vitamin B12 and folic acid deficiency in the early stages of pregnancy cause neural tube defects and defects in the spine in the new-borns. One of the reasons for children born with cleft palate is B12, folic acid, and other B-complex deficiencies in the mother during her pregnancy. Vitamin B12 and folic acid are necessary for red blood cell formation. Iodine deficiency causes mental retardation. Studies show that a normally growing fetus becomes mentally retarded when there is iodine deficiency in the pregnant mother. Children’s IQ in endemic iodine-deficient communities is reduced by about 13 points.

Economic losses due to micronutrient deficiencies

Malnutrition costs loss of one per cent of the GDP in India which is more than the annual revenues of Tamil Nadu. Add to this the huge cost of medical expenses that are not affordable by most sections.

Combating multiple micronutrient deficiencies

Multiple micronutrient deficiencies are widely prevalent in the poor. Hence giving a single micronutrient is ineffective.
Dietary diversification, fortification, and supplementation are the three solutions to this problem. Dietary diversification is impractical due to the low purchasing power of the poor and the steep increases in food prices. High doses of micronutrients in the form of tablets or syrups improves its status for a short period, but once they are stopped, their levels drop in the blood. Successful fortification involves universal use of the fortified product in about the same quantities by all the people every day.

Presently, the government has a national anaemia control programme where pregnant women are given 100 iron folate tablets per pregnancy. However, problems in supply, side effects of gastric irritation, black stools and lack of sufficient counseling prevent full consumption of iron tablets. Moreover, folic acid to prevent neural tube defects is unavailable in the early stages of pregnancy. The neural tube of the fetus closes in the first few weeks of pregnancy when a woman does not even know that she is pregnant. There is also a government vitamin A programme, though not in all the states of our country, where high dose Vitamin A is given to children.

Primary and middle school children and in many areas pregnant and lactating women are inadequately covered. In states like UP, there is no Vitamin A supplementation. So, this programme needs to be strengthened.

Way forward

In 2018-19, multiple micronutrient fortified salts were given free to 15,000 families for a year. This benefitted about 60,000 people.

Corporates and companies could give their CSR funds to this cause, so that the multiple micronutrient fortified salts could be given free of cost to more deserving families. The fortified salt could be used as an effective tool to break the vicious cycle of malnutrition and micronutrient deficiencies leading to poverty.

Pioneer of fortified salt

K Ramu gained vast experience in marketing vitamins and chemicals at Voltas Ltd for over twenty years. Founder Chairman of Sundar Chemicals P Ltd, one of the leading manufacturers of nutraceutical and animal nutrition products and Founder Trustee of Sundar Serendipity Foundation, Ramu has been deeply involved in the use of micronutrients for eradicating Hidden Hunger caused due to micronutrient deficiencies. He was the first to commercially produce Iron fortified salt and later double fortified salt to combat iron and iodine deficiencies in India. He has been involved in the manufacture of a multiple micronutrient fortified common salt, fortified with Vitamin A, iron, iodine, B12, folic acid and zinc.

A few paise more can address anaemia

Sundar Serendipity Foundation [SSF] has done extensive work in the multiple micronutrient fortification of common salt. Founder K. Ramu and Managing Trustee Dr. Malavika have been working on the product for several years and have perfected the technology for stable fortification of many vitamins and minerals in salt. The studies and field trials by these pioneers also confirmed handsome improvements in tackling anaemia in pregnant women, children, and in rural communities, as well as in tea plantation workers.

Malavika is the Managing Trustee of SSF, a non-profit organisation. This charitable trust has been created to address the mammoth problem confronting India and other developing countries, namely hidden hunger caused due to multiple micronutrient deficiencies. SSF has been working on combating these deficiencies in the most vulnerable groups, namely women and children in malnourished communities.

Look at the evolution of the use of salt: in the early stages right up to the 1960s, salt was raw, collected from salt pans along the coast (or along the rocky mountains), and sold raw with little refining or packaging. During later stages, refining and packaging evolved. The next stage witnessed the fortification of salt with iodine and subsequently with iron. Multiple micronutrient fortification of salt is the next stage.

The entire family gets the daily requirement of iron, iodine, B12, folic acid, vitamin A, and zinc at just about 30 to 35 paise per person per day. It may be a few rupees costlier than conventional packaged salt. Since a family of about four persons consumes just 1 kilogram of salt per month, the additional cost is just a few rupees per family per month. If corporates sponsor the multiple micronutrient fortified salt as a part of their CSR, large scale production could further bring down the price of this.

Presently, state governments and Akshaya Patra are large buyers of salt for their free mid-day meals programme for school children. Understandably, there is inflexibility over costs incurred on this programme offered free as a welfare measure. Thus, there is lack of interest in affording a costlier salt.

Aware of the substantial gains achieved by the school meal programme which is implemented as the nutritious noon meal programme, there is the need to improve the nutritional content. Tamil Nadu that pioneered the concept which spread nationwide has included the offer of eggs on considerations of nutrition. There is a strong case for further enhancing the nutritional content by switching to multinutrient fortified salt.

Akshaya Patra that effectively mobilises the needed resources through the CSR budgets of corporates and from philanthropists could take the initiative to switch to multiple micronutrient fortified salt. Policymakers in different states who administer the nutritious mid-day meal programme should think of budgeting a little more to reap the advantages of multinutrient-fortified salt.

Clinical trials on Fortified Salt
Increase in productivity or workperformance

Clinical trials on the fortified salt showed an increase in the productivity of tea pickers. At the year-end of using salt fortified with iron and iodine, the tea picker’s average hemoglobin level increased which could increase annual tea production in that plantation by 330 tonnes. This the magnitude of increase in productivity in one estate where the study was undertaken.

Improved cognition, better growth rates in children

When a multiple micronutrient salt was provided to children for one year, there was a significant improvement in micronutrients in the blood and concomitant improvement in memory tests. In another study on the multiple micronutrient fortified salt, we found that the heights and weights of the children had increased significantly.
Study in communities in 3 states

This multicentric study was conducted in three states of India – Gujarat, MP, and Karnataka. There was a statistically significant improvement of haemoglobin in the study areas in all three states where salt fortified with iron and iodine was given. Urinary iodine also improved significantly, showing the absorption of both iron and iodine from fortified salt.

Cost-benefit ratio

For the delivery of the multiple micronutrients through the multiple micronutrient fortified salt, the cost per person per day is just 30-35 paise. The cost of multiple micronutrients through tablets or syrups will cost a person substantially more. One kilogram of the fortified salt is sufficient for one month for a family of about four. Fortified salt is the most economical way of micronutrient delivery.

Economic benefits of fortification

Reduced morbidity and reduced health care costs, reduced days lost in school or at work, and therefore improved school and work, reduced school dropouts, and increased retention rates, which raise the number of years of schooling and academic performance. These translate to reduced public health expenditure and improved productivity or work performance.

Anaemia in pregnant women and young kids has been a major health issue. Low birth weight (LBW) babies and anaemia are estimated to impact more than a third of children in India. These are the result of micronutrient deficiencies, notably iron, zinc, and vitamins, described as hidden hunger. This impacts severely on the growth of the child, its attention, memory, concentration and cognition, and results in poor productivity; impairs immune functions leading to susceptibility to diseases. Cumulatively, hidden hunger results in a humongous loss of national production.

Tamil Nadu was the earliest state to identify the problem: in the 1950s, the then Chief Minister Kamaraj introduced a programme to provide food to needy school children. In 1982, then Chief Minister MG Ramachandran gave full form to this brilliant concept by introducing the free mid-day meal programme for all poor school children. This was found effective in arresting school dropouts and ensuring one good meal daily. Nutritional aspects were addressed by introducing salt fortified with iodine and iron. The scheme was adopted as an important component of child welfare and implemented nationwide.

While the mid-day meal programme addresses one part of mitigating hunger, it needs a stronger focus on eradicating anaemia by meeting the deficiencies of vitamins and minerals like zinc.

Sundar Serendipity Foundation through years of research and development has perfected the technique for fortifying salt with not just iodine and iron but also with other essential vitamins and minerals.

This important work needs to be reached to millions of children by policymakers, philanthropists, and business leaders with a high degree of social consciousness. The effort appears an extremely fit case for spending from the Corporate Social Responsibility (CSR) budgets. Can one think of a more noble act of philanthropy or social purpose than helping the child blossom to its full potential?

Anaemia, malnutrition widely prevalent

Maternal anaemia is responsible for 20-22 per cent of maternal deaths due to complications during pregnancy. 50 per cent of the women and children and 25 per cent of men in India are anaemic. Anaemia is also one of the reasons for LBW babies of less than 2500 grams.

In Tamil Nadu, the prevalence of anaemia in percentages is 50.7 in young children, 55.1 in women and 20.4 in men; central and northern India being the worst contributors. The overall picture is bleak.

NFHS data only gives information on the prevalence of anaemia and does not give details on the other micronutrient deficiencies like vitamin A, zinc, B12, folic acid and iodine. We have seen that all these deficiencies exist substantially.

Multiple micronutrient fortification of salt

Multiple micronutrient fortified salt provides one of the solutions to this massive problem.

Salt being universally used by everyone in about the same quantities every day is an ideal vehicle for fortification. But multiple micronutrient fortification of salt is very difficult because the multiple micronutrients interact with each other and destroy themselves. All the micronutrients have to be micro-encapsulated so that these micronutrients are stable in environments most suitable for them to ensure they are not in contact with themselves. We have achieved multiple micronutrient fortification of common cooking salt with vitamin A, B12, folic acid, iron, iodine, and zinc. It is white in colour and does not cause changes in the taste or colour of the food cooked. It is ensured that micronutrients are stable in the salt and absorbed by the body. It has been accepted in the cuisines of Tamil Nadu, Karnataka, West Bengal, Andhra Pradesh, Gujarat, and Madhya Pradesh as found in our studies.

The poor, however, use only crystal salt. Therefore, it has to be enriched with iron, iodine, B12, folic acid, and zinc. This was a great challenge, but we did this because this was the only way to reach these micronutrients to the poor all over the country.

Low birth weight babies

A normal birth weight is 2500 grams or more in every human being. Unfortunately, nearly 30 per cent of the new-borns in India do not get this basic birth weight. We are referring to the full-term new-borns with LBW due to growth retardation in the womb. This is one of the cruellest things, as a child with LBW starts off in life on a negative scale, for basically no fault of the child. LBW children have deficiencies in cognition and lower developmental test scores than children with normal birth weight.

The child being of lower birth weight to aid an easy delivery is a part of the widespread belief among rural India – they reason that the child can always grow well later. So women eat less and continue to do hard physical work in the crucial third trimester, the time for the maximal growth of the fetus. This is a myth, as the growth curve of a LBW child is lower than a normal child and it is a battle for the child from day one, as the child suffers deficiencies in cognition and lower development test scores. Even survival is closely associated with birth weight. That is why we call LBW children as children who have lost their childhood.

The Iron irony…

Another myth is the rural people associating their black stool when iron tablets are taken, to think that the iron tablets will similarly produce dark-coloured babies! Hence women are discouraged from taking iron tablets during pregnancy and are encouraged to consume costly saffron. Further evidence suggests that thin children are usually the issue of thin mothers and both are caught up in an inter-generational cycle of poverty and malnutrition.

nderweight or very thin children, suffering from macro and micronutrient deficiencies, are much more susceptible to chronic diseases in mid-life, including cardiovascular diseases, hypertension, and diabetes which, combined with poor adult diets, predispose for adult obesity. Thus, poor children risk a ‘double burden of disease.’ Proper nutrition for the mother and infant will avert a substantial disease burden across the life cycle of the new generation.

Neglect in the most crucial months

Neglect of the pregnant mother’s nutrition leading to growth retardation of the fetus in her womb is one of the major causes of LBW babies.

The first three years of life form the most critical period of brain development with proper nutrition being the critical factor. Adequate health and nutrition during the prenatal phase and infancy can prevent many learning disabilities.

Role of Vitamin A and zinc

Rajesh is an auto driver. He cannot see well when it gets dark in the evening. He almost met with an accident because of this. He is the sole breadwinner of his family, and he has to work at night also. He does not realise that he is suffering from night blindness due to Vitamin A deficiency. Severe vitamin A deficiency can even result in blindness. Vitamin A is also responsible for the proper functioning of the immune system.

Prakash who is 12 years old, is shorter than his 8-year-old cousin. Prakash does not realise that he is suffering from zinc deficiency contributing to his short stature. Zinc is necessary for normal growth and short and stunted features are a result of zinc deficiency. The proper functioning of the immune system is also dependent on zinc. Vitamin A reduces infant deaths and sickness. Children with diarrhoea receive zinc along with oral rehydration therapy. Zinc reduces the incidence of diarrhoea in children. Zinc might significantly contribute to an increase in the heights and weights of children.

Vitamin B12, folic acid and iodine

Vitamin B12 and folic acid deficiency in the early stages of pregnancy cause neural tube defects and defects in the spine in the new-borns. One of the reasons for children born with cleft palate is B12, folic acid, and other B-complex deficiencies in the mother during her pregnancy. Vitamin B12 and folic acid are necessary for red blood cell formation. Iodine deficiency causes mental retardation. Studies show that a normally growing fetus becomes mentally retarded when there is an iodine deficiency in the pregnant mother. Children’s IQ in endemic iodine-deficient communities is reduced by about 13 points.

Economic losses due to micronutrient deficiencies

Malnutrition costs loss of one per cent of the GDP in India which is more than the annual revenues of Tamil Nadu. Add to this the huge cost of medical expenses that are not affordable by most sections.

Combating multiple micronutrient deficiencies

Multiple micronutrient deficiencies are widely prevalent in the poor. Hence giving a single micronutrient is ineffective.
Dietary diversification, fortification, and supplementation are the three solutions to this problem. Dietary diversification is impractical due to the low purchasing power of the poor and the steep increases in food prices. High doses of micronutrients in the form of tablets or syrups improves its status for a short period, but once they are stopped, their levels drop in the blood. Successful fortification involves universal use of the fortified product in about the same quantities by all the people every day.

Presently, the government has a national anaemia control programme where pregnant women are given 100 iron folate tablets per pregnancy. However, problems in supply, side effects of gastric irritation, black stools and lack of sufficient counseling prevent full consumption of iron tablets. Moreover, folic acid to prevent neural tube defects is unavailable in the early stages of pregnancy. The neural tube of the fetus closes in the first few weeks of pregnancy when a woman does not even know that she is pregnant. There is also a government vitamin A programme, though not in all the states of our country, where high dose Vitamin A is given to children.

Primary and middle school children and in many areas pregnant and lactating women are inadequately covered. In states like UP, there is no Vitamin A supplementation. So, this programme needs to be strengthened.

Way forward

In 2018-19, multiple micronutrient fortified salts were given free to 15,000 families for a year. This benefitted about 60,000 people.

Corporates and companies could give their CSR funds to this cause so that the multiple micronutrient fortified salts could be given free of cost to more deserving families. The fortified salt could be used as an effective tool to break the vicious cycle of malnutrition and micronutrient deficiencies leading to poverty.

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