Combating malnutrition through nutrient delivery techniques

Authors: Prof. Amit Arora, Associate Professor, CTARA, Indian Institute of Technology, Bombay and
Ms. Nisha Pujari, Research Scholar, CTARA, Indian Institute of Technology, Bombay

“The doctors of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition.” – Thomas Edison

Good nutrition is an essential driver of sustainable development because it plays a critical role in brain development, generates broad-based economic growth, and signals the fulfilment of people’s rights to food and good health.  Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients (WHO, 2019).

Micronutrients are essential elements required in small quantities throughout our life to orchestrate a range of physical and mental functions to maintain health. The consequences of their absence are severe and lead to micronutrient malnourishment (CDC, 2019). According to the national data for India (NFHS-5), the condition of wasting and micronutrient malnutrition has worsened in the last few years. The most widespread and recognized micronutrient deficiencies are of iron, zinc, vitamin A, iodine, vitamin D, and folate, often occurring concurrently in the sample population (Suchdev, 2017). As per NFHS 5, the percentage of total children aged 6-23 months receiving an adequate diet is very low (~11.3%). Anaemic children aged between 6 and 59 months have also gone up significantly from 58.6% to 67.1%. Likewise, 59 out of 100  women aged 15-19 years are anaemic.

Many strategies have been suggested to combat micronutrient deficiencies, such as exclusive breastfeeding for the first 6 months, controlling parasitic infections, food fortification, food diversification and nutritional supplementation. Food fortification is considered as a relevant and potent intervention by the authorities to reduce the burden of micronutrient deficiencies among children and mothers. It involves adding micronutrients to processed foods, which increases their concentration and thus fulfilling dietary requirements.

The selection of nutrients is based on evidence of low intakes in a population and/or widespread nutrient deficiencies which vary between countries and populations. Fortification programs, therefore, need to be carefully designed to meet the nutrient needs of a given population. Food processing has enormous potential to both increase dietary-diversity and enhance concentrations of micronutrients in commonly consumed foods. Technologists and scientists are making efforts in employing food‐to‐food fortification, by adding micronutrient‐dense foods to food recipes at household as well as commercial level to increase their micronutrient quality. 

Food-based strategies to combat micronutrient malnutrition

Evidence-based interventions for malnutrition have been well studied and can be categorized as nutrition-specific (address immediate causes, often at the individual level) or nutrition-sensitive (address underlying causes, often at the community level). Policy and programme makers incorporate food-based strategies such as dietary diversification, food fortification and supplementation, along with other additional measures on food safety, nutrition education and public health. These approaches should be regarded as complementary, with their relative importance depending on local conditions and local needs. Food-based strategies are discussed as follows:

1. Dietary Diversity
   Increasing dietary diversity is a preferred way of improving the nutrition of a population because it has the potential to improve the simultaneous intake of many food constituents including micronutrients. Diverse diets have been reported to provide vitamins and minerals that prevent ‘hidden hunger’ and micronutrient deficiency diseases (Dulal et al., 2017; Jones et al., 2014; Nithya & Bhavani, 2018; Rosenberg et al., 2018). Increasing dietary diversity means increasing the consumption quantity and range of micronutrient-rich foods. In practice, this requires implementation programmes to improve the availability and consumption of different micronutrient-rich foods (such as animal products, fruits and vegetables) in adequate quantities, especially among those who are at risk or vulnerable to micronutrient malnutrition (Nithya & Bhavani, 2018). However, increasing dietary diversity on a sustained basis has its challenges. One is the introduction of behavioural change through counselling about different foods and their nutritional benefits. Lack of resources for producing and purchasing higher quality foods can sometimes present a barrier to achieving greater dietary diversity, especially in the case of poorer populations (L. Allen et al., 2006)
2. Supplementation
   Supplementation is the term used to describe the provision of relatively large doses of micronutrients, usually in the form of pills, capsules or syrups. Micronutrient supplements during pregnancy can act as a precautionary measure for reducing morbidity and mortality in infants and also in treating maternal complications during pregnancy (Lawn et al., 2014). In our country, supplementation programmes are run to provide iron and folic acid to pregnant women, and vitamin A to infants, children under 5 years of age and postpartum women. Recently, the Ministry of Health and Family Welfare (MoHFW) has launched the Weekly Iron and Folic Acid Supplementation Programme to meet the challenge of the high prevalence and incidence of anaemia amongst adolescent girls and boys.
   Supplementation usually requires the procurement of micronutrients in a relatively expensive pre-packaged form, an effective distribution system and a high degree of consumer compliance (L. Allen et al., 2006). Some adverse effects observed with high-dose supplements and logistical and human-resource constraints may result in non-compliance and the long-term sustainability of such programmes. In such cases, mass fortification of staple foods becomes an important option to combat vitamin and mineral deficiencies. There are fewer concerns related to mass food fortification and it can be a complementary intervention to supplementation for efforts to decrease vitamin and mineral deficiencies (Peña-Rosas et al., 2019).
3. Food fortification
   Food fortification involves adding micronutrients to processed foods. It describes the improvement of essential micronutrient content in foods to enhance the nutritional and health benefits with minimal risk to health. In many situations, this strategy can lead to relatively rapid improvements in the micronutrient status of a population, and at a reasonable cost, especially if an advantage can be taken of existing technology and local distribution networks (L. Allen et al., 2006).  There have been studies with single (Dean et al., 2020), dual (Jannasch et al., 2020), and multiple micronutrient fortification, including zinc, iron, copper, selenium, vitamin A, vitamin B complexes, vitamin C and vitamin E (Das et al., 2019). Minerals are fortified in their salt forms such as ferrous sulphate, ferrous gluconate, ferrous lactate, zinc oxide, zinc sulphate, zinc acetate, zinc chloride, calcium carbonate, calcium phosphate, tri-calcium citrate, calcium lactate, calcium lactate gluconate, calcium gluconate, etc. (Gharibzahedi & Jafari, 2017). Considering the regional diversity in terms of food availability, fortification should be done in a customized manner to ensure compliance. In addition, fortificants should be low in cost with good absorption, and well accepted by the target population in terms of taste and organoleptic properties. In most cases, it is preferable to use food vehicles that are centrally processed and to have the support of the food industry (Chadare et al., 2019).  However, of these three methods (dietary diversity, food fortification and supplementation), programmes that deliver micronutrient supplements often see a quick improvement in the micronutrient status of the targeted population. Food fortification tends to have a less immediate but nevertheless a much wider and more sustained impact. Although increasing dietary diversity is generally regarded as the most desirable and sustainable option, it takes the longest to implement (L. Allen et al., 2006; Gharibzahedi & Jafari, 2017).

Food-to-Food fortification

Food-to-food fortification is a technique of fortifying food products with one or more food ingredient(s), thus making nutrient-dense food. The incorporation of nutritious ingredients calls for modification in the original food recipe, creating a new product with higher nutritional benefits. Such fortification techniques offer a variety of tastes and textures that are unique along with enhanced protein, vitamin, fibre and/or mineral contents and beneficial effects on its quality (Platel & Srinivasan, 2016). Cumin, moringa and sesame-fortified bread and soy-butter, moringa and cumin-fortified salty biscuits demonstrated improved total content and bio-accessible minerals. Its inclusion in food products could be a useful alternative or complement conventional fortification. This will help to improve the mineral status of deficient populations. Food‐to‐food fortification often uses locally available foods to enhance the nutrient intake of the population. This approach consists of selecting and associating foods in such a way as to optimize the bioavailability of useful micronutrients to consumers.

IIT Bombay’s intervention

The Nutrition Groups at IIT Bombay emphasises the development of food-based nutrient-rich, safe, affordable and ready-to-use formulations. Achieving optimal nutrition through the intake of healthy foods has the capability to optimise the physiological functions of each human while ensuring maximum well‐being. The key variable of this research is the presence of macro and micronutrients in sufficient quantity without compromising on quality parameters. Our research team at IIT Bombay is working on developing products with the capability to deliver the full range of micronutrients mostly through the natural product route, avoiding the chemical route. Our aim is also to create local capacity among women’s SHGs or social start-ups for decentralized production with appropriate Quality Control and Quality Assurance protocols. Given the priority accorded to health and nutrition projects in CSR funding, support to the food products lab can go a long way in addressing the problem of hidden hunger among malnourished children and women and benefit the programme implementation in aspirational districts

Some of the products which have been developed in CTARA are – 

(i)    Egg equivalent Idli and nutrition bar  
A completely vegetarian formulation was developed in the form of nutritious ‘Idlis’ and bars that can act as nutrition replacements provided by non-vegetarian foods such as eggs. The product’s theoretical nutrient profiling shows that 2 units of Idli or 1 standard Nutri bar are sufficient to give equivalent nutrition to an Egg. 


(ii)    Magic add-on dry powder 
This powder can be added to any given homemade recipe (e.g. Puree, daliya, Khichdi, dal-rice etc.) and as a result, the child will get a majority of the essential nutrients required for optimal growth and development. The major advantage here is gaining nutrient adequacy without changing dietary habits or preferences. Financial calculations for the developed formulation (DF) suggest that affordability is achievable at a mass-product scale to achieve reasonable dissemination and ultimately greater impact on children.

Other examples include Healthy alternatives to commercially available Ready to Use Therapeutic Foods (RUTF)

Challenges of food fortification
 
Theoretically, the fortification techniques aim at the efficient lowering of micronutrient malnutrition. These, however, still do not reflect in the micronutrient status of individuals based on reports. The following are some challenges faced during the choice and implementation of food fortification strategies:

1. a)     Cost 
   There is a lack of simple and affordable technology that can use stable and bioavailable nutrients while maintaining the commonly preferred taste and appearance of foods. Increased food prices remain an issue affecting the food security and livelihoods of the needy. Despite various international aid, basic foods are still not accessible because they are unaffordable to vulnerable groups who often grow and process their own staple foods. Major challenges to local‐scale fortification programs include the initial cost of the mixing equipment, the price of the premix, achieving and maintaining an adequate standard of quality control, and sustaining monitoring and distribution systems.
2. b)     Concerns about absorption and bioavailability
   Both the density and bioavailability of micronutrients in the diet are important for achieving optimal micronutrient status. Iron, zinc, and calcium can interact with each other to inhibit their respective absorption. For e.g. The ideal iron fortificant is highly soluble in water, similar to ferrous sulphate for the iron to be accessible for intestinal absorption. At the same time, the iron needs to be in a form that prevents it from interacting with dietary compounds that can induce undesirable organoleptic changes and reduce iron bioavailability by the formation of insoluble complexes. Fat-soluble vitamins such as vitamins A and E are poorly dispersible in water, making it difficult to incorporate them in beverages and foods with high moisture content.

Obtaining higher concentrations of micronutrients from food alone, to meet high RDA for adolescent girls and pregnant women is challenging. Processing techniques may lower anti-nutrients but at the same time, it may increase the risk of losses and degradation of minerals and vitamins, respectively.

c)     Toxicity

Toxicity may occur as a combined effect of more than one micronutrient. Increased instances of anaemia have been found in individuals with high levels of folate and low level of vitamin B12 (Rosenberg et al., 2018). Acute iron toxicity is usually seen in children with accidental ingestion of iron-containing syrups. Similarly, for zinc, folic acid, and selenium there are available documents with either reports on toxicity or regulation on the maximum limit (Food Safety and Standards Authority of India, 2019). Usual intakes below the upper limit have a low risk of adverse effects. Some nutrients do not have an upper limit because they are assumed to be safe at any level of intake (e.g., vitamin B12).

The goal of any national food fortification policy is to prevent nutritional deficiencies by bridging the gap between the requirement and availability of nutrients. In exceptional cases of widespread and severe deficiencies, the fortification can be up to 100% of the RDA. In practice, the level of fortification is about 15 to 30 % of RDA (computed per 600 calories of processed food) as per the regulations in India (ICMR, 2018). When these precautions are followed, food fortification carries a minimal risk of chronic toxicity.

1. d)    Anti-nutritional factors
   Poor dietary diversity and dependence on cereal-based diets are common in low- and middle-income countries. Cereals, in addition to being poor sources of vitamins and minerals, also contain high quantities of other dietary compounds, such as phytates, which decrease the absorption of certain micronutrients, often called ‘anti-nutrients’ (Graham 2001). One of the most important concerns in the processing of mineral-rich foods is the formation of strong complexes between bivalence elements (e.g., Ca2+, Mg2+, Zn2+, Fe2+, Cu2+), and phytate, oxalates, fibre, and compounds of tannin and lectin (Shubham et al., 2020). For instance, iron and zinc absorption is significantly inhibited by phytic acid, present in cereals and other grains; polyphenols, contained in red wine and chocolate; or calcium, abundant in dairy products (Peña-Rosas et al., 2019). 
   
   Crop Diversity and Nutrition Security
   
   To be able to reach the overarching goal of nutrition security through improved dietary diversity scores of children and mothers, access to high-quality and diverse raw materials has to be ensured. Crop diversity at affordable and scalable capacity would be central to the food-to-food fortification strategy. India is one of the largest countries in the world has to ensure self-sufficiency in food. The government’s initiatives to increase the production of rice, wheat, pulses, and other crops have brought India to a very secure condition in terms of calorie sufficiency as a whole. For example, rice alone contributes to 40% of total grain production in India followed by wheat (~34% contribution).

India is blessed with hundreds of highly nutritive indigenous crops which are popular in many regions. However, in the past six decades, India has witnessed a decrease in the area under such crops.

A classic example is the production volume decline in the variety of millets over the last few decades. Since there is no minimum support price for such crops, the generation of demand for such crops based food products to improve regional nutrition security would help farmers in realising better prices. Of course, this would entail partnerships with local grassroots organisations to build a sustained momentum to establish a strong value chain.  Safeguarding food and nutrition security through the promotion of diverse crop production systems should be looked at by policymakers more closely.

Conclusion 

Micronutrient malnutrition is a major impediment to socio-economic development. Vitamins and minerals have very different stability and bioavailability in the food matrix. Therefore, the development of a fortification technology that makes them bioavailable and more compatible with the food vehicle would be crucial.  To quantify the size of the gap between usual intakes and requirements in a population group, the distribution of usual intakes by individuals in the population groups of concern (e.g., young children or women of reproductive age, low socioeconomic status) should be compared to the average requirement. A concerted effort is needed for the development of ready-to-consume food products rich in multiple micronutrients, addressing food accessibility and affordability issues, while enhancing bioavailability and forming efficient food synergies. 

“Those who think they have no time for healthy eating will sooner or later have to find time for illness.” – Edward Stanley

REFERENCES: CLICK HERE

Contact author: Prof. Amit Arora
Email: aarora@iitb.ac.in 
Profile link –  https://sites.google.com/site/personalwebpageamitarora/

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