Perspective: When the cure might become the malady: the layering of multiple interventions with mandatory micronutrient fortification of foods in India.

When public health programs with single nutrients are perceived to have a poor impact on the target health outcome, the policy response can be to supply more, by layering additional mandatory programs upon the extant programs. However, we argue for extreme caution, because nutrients (like medicines) are beneficial in the right dose, but potentially harmful when ingested in excess. Unnecessary motivations for the reactionary layering of multiple intervention programs emerge from incorrect measurements of the risk of nutrient inadequacy in the population, or incorrect biomarker cutoffs to evaluate the extent of nutrient deficiencies. The financial and social costs of additional layered programs are not trivial when traded off with other vital programs in a resource-poor economy, and when public health ethical dilemmas of autonomy, equity, and stigma are not addressed. An example of this conundrum in India is the perception of stagnancy in the response of the prevalence of anemia to the ongoing pharmacological iron supplementation program. The reaction has been a policy proposal to further increase iron intake through mandatory iron fortification of the rice provided in supplementary feeding programs like the Integrated Child Development Services and the School Mid-Day Meal. This is in addition to the ongoing pharmacological iron supplementation as well as other voluntary iron fortifications, such as those of salt and manufactured food products. However, before supplying more, it is vital to consider why the existing program is apparently not working, along with consideration of the potential for excess intake and related harms. This is relevant globally, particularly for countries contemplating multiple interventions to address micronutrient deficiencies. Supplying more by layering multiple nutrient interventions, instead of doing it right, without thoughtful considerations of social, biological, and ethics frameworks could be counterproductive. The cure, then, might well become the malady.

Micronized ferric pyrophosphate supplied through extruded rice kernels improves body iron stores in children: a double-blind, randomized, placebo-controlled midday meal feeding trial in Indian schoolchildren.

BACKGROUND: Micronized ferric pyrophosphate (MFPP) in extruded rice kernels mixed in a rice-based meal could be an effective strategy for improving iron status of children in India. OBJECTIVE: The objective was to determine the impact of MFPP supplied through extruded rice kernels in a rice-based meal on iron status of children participating in the midday meal (MDM) scheme in India. DESIGN: The sensory characteristics of cooked rice containing MFPP in extruded rice kernels, in vitro availability, and loss of iron during cooking from a typical MDM consisting of 125 g rice (dry weight) containing 19 mg Fe [fortified rice (FR); normal rice mixed with Ultra Rice (extruded kernels containing MFPP of ∼3.14-µm mean particle size)] in comparison with unfortified rice (UFR) were tested. A double-blind, 8-mo, placebo-controlled trial was conducted in 5-11-y-old schoolchildren (n = 140) who were randomly assigned to receive either an FR-MDM or a UFR-MDM. Average consumption amounts of the MDM, height, weight, hemoglobin, ferritin, and C-reactive protein were measured at baseline and at 8 mo. RESULTS: The sensory qualities of cooked FR and UFR were similar. The in vitro iron availability from FR-MDM (1.3%) was significantly (P < 0.05) lower than that from UFR-MDM (3.3%). Providing FR-MDM to the schoolchildren for 8 mo improved ferritin significantly (P < 0.001), by 8.2 ± 2.10 µg/L. However, the increase in hemoglobin was similar between groups (FR: 0.99 ± 0.10 g/dL; UFR: 1.15 ± 0.10 g/dL), which suggests that other factors beyond additional iron intake had a large influence on hemoglobin concentration. The prevalence of iron deficiency decreased significantly (P < 0.05) in the FR group (33-14%) and increased marginally in the UFR group (31-37%). The prevalence of anemia and iron deficiency anemia was similar between groups at baseline and at 8 mo. CONCLUSION: Regular intake of 19 mg Fe/d in MFPP supplied through extruded rice kernels improves iron stores and reduces iron deficiency among schoolchildren in India.