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Indian experience

Indian Multi-purpose Food

One met hod of fortification of the common dietaries is to provide a supplement that the consumer can add to his food to provide the required extra vitamins and proteins. In some ways this is a more elegant approach than broadcast fortification of the staple grains. It is selective in its approach and involves consumer participation. This approach was tried through Indian Multi-purpose Food (IMPF). IMPF is a blend of 75 per cent of edible peanut flour and 25 per cent of Bengal gram (Cicer arietinum). It provided 42 per cent of fairly well-balanced protein with added vitamins, calcium, and iron (table 4). It was recommended for use along with other foods and provided a fair amount of the daily requirements. Several studies of its nutritive value both with rats and children were significantly in its favour. Consumer acceptance of IMPF was well established and guidelines for recipes were prepared (Subrahmanyan et al. 1957). The large volume of sales that it enjoyed during the project proved its popularity. However the project was not continued perhaps due to lack of marketing techniques in its sale and poor governmental support (Orr 1972).

TABLE 4. Chemical Composition of Indian Multi-purpose Food

Sources: V Subrahmanyan et al. 1957

Synthetic Rico

Fortification of a starchy material with a high protein source like edible peanut flour was also tried by the scientists at the Central Food Technological Research Institute (CFTRI) (Subrahmanyan 1954). The technique adopted was to prepare a dough with tapioca flour (Manihot utilissima) and extrude it through a macaroni press with a suitable die and cutter. The grains formed were treated in such a way that they did not disintegrate while cooking but were not too tough for digestion. The grains were fortified with minerals and vitamins by mixing the fortificants with the dough. Nutritional evaluation of the product both with children and rats was carried out. The project was successful both nutritionally and technologically but the programme of establishing a plant at Kerala, which is the major tapioca-growing area, did not come off, for reasons other than the technological feasibility of the project. A similar trial under the sponsorship of USAID was reported to be in progress in 1971 in Thailand, using extruded imitation rice kernels containing lysine, threonine, vitamins, and minerals (Borenstein 1971).

Fortification of Wheat Flour

Fortification of whole wheat flour (atta) with edible peanut flour was recommended by the CFTRI to raise the protein content of wheat flour (normally about 11 to 13.5 per cent) by adding 5 per cent edible peanut flour. Since peanut flour protein is poor in both lysine and sulphur acids, addition of peanut flour to wheat flour did not upgrade the protein of wheat very much. Also it introduced problems of acceptability as the chapati (unleavened bread) made using this flour was dark in colour and not soft. A consumer acceptance trial at Bombay, organized by the Protein Foods and Nutritional Development Association of India, confirmed these findings.

Although the project was initially proposed to be of a fairly large magnitude and was to have been carried out at Poona, it was shifted to Bombay. It involved three fair price shops and was limited to six weeks duration, during July to August 1973. The whole wheat flour (atta) was fortified with 5 per cent edible groundnut flour and some vitamins and minerals, and was sold at the same price as whole wheat flour. Although, according to the questionnaire, 70 per cent were willing to use it, only 8.3 per cent of those who purchased wheat bought the fortified atta. Perhaps it was so because of fear of an unknown food material. The actual number of purchasers of the fortified wheat flour was 174 and the total quantity of the material purchased was only 606 kg. A consumers' survey indicated that only 14 per cent of the users were satisfied, the general complaint being that chapathis made of fortified atta were hard. The fortified flour, although packaged in polythene bags, showed significant insect infestation and this contributed greatly to non-acceptance of the product. [Aiyar personal communication 1982].

Fortification of Bread

Modern Bakeries, a public sector organization of the Government of India, opted for fortification of its Modern bread with lysine, vitamins, and a few minerals. The objective was obviously to correct the lysine deficiency in wheat flour and make the bread better utilized metabolically. Significant improvement in the weight and height of children fed chapati using lysine-fortified wheat has been reported by Shashi Prabha and Bagchi (1978). Similar reports using bread from lysine-fortified wheat flour has been reported in Haitian children by King et al. (1963). Lysine in bread does not alter the taste or texture of bread but probably part of it becomes unavailable during baking if reducing sugars are present. However the fortification of Modern bread with lysine has now been given up by the producers. Occasionally they use soya flour as a wheat supplement, particularly for bread used in school feeding programmes.

Fortification of Salt

Iron-deficiency anaemia is prevalent among women of child-bearing age and in children, both in developed and developing countries (WHO 1975). It is said to be the most widespread nutritional deficiency disease in India (Gopalan 1970). Parasitic hookworm infection has been reported to be a major cause of this. The disease has been shown to contribute significantly to the mortality and morbidity of children, and of women of child-bearing age. One of the remedies suggested is to provide ferrous salt with folic acid to pregnant and lactating mothers and young children. This can benefit only those with whom contact can be established, and does not help the much larger groups in villages and poorly developed areas. It appears to have met with little success (Nadiger et al. 1980). The disease is so widespread that only a broadcast method like fortification of a basic food item consumed by all groups irrespective of age, economic status, and rural or urban setting can meet the requirements. Such a vehicle for fortification in the Indian milieu is salt. A project for salt fortification was undertaken by the Food and Nutrition Board of the Government of India in collaboration with the National Institute of Nutrition (NIN).

In fortification of any food material with iron salts the major consideration is the absorption and utilization of iron by the human body. The Workshop on Measures to Increase Iron in Foods and Diets, organized by the Food and Nutrition Board of the National Academy of Science, United States, in 1970, observed that, "in large-scale studies iron fortification has failed to show expected benefits because iron in the compound used for fortification has been unavailable, or the amount of iron added has been insignificant" (National Academy of Sciences 1970).

The characteristics of some of the iron salts used for fortification and their absorption in human systems is shown in table 5. Elwood et al. (1970) using labelled iron in chapati have shown poor absorption of both iron in the wheat and from the iron salt used for fortification. They have stressed the need to discover or develop an iron salt that can be added to flour in relatively high concentration but that will not affect the keeping quality or baking quality of wheat.

TABLE 5. Bio-availability of Iron Salts Used in Fortification

a. Monosodium glutarnate
Source: Zoller et al. 1980.

To overcome the problems of bio-availability, storage, and utilization in Indian culinary practices, the fortification of salt with iron has been intensively studied by the NIN (NIN 1977). Bio-availability of different combinations of labled ferrous or ferric salts with orthophosphoric acid or its salts and acid sodium sulphate have been studied (Narasinga Rao and Vijayasarathy 1975; Narasinga Rao 1978; Nadiger et al. 1980). The problems of storage in containers that are usually used in Indian homes have been investigated, and the availability of the iron in different forms when used with salt has been tested ("Standards of Identity" 1974). The final formula recommended by the NIN was to fortify the salt with a combination of ferric orthophosphate and sodium acid sulphate, at such a level as to contain 1 mg of iron per gram of salt. The cost of such fortification was estimated to be 17 paise per kg. A large quantity of this fortified salt was produced by the Food and Nutrition Board and the consumer acceptance and the nutritional effect on consumers was tested at four centres - the All-India Institute of Hygiene and Public Health, Calcutta; the All-India Institute of Medical Sciences, New Delhi; the National Institute of Nutrition, Hyderabad; and the Institute of Child Health, Madras. The first three were tested under rural conditions and the last under urban conditions. The results have confirmed that salt fortified with iron is acceptable and that the consumption of such salt was associated with an improvement in haemoglobin status and a reduction in prevalence of anaemia even in the presence of hookworm. The programme is now ready for adoption on a large scale (Dutta personal communication 1981).

Iron Fortification of Other Foods

Fortification of other foods with iron has been tried (table 5). Fortification of sugar has been studied in detail by Disler et al. (1975) and Layrisse et al. (1976a, b), and has proved a suitable vehicle for iron fortification. However, sugar may not be a very useful medium for fortification in India as many of the lower economic groups use very little sugar. Fortification of tea was seriously considered in India by the Food and Nutrition Board as a vehicle for iron fortification. Unlike coffee, tea is consumed throughout the country and even by children. However, the bio-availability of iron in tea is much reduced by the chemical constituents of tea. An interesting development is the fortification of monosodium glutamate (MSG). MSG is used regularly in many of the South-East Asian countries, and almost 94 per cent of the population in the Philippines use MSG. Tests with ferrous sulphate encapsulated with zinc stearate and with ferric phosphate showed that the former had an availability coefficient of 70 per cent and the latter 50 per cent as compared to 100 per cent for ferrous sulphate. Both were free-flowing and did not impart any significant colour (Zoller et al. 1980).

Fortification of Processed Foods

Many processed foods are fortified with vitamins, calcium, and iron, and in some cases with amino acids. Infant foods and weaning foods are usually fortified either on the initiative of the manufacturers or in accordance with the specifications of the Indian Standards Institution (ISI). Table 6 (see TABLE 6. Fortification of Baby Fonds^a) shows the fortification of certain processed foods, and table 7 shows the amount of vitamins a child of six months would derive from these foods in a normal day in comparison with his/her actual requirements. Added to this there are vitamin preparations with mineral salts (calcium and iron) which are being advertised as a "must" for children, and which doctors suggest that mothers should give their children. Possibilities of over-vitaminization or over-feeding with minerals for children may happen in this way. To avoid this, Lachance (1970) has suggested that the vitaminization of a food should be based on its calorie content, that is, the vitamin or minerals should be proportionate to the calories that the food supplies. On this basis table 8 (see TABLE 8 Suggested Fortification of Baby Foods) and table 9 (see TABLE 9. Suggested Fortification for Weaning Foods) have been prepared suggesting levels of fortification of infant foods and weaning foods, and comparing them with present vitaminization according to ISI standards.

TABLE 7. Vitamin and Mineral Intake of Children on Fortified Baby Foods^a

a. A child of six months weighing 6 kg requires about 700 calories/day. Assuming that the child is receiving 2/3 its calories from baby food and 1/3 calories from weaning food, namely, 467 calories from baby food and 233 calories from weaning food, the child will get the above quantities of vitamins against its daily requirement.
In addition, the mother is advised by doctors to give tablets of calcium with vitamin D (160 IU), tablets of vitamin C /200 mg) and vitamins A and D preparations (6.000 IU. vitamin A and 1,000 IU vitamin D) or multi-vitamin tablets

Cost of fortification

Fortification is taken up by governments with the object of social welfare and to overcome endemic nutritional diseases. Under these circumstances the cost factor has no relevance, as the cost of disease by comparison is enormous in terms of loss of life, hospitalization expenses and, more important, the loss in output of the individuals. Generally, the sponsoring authority will not put the cost of fortification on the staple food as this will discourage the target group.

But any programme that is subsidized has a short life. Hence unless the consumer is convinced that the fortification is for the general good and is willing to pay for the benefit, the programme cannot continue. The prevailing costs of vitamins and minerals are shown in table 10 (see TABLE 10. Price of Fortificants). The costs of amino acids (1977 prices) are also shown (Austin 1979). On the basis of this the cost of fortification of one tonne of wheat or rice is shown in table 11 (see TABLE 11. Cost of Fortification of One Tonne of Wheat (in Rs)).

Data for fortification in the three field experiments of USAID are shown in table 3.

Fortification of processed foods with vitamins is comparatively cheap and because of this there has been indiscriminate fortification. This can be reduced if the suggestion of linking calories and vitamins in the products is adopted.

Is food fortification necessary?

The question as to whether food fortification is necessary has to be considered under three subheads: (a) fortification of staple foods with the object of prophylaxis against general malnutrition; (b) fortification of staple foods with the object of wiping out a nutritional disease that is prevalent; and (c) fortification of processed foods.

Fortification as a Means of Improving Nutrition

There have been many fortification programmes that governments have undertaken. Such programmes have been based on the fortification of an individual staple food with vitamins and minerals. Most of these programmes have had very little popular support. Given the option, the consumers have preferred the unfortified product to the fortified one, though there was no price difference between the two (Austin 1979; Aiyar personal communication 1981). This is generally so because the public has an inherent dislike of "new foods," particularly so when the good that the food is supposed to do is not perceptible, as in the case of fortification with vitamins or amino acids. Past experience has been that, when possible, the consumer picks out the fortificant grains from the bulk. Table 12 (see TABLE 12. Balanced Diets as Recommended by the ICMR) shows the dietaries recommended by the Indian Council of Medical Research (ICMR) for good nutrition. These diets, which are within the means of a large majority of the population, can meet all their requirements (see TABLE 13. Nutrient Composition of the Recommended Balanced Diets of the NIN as Compared to the Dietary Requirements of the ICMR). Fortification of any one staple food becomes unnecessary if the consumers are educated in proper dietaries.

Parboiling that is practised in several parts of the country is a natural and accepted form of fortification of cereal grains with vitamins. Parboiled rice has a higher concentration of vitamins than raw or polished rice. Similar techniques for wheat (termed bulgar wheat) are also available. Consumer acceptance of such processes is assured. Similarly a high extraction of flour in roller flour milling ensures better vitamin content than low extraction. A third method that will not have problems of consumer acceptance is genetic improvement of cereals to evolve strains with better nutritional content.

Amino acid fortification of staple food is an entirely different question. Experiments based on animals, or even on selected groups of children, cannot answer the question of the necessity for fortification. The benefit of fortification shown in some trials has been negated by other groups, and no unequivocal answer regarding benefits is yet available. Hegsted's dissenting note to the 1969 PAG meeting on fortification is still valid: "If the benefit to be derived is unknown, cost/benefit analysis is not possible. However, programmes of this nature based upon theoretical or laboratory data alone are fraught with danger." The cost of fortification of cereals with amino acids is heavy, particularly if the second limiting amino acid, threonine, has also to be included.

Fortification with protein concentrates has some advantages over mere fortification with amino acids: it provides calories in addition to the required amino acids, and it will not increase the cost of the blend since protein concentrates sell at nearly the same price as cereals. Soy flour has the advantage over peanut flour in providing a sufficient quantity of lysine. Technological improvements, however, are necessary to ensure that other disadvantages, like undesirable flavours and colours, or changes in texture of the processed products using such flours, are eliminated. Consumer acceptance is a necessary component in such fortification. A project for a tailored tur dhal to overcome the legume shortage is being considered. This will have the advantage of providing a balanced protein with necessary calories and vitamins for that large section of the population who may not be in a position to purchase costly pulses. Technological possibilities to achieve consumer acceptance have to be explored.

Fortification of Staple Foods to Overcome Specific Nutritional Diseases

Programmes like salt fortification with iron or iodine, or fortification of milk powder with vitamin A, have much to recommend them. Such programmes have a specific purpose and can achieve the objective in a definite period. Such programmes are of immense value in wiping out nutritional diseases.

Fortification of Processed Foods

It has now become common practice to fortify all processed foods with vitamins, minerals, and even amino acids. The need for such fortification is frequently not established, and it is often used as a gimmick for sales promotion. It has been pointed out earlier that fortification is always disproportionate to the requirements. Excess intake of vitamins and minerals may bring about serious nutritional problems. The suggestion to link the calorie level of such foods with vitamin fortification is a very useful one.

Conclusion

Processing of foods involves loss of nutrients. To make good such losses foods are enriched with nutrients. Staple foods are fortified, by governments or other bodies, with the object of overcoming endemic nutritional diseases or as a prophylactic measure. Manufactured consumer goods are also fortified with nutrients, either with the object of ensuring the nutritional adequacy of the product or to achieve better sales. In India several such schemes have been tried with more or less success. Fortification when undertaken has to be based on a detailed study of the need, and the mode of fortification. Economics, consumer acceptability, and means of achieving the objective should be the guidelines for such projects.

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