Fight Hidden Hunger through National Programs and Food Based Approaches

Abstract

Nearly 2 billion people, or one-third of the world’s population, suffer from micronutrient deficiencies. Micronutrient deficiencies or hidden hunger and the negative consequences of a diet deficient in essential vitamins, minerals, or trace elements continue to be serious public health concerns among Indians. This hidden hunger is especially prevalent among vulnerable populations, such as pregnant women, small children, and teenagers. As a result, the government has developed many national initiatives to combat malnutrition and micronutrient deficiencies, including ICDS, NFSM, Poshan Abhiyan, Swachh Bharat Abhiyan, and others. Governments also use food-based techniques to combat malnutrition and hidden hunger, including supplementation, food fortification, bio-fortification, and dietary diversification. This chapter presents statistics from the NFHS 4 and 5 and numerous national programs and food-based measures taken by governments to combat hidden hunger.

1. Introduction

Hunger is a complicated issue, and several names are used to characterize its varied manifestations.

Generally, the term “hunger” refers to the distress caused by a deficiency of caloric. According to the United Nations’ Hunger Report, hunger states “define periods when populations are facing significant food insecurity” in which people do not have enough food to survive. Hunger, according to the FAO, is defined as a circumstance in which a person has an unusual and uncomfortable feeling as a result of a deficiency of food components in their diet that is required for a healthy life.

Undernutrition is defined as a deficiency in calories or one or more important nutrients. Undernutrition can arise individuals are unable to get or prepare food, have a disorder that makes it difficult to eat or absorb food or require an excessive amount of calories. Undernutrition is frequently visible: people are underweight, their bones frequently fall out, their skin is dry and stretchy, and their hair is dry and starts falling out. Clinicians can usually diagnose malnutrition based on a person’s appearance, height and weight, and overall health (including information about diet and weight loss). Food is provided to people through the mouth, if possible, in progressively increasing volumes, but it is also supplied via a tube carried from the throat to the stomach or put into a vein (intravenously). Undernutrition is commonly assumed to be caused by a lack of calories (i.e., overall food consumption) or protein. Vitamin and mineral deficiencies are so often thought to be different illnesses. However, when there is a calorie deficiency, vitamins and minerals are often more likely to be present. These, in turn, are the result of several factors, including household food insecurity, poor maternal health or childcare practices, and a lack of access to health services, safe drinking water, and sanitation.

Malnutrition refers to both under- and over-nutrition. Micronutrient deficiency occurs when vitamin and mineral intake or absorption is insufficient to sustain healthy growth and development in children and proper physical and mental function in adults. Poor nutrition, disease, or unmet micronutrient needs during pregnancy and lactation could all be contributing factors [1]. Over 2 billion individuals worldwide suffer from hidden hunger, more than double the 805 million people who do not get enough calories to consume [2]. The subcontinent of South Asia and much of Sub-Saharan Africa are hotspots for hidden hunger. In Latin America and the Caribbean, where diets are less reliant on single staples and where intensive micronutrient interventions, nutrition education, and basic health care are more prevalent, the rates are lower [3]. While the poorest countries bear a disproportionate amount of the expense of hidden hunger, micronutrient deficiencies, especially iron and iodine deficiency, are also widespread in the developed world. The worldwide malnutrition problem is becoming more complicated. Developing countries are shifting away from traditional diets based on minimally processed foods and toward highly processed, energy-dense, micronutrient-deficient foods, and beverages, which contribute to obesity and chronic diseases linked to diet. As a result of this nutritional change, many developing countries are experiencing the “triple burden” of malnutrition, micronutrient deficiencies, and obesity [4]. As a result, people’s food does not provide the vitamins and minerals they require for proper growth and development. It has an impact on two billion individuals all over the world [5]. Micronutrient deficiencies are thought to be responsible for 1.1 million of the 3.1 million children who die each year due to malnutrition [6, 7]. By impairing the immune system, vitamin A and zinc deficiency have a negative impact on children’s health and survival. Zinc deficiency inhibits growth in children and can cause stunting. Iodine and iron deficiencies hampered children’s physical and intellectual development [8].

Women and children have higher dietary needs than men [9]. Throughout pregnancy and conception, the nutritional state of women has a long-term impact on the fetus’s growth and development. Iodine deficiency causes nearly 18 million infants to be born with brain damage each year. Severe anemia is responsible for the deaths of 50,000 women each year after giving birth. In addition, 40 percent of women in impoverished countries suffer from an iron deficiency, which saps their energy. Women, infants, and young children are the primary targets of most initiatives to eliminate hidden hunger and improve nutrition outcomes. Treatments that focus on these people can have a high rate of return on investment by improving later-life health, nutrition, and cognition. Iodine, iron, zinc, and other micronutrient deficits are the most commonly identified micronutrient deficiencies in people of all ages (Table 1). Vitamin A deficiency affects an estimated 190 million preschool children and 19 million pregnant women [10], making it a less common but significant public health issue. Other important micronutrients, such as calcium, vitamin D, and B vitamins like folate, are typically insufficient [11]. Although concealed hunger is most commonly associated with pregnant women, toddlers, and teenagers, it affects people at all stages of their lives. The major objective of this chapter is to present information regarding government programs and food-based techniques in industrialized countries like India to combat hidden hunger.

Micronutrients deficiency	Effects
Vitamin A	Visual impairment, night blindness, increased risk of severe illness and death from common infections; (in pregnant women) night blindness, increased risk of death
Vitamin D	Mood changes, bone loss, muscle cramps, bone and joint pain, fatigue
Vitamin B12	Fatigue, breathlessness, numbness, poor balance and memory trouble.
Folic Acid	Megaloblastic anemia
Iron	Anemia, impaired motor and cognitive development, increased risk of maternal mortality, premature births, low birth weight, low energy
Iodine	Brain damage in newborns, reduced mental capacity, goiter
Zinc	Weakened immune system, more frequent infections, stunting

Table 1.

Micronutrient deficiencies and their effects on people.

2. Methodology for the review of the literature

PubMed, Google, and other databases are searched for relevant material. We conducted a search of all review papers using the keywords “hidden hunger, malnutrition, India.” Additionally, the global scenario, efforts, control programmes, critical evaluations, government reports, agency reports, and publicly available data were analyzed. The necessary data was gathered, compiled, and analyzed.

3. Rank of India in GHI

India’s greatest national treasure is its children; nonetheless, hunger continues to be a significant threat to children’s survival, growth, and development. It has assumed the proportions of a secret emergency in India. India is ranked 94th out of 107 analyzed countries on the 2020 Global Hunger Index (GHI), with a score of 27.2 for a “serious” level of hunger. Additionally, it states that wasting is “very prevalent” among children under the age of five in India. According to the Global Health Initiative, India has the greatest proportion of wasted children (children who are underweight for their height) of any country in the world (17.3 percent). Furthermore, India has 14% of malnourished children under the age of five and 34.7 percent of stunted children under the age of five. Whereas India ranks 101st out of 116 countries on the 2021 Global Hunger Index, with a score of 27.5, India has a severe level of hunger. Pakistan, Nepal, and Bangladesh, India’s neighbors, have achieved a higher ranking. Nepal ranks 77th, Bangladesh ranks 76th, and Pakistan ranks 92nd [12, 13].

4. Outcomes of nutritional interventions

The National Family Health Surveys NFHS-4 (2015–2016) and NFHS-5 (2019–2021) data show falling patterns in some of India’s important health characteristics as a result of these nutritional initiatives [14, 15].

4.1 Data on nutrition indicators as per the last available national survey (NFHS-5)

During the 2019–2020 academic year, the NFHS-5 collected data from around 6.1 lakh households. Many of the indicators in NFHS-5 are comparable to those in NFHS-4, which was conducted in 2015–2016 to allow for temporal comparisons. It serves as a tracking indicator for the country’s Sustainable Development Goals (SDGs), which it wants to accomplish by 2030. Preschool education, disability, access to a toilet facility, death registration, bathing practices during menstruation, and techniques and reasons for abortion are all included in NFHS-5. New target areas in NFHS-5 will offer the necessary feedback for enhancing existing programs and developing new policy intervention techniques. Expanded domains of child immunization components of micronutrients for children are among the topics. Expanded age ranges for evaluating hypertension and diabetes among all people aged 15 and up are among the noncommunicable disease (NCD) components. The NFHS-5 asked for information on the percentage of women and men who had ever accessed the Internet for the first time in 2019.

4.2 Key findings of the NFHS-5

• 5% of children under the age of five are stunted (low height for their age).

• About 3% of children are wasted (low weight for height).

• 32% are underweight (low weight for their age).

• More crucially, according to the most recent national survey, 7.7% of children suffer from severe acute malnutrition.

• State-by-state, child nutrition indices indicate a heterogeneous pattern. While many states and UTs have seen improvements, some have seen a slight downturn.

• Malnutrition has gotten worse. Stunting has been raised in 11 out of 18 states. Wasting is going up in 14 states.

• Stunting: The percentage of stunted children has increased in 13 of the 22 states and UTs surveyed.

• Wasted: In comparison to NFHS-4, the percentage of children under the age of five wasted has increased in 12 of the 22 states and UTs surveyed.

• Obesity: The percentage of overweight children under the age of five has increased in 20 states and territories.

• Children who had diarrhea in the 2 weeks prior to the study increased from 6.6 to 7.2 percent.

4.3 Related indicators

• Children under 6 months who were exclusively breastfed also showed a sharp improvement, going from 54.9 to 63.7%.

• The proportion of children (12–23 months) who were fully vaccinated improved from 62–76%.

• The proportion of anemic children (5–59 months) increased from 58–67%.

• Women aged 15–49 who were anemic increased from 53–57% and men of the same age increased from 29–31% between both editions of the NFHS.

• In most states and UTs, the sex ratio at birth (SRB) has remained constant or increased.

• The majority of the states are at a normal sex ratio of 952 or above.

• SRB is below 900 in Telangana, Himachal Pradesh, Goa, Dadra & Nagar Haveli, and Daman & Diu.

• States such as Tripura, Manipur, Andhra Pradesh, Himachal Pradesh, and Nagaland have also shown an increase in teenage pregnancies.

• Children in the age group (6–23 months) receiving an adequate diet also showed a sharp improvement, from 9.6 to 11.3%.

4.4 The status of child mortality in India

• Between 2019 and 2021, the U5MR dropped dramatically from 49.7 to 41.9%.

• In India, the U5MR is 41.9 per 1000 live births, whereas the IMR is 35.2/1000 live births, and the NMR is 24.9 per 1000 live births.

• Infant and child mortality rates have decreased in most Indian states. The best performers were Sikkim, Jammu & Kashmir, Goa, and Assam, which saw significant reductions in neonatal mortality rate (NMR), infant mortality rate (IMR), and under-five mortality rate (U5MR).

• All three categories of child mortality increased in Tripura, Andaman & Nicobar Island, Meghalaya, and Manipur.

• Among the 22 states and union territories surveyed, Bihar had the highest prevalence of NMR (34), IMR (47), and U5MR (56), whereas Kerala had the lowest death rates.

• In the last 5 years, Maharashtra’s child mortality rate has remained unchanged.

• Improved Sanitation and Cooking Facilities: Over the last 4 years, the percentage of households with improved sanitation and clean cooking fuel has increased in almost all of the 22 states and UTs (from 2015 to 2016 to 2019–2020).

• Anemia among women and children continues to be a cause of concern. In 13 of the 22 states and UTs, more than half of the children and women are anemic. In addition, despite a significant increase in the consumption of IFA tablets by pregnant women for 180 days or more, anemia among pregnant women has increased in half of the States/UTs compared to NFHS-4.

The state of hidden hunger in India is alarming. A lot of work has been done, and while progress has been made, the pace of improvement is too slow.

5. An initiative taken by the Indian government to tackle hidden hunger

5.1 Direct policy measures

5.1.1 Integrated child development services (ICDS)

Integrated Child Development Services (ICDS) is an Indian government programme that provides Supplementary nutrition, nutrition and health education, vaccinations, health screenings, referral services to children and their mothers under the age of six, non-formal pre-school education, and contraceptive counseling for teenagers. The scheme was initiated in 1975, suspended in 1978 under Morarji Desai’s government, and then reintroduced under the Tenth Five Year Plan. The tenth five-year plan also established a link between ICDS and Anganwadi centers, which are primarily located in rural regions and manned by frontline workers. Along with boosting child nutrition and immunization, the initiative aims to eliminate gender inequality by ensuring equitable access to resources for girls and boys [16].

5.1.2 Mid-day meal scheme

The Midday Meal Scheme is a school meal program in India that aims to improve the nutritional status of school-aged children across the country. On working days, the program provides free lunch to children in primary and upper primary classes who attend government, government-aided, local body, Education Guarantee Scheme, and alternative innovative education centers, Madarsa and Maqtabs, supported by the Sarva Shiksha Abhiyan, and Ministry of Labour-run National Child Labour Project schools. With 120 million children served in 1.27 million schools and Education Guarantee Scheme centers, the Midday Meal Scheme is the world’s largest of its kind. In September 2021, the MoE (Ministry of Education), which serves as the scheme’s nodal ministry, changed the scheme’s name to PM-POSHAN (Pradhan Mantri Poshan Shakti Nirman) Scheme. According to the Central Government, by 2022, the scheme would cover an extra 24 lakh children getting pre-primary education at government and government-aided institutions. The program has undergone various adjustments since its introduction in 1995. The Midday Meal Scheme is established by the National Food Security Act of 2013. The National School Lunch Act in the United States is the legal basis for the Indian school lunch program.

5.1.3 National Health Mission

The National Health Mission (NHM), which combines the National Rural Health Mission with the National Urban Health Mission, was announced by the Indian government in 2013. It was renewed in March 2018 for another year, till March 2020. It is headed by a Mission Director and controlled by National Level Monitors chosen by the Government of India. The National Health Mission (NHM) is responsible for several key initiatives, including Rogi Kalyan Samiti, Hospital Management Society, Untied Grants to Sub-Centres, Health Care Contractors, Accredited Social Health Activists National Mobile Medical Units (NMMUs), Janani Suraksha Yojana, National Ambulance Services Some of the initiatives include Janani Shishu Suraksha Karyakram (JSSK), Rashtriya Bal Swasthya Karyakram (RBSK), maternal and child health wings (MCH Wings), free medications and diagnostic services, district hospital and knowledge center (DHKC), National Iron+ Initiative, and tribal tuberculosis eradication.

5.1.4 Rajiv Gandhi schemes for the empowerment of adolescent girls (RGSEAG)

SABLA is another name for this program. The initiative was unveiled by the Indian government on November 19, 2010, in the Plenary Hall of the Vigyan Bhavan in New Delhi. According to the Plan, adolescent girls between the ages of 11 and 18 will be included in all ICDS programs. The scheme’s goals are to help adolescent girls achieve self-development and empowerment, improve their nutrition and health, raise awareness about health, hygiene, nutrition, adolescent reproductive and sexual health (ARSH), and family and child care, improve their home-based skills, life skills, and vocational skills, mainstream out-of-school adolescent girls into formal or non-formal education, and inform and guide adolescent girls.

5.1.5 Indira Gandhi Matritva Sahyog Yojna (IGMSY) (a conditional maternity benefit scheme)

Under IGMSY a centrally sponsored scheme sanctioned by the Government of India in October 2010 under which grant-in-aid is distributed to states and UTs. promoting (ideal) infant and young child feeding (IYCF) practices, particularly early and exclusive breastfeeding for the first 6 months; and contributing to a more supportive environment by providing economic incentives to pregnant and nursing mothers for improved health and nutrition.

5.1.6 Mission for integrated development of horticulture schemes

The National Horticulture Mission (NHM) is one of the sub-schemes of the Mission for Integrated Development of Horticulture (MIDH), and it is implemented through State Horticulture Missions (SHM) in selected districts across 18 states and six union territories. Farmers or beneficiaries should contact the district’s Horticulture Officer to receive benefits and assistance under the scheme.

5.1.7 National Food Security Mission

The government of India introduced this centrally funded initiative, termed the “National Food Security Mission,” in October 2007 in response to stagnated foodgrain output and an increasing consumption requirement of India’s growing population. The mission was a spectacular success, with increased output of rice, wheat, and pulses. During the 12th Five Year Plan, the mission was expanded with new targets of an additional 25 million tonnes of food grain output by the end of the Plan, including 10 million tonnes of rice, 8 million tonnes of wheat, 4 million tonnes of pulses, and 3 million tonnes of coarse cereals. Based on previous experience and the performance of the 12th Plan, the program has been extended to 2019–2020, corresponding with the Fourteenth Finance Commission (FFC) period. Rice will account for 5 million tonnes, wheat will account for 3 million tonnes, pulses will account for 3 million tonnes, and coarse cereals will account for 2 million tonnes, to increase foodgrain production by 13 million tonnes.

5.1.8 The mahatma Gandhi National Rural Employment Guarantee Scheme (MGNEREGS)

The Mahatma Gandhi Employment Guarantee Act 2005 (or, NREGA, later renamed as the “Mahatma Gandhi National Rural Employment Guarantee Act” or MGNREGA), is an Indian labour law and social security measure that aims to ensure the “right to work”. This act was enacted on August 23, 2005 by Prime Minister Dr. Manmohan Singh’s UPA government. It aims to improve rural residents’ livelihood security by offering at least 100 days of paid employment per year to each household whose adult members volunteer to perform unskilled manual labour. The MGNREGA was established with the goal of “improving livelihood stability in rural regions by providing at least 100 days of guaranteed wage employment every fiscal year to every household with adult members who volunteer to perform unskilled manual work.”

5.1.9 Swachh Bharat Abhiyan

The Swatchh Bharat Mission (SBM), also known as the Swatchh Bharat Abhiyan or the Clean India Mission, is an Indian government-led campaign to eliminate open defecation and improve solid waste management in 2014. It is a revamped version of the Nirmal Bharat Abhiyan, launched in 2009 but failed to achieve its goals. On October 2, 2014, Prime Minister Narendra Modi launched the campaign in Rajghat in New Delhi. With 3 million government workers and students from around the country participating in 4043 cities, towns, and rural villages, India’s largest cleaning campaign to date.

5.1.10 The National Rural Drinking Water Program

On August 7, 2018, India’s Comptroller and Auditor General (CAG) issued its findings on the “National Rural Drinking Water Programme.” In 2009, the National Rural Drinking Water Program (NRDWP) was created. It strives to provide rural residents with safe and sufficient water for drinking, cooking, and other home requirements on a sustainable basis.

5.1.11 Eat right India campaign

On July 10th, 2018, FSSAI launched “The Eat Right Movement” to boost public health in India and counteract unfavorable nutritional trends associated with lifestyle disorders. On a unified platform, the food industry, public health specialists, civil society and consumer organizations, influencers and celebrities promised to make real efforts to magnify “The Eat Right Movement” in the country.

5.1.12 Poshan Abhiyan

On behalf of the Ministry of Women and Child Development, Prime Minister Narendra Modi launched the POSHAN Abhiyaan in Jhunjhunu, Rajasthan, in March 2018. Its goal is to reduce undernutrition and other related issues by organizing various nutrition-related programs. Stunting, malnutrition, anemia (especially among young children, women, and adolescent girls), and low birth rates are also addressed. It will oversee and evaluate the implementation of all such plans, using existing organizational structures within line ministries where possible. By 2022, it plans to expand interventions supported by the ongoing World Bank-funded ICDS Systems Strengthening and Nutrition Improvement Project (ISSNIP) to all districts in the country.

5.1.13 Pradhan Mantri Matru Vandana Yojana

The Ministry of Women and Child Development administers the Maternity Benefit Scheme, a federally funded program. It is a maternity benefit program that began on January 1, 2017, in all districts of the country.

5.1.14 National Food Security act

The National Food Security Act of 2013 (also known as the “Right to Food Act”) is an Indian law that aims to provide subsidized food grains to about two-thirds of the country’s 1.2 billion people. It was signed into law on September 12, 2013, with a retroactive date of July 5, 2013. The existing government of India’s food security programs is converted into legal entitlements under the National Food Security Act, 2013 (NFSA 2013). The Midday Meal Program, Integrated Child Development Services Program, and Public Distribution System are all part of it. Furthermore, the NFSA 2013 recognizes maternity benefits. The Integrated Child Development Services Scheme and the Midday Meal Scheme are universal. In contrast, the PDS will serve roughly two-thirds of the population (75 percent in rural areas and 50 percent in urban areas).

5.1.15 Mission Indradhanush

The government of India’s health mission is known as Indradhanush. Union Health Minister J. P. Nadda introduced it on December 25, 2014. The effort’s goal is to achieve and maintain 90 percent vaccination coverage in India by 2020. Vaccination is available nationwide against eight vaccine-preventable diseases, including Diphtheria, Whooping Cough, Tetanus, Polio, Measles, a severe form of childhood tuberculosis, Hepatitis B, and meningitis and pneumonia caused by Haemophilus influenza type B, as well as Rotavirus diarrhea and Japanese Encephalitis in selected states and districts.

5.2 Indirect policy measures

• Increasing food grain production to ensure food security.

• By supporting the production and availability of nutritionally dense food items, we may endeavor to improve the population’s dietary pattern.

• Increasing the poor’s purchasing power and lowering their susceptibility in order for them to purchase a balanced, nutrition-dense diet.

• Expansion and improvement of the public distribution system

• Increasing student awareness of nutrition through school curricula, etc.

• Food adulteration should be monitored and prevented.

• Initiate more community involvement in nutrition surveillance.

6. Eradicating micronutrient deficiencies: Approaches based on food

The term “hidden hunger” refers to a more subtle sort of shortage produced by consuming inexpensive, satisfying foods that are low in important vitamins and minerals. While the implications of subclinical micronutrient deficiencies are becoming more understood and monitored, they frequently go unreported in the population. This is why vitamin deficits have been dubbed “hidden hunger.” Micronutrient deficits can occur even in places with an adequate food supply to support the population’s energy needs. When people cannot afford to diversify their diets sufficiently with fruits, vegetables, or animal-source foods containing micronutrients, shortages are unavoidable. Micronutrients are vitamins and minerals that humans require in order to boost cellular growth and metabolism. Iron, iodine, and vitamin A deficiency are the most prevalent forms of micronutrient malnutrition with serious public health effects. Other micronutrients have been demonstrated to contribute to illness prevention (e.g., folic acid and calcium) or growth promotion (e.g., zinc) [17].

FAO views food-based initiatives as a sustainable way to address the nutritional needs of population groupings. These are as follows:

1. Supplementation

2. Fortification

3. Bio-fortification

4. Dietary diversification

5. Community-based interventions for micronutrient status improvement

6.1 Supplementation

Supplementation is a technical term that refers to the process of delivering nutrients directly to the target population via syrup or pill. It has the advantage of providing an appropriate amount of a specific nutrient or nutrients in an easily absorbed form and is frequently the quickest option to address deficiency in people or demographic groups diagnosed as insufficient. Supplementation programmes are typically used as a temporary treatment and then phased out in favor of long-term, sustainable food-based interventions like fortification and dietary change, which typically involve increasing food diversity.

6.2 Fortification

By 2024, all rice available at ration shops, rice available in mid-day meals, and rice available through all schemes will be fortified, Prime Minister Narendra Modi declared during his 75th Independence Day address from the Red Fort in New Delhi. The Prime Minister’s declaration is crucial for the nation and represents a forward-thinking strategy, as the government distributes approximately 300,000 tonnes of rice annually through various programmes authorized by the National Food Security Act, 2013. (NFSA). The Centre has allocated 328 lakh tonnes of rice under the NFSA for TPDS (Targeted Public Distribution System), MDM (Mid-day Meal), and ICDS (Integrated Child Development Services). Rice fortification will assist in addressing micronutrient deficiencies or “hidden hunger,” both of which contribute to undernutrition, a type of malnutrition. But before we discuss the benefits of the aforementioned declaration, if done properly, let us first define fortification and why it is necessary to combat malnutrition in India [18]. Food fortification is a cost-effective, scalable, and sustainable worldwide solution that tackles micronutrient deficiency. In October 2016, the Food Safety and Standards Authority of India (FSSAI) operationalized the Food Safety and Standards (Fortification of Foods) Regulations, 2016 to fortify staple foods such as wheat flour and rice (with iron, vitamin B12, and folic acid), milk and edible oil (with vitamins A and D), and double fortified salt (with iodine and iron) in order to address India’s high burden of micronutrient malnutrition. The “+F” symbol has been designated for the purpose of identifying fortified foods. Each package of fortified food shall bear the words “fortified with (fortificant name)” and the +F logo. Additionally, it may have the tagline “Sampoorna Poshan Swasth Jeevan” beneath the emblem, which is optional and not required (Figure 1) [19].

Figure 1.

Food fortification logo used on fortified foods in India in Hindi and English language. [Source: https://fssai.gov.in/knowledge-hub-logos.php?pages=2].

Fortification is the process of supplementing staple foods such as rice, wheat, oil, milk, and salt with essential vitamins and minerals such as iron, iodine, zinc, and vitamins A and D to increase their nutritional content. These nutrients may have been present in the food at the time of manufacture or may have been lost during processing.

6.2.1 Need of food fortification

Micronutrient deficiency or malnutrition, commonly referred to as “hidden hunger,” is a severe health concern. Access to safe and nutritious food is critical, and occasionally, owing to a lack of a balanced diet, a lack of variety in the diet, or food insecurity, individuals do not receive essential micronutrients. Often, significant minerals are lost during food processing as well. One strategy for addressing this issue is the fortification of food. This strategy complements other strategies for improving nutrition, such as diet variety and food supplementation. India suffers from a high rate of micronutrient deficiencies caused by Vitamin A, Iodine, Iron, and Folic Acid, which result in night blindness, goiter, anemia, and a variety of birth abnormalities. According to the National Family Health Survey (NFHS-4), anemia affects 58.4% of children aged 6 to 59 months, 53.1 percent of women of reproductive age, and 35.7 percent of children under the age of five. Fortification is an internationally proven technique that addresses the population’s widespread vitamin deficiencies.

6.2.2 Benefits of food fortification

The benefit-to-cost ratio of food fortification is extremely favorable. According to the Copenhagen Consensus, every rupee spent on fortification results in an economic value of nine rupees. Although the equipment and vitamin and mineral premix require an initial investment, the ultimate cost of fortification is quite inexpensive. Even if all programme costs are passed on to customers, the price rise will be between 1 and 2 percent, which is less than the regular price variance. The following are some of the numerous advantages of food fortification:

• Because staple foods are extensively consumed, nutrients are added to them. Thus, this is an ideal way to simultaneously improve the health of a wide segment of the population.

• It is a safe approach to enhancing people’s nutrition. The addition of micronutrients to food poses no risk to human health. The amount supplied is minimal and considerably below the Recommended Daily Allowances (RDA), and is strictly monitored to ensure safe use.

• It is a cost-effective strategy that does not require individuals to alter their dietary habits or eating patterns. It is a socially and culturally acceptable method of nutrient delivery.

• It has no effect on the food’s properties such as taste, aroma, or texture [20].

In this circumstance, fortification is the most practical option in terms of population access. This is referred to as the fortification of staple foods. The government of India has recognized this truth. This is why standards for five fortified essentials have been released, along with a logo (+F) to distinguish fortified foods: wheat flour, rice, edible oil, milk, and Double Fortified Salt. Recently, regulations for processed meals such as breakfast cereals, buns, rusks, pasta, and noodles were also released. Additionally, in collaboration with Tata Trusts, the Food Fortification Resource Centre (FFRC) has been located at FSSAI under the Ministry of Health and Family Welfare. The Food Fortification Resource Centre (FFRC) is a non-profit organization dedicated to the advancement of food fortification. The FFRC was established as a resource hub to serve as a shared platform for bringing together all major actors in food, nutrition, and health to collaborate on eradicating hidden hunger (Figure 2) [21].

Figure 2.

Diagrammatic representation of food fortified with minerals and vitamins in India. [Source: https://www.insightsonindia.com/wp-content/uploads/2021/08/F.jpg].

6.2.3 Fortified foods

Salt is an excellent medium for iodine fortification and has been effectively used to combat iodine deficiency around the world. The properties of iodine salts used in fortification Salts of iodates and iodides in sodium and potassium are the two chemical forms employed in salt iodization. Fortification levels range between 30 and 200 parts per million. The WHO recommends that, under typical situations where salt is lost at a rate of 20% from manufacturing to household, an additional 20% be lost during cooking prior to consumption. The average person consumes 10 g of salt each day. This method was developed by the National Institute of Nutrition in Hyderabad to address the dual problems of iron and iodine deficiency. Given the widespread consumption of staple cereals, fortification makes sense. Wheat flour is enriched with iron and other minerals in various countries. There have been concerns concerning the bioavailability of iron from wheat atta due to its high phytate (absorption inhibitor) concentration. Certain chemicals, such as Na-Fe-EDTA and perhaps the enzyme phytase, may overcome phytate’s inhibitory effect. The higher expense of this salt may be offset by the fact that it has a higher bioavailability and therefore requires less fortification. Rice is the staple food for more than half of India’s population. Fortification of rice has been attempted by combining fortified extruded grains from rice flour with unfortified rice (Ultra rice). Wheat flour fortification with thiamin, riboflavin, niacin, and iron has been used successfully for a long period of time.

Vitamin A added to wheat flour showed excellent stability in studies conducted in the United States. In the Philippines and Sri Lanka, efficacy trials on wheat flour fortified with vitamin A and wheat flour fortified with iron are presently underway. Since late 1997, the United States and Canada have required wheat to be fortified with folic acid. In South America, in Chile and Costa Rica, fortification of wheat flour with folic acid has proved helpful in minimizing neural tube abnormalities. Zinc sulphate fortification of wheat flour was observed to decrease iron absorption; however, zinc oxide had no such inhibitory impact. Around 2.2 million tonnes of wheat flour are fortified in India. Since 2000, a few states, including Madhya Pradesh and Gujarat, and a few districts in West Bengal have fortified wheat flour. Numerous countries have enriched cereal products with folic acid to help minimize the prevalence of neural tube abnormalities. Fortification with folic acid, maybe in conjunction with vitamin B12, may also help reduce serum homocysteine levels. Because vitamin A is fat soluble, fats and oils may be useful carriers for it. In India and Pakistan, vegetable ghee (hydrogenated vegetable oil) is fortified. Margarine is vitamin A-fortified in approximately 24 countries, including Brazil, Chile, Colombia, Mexico, and Indonesia. Brazil is conducting trials on vitamin A-fortified soybean oil. Edible oils enriched with vitamin A and D are sold through market channels in India’s Madhya Pradesh and Rajasthan regions. In Venezuela, vitamin A, thiamin, riboflavin, niacin, and iron are added to precooked corn flour. In countries such as Mexico, where corn is the predominant food, fortification of maize with micronutrients is being studied. Maize flour is fortified with iron, zinc, and a vitamin B complex. Maize flour was enriched with soy protein and examined for its ability to aid in the development of the brain in rats. Additionally, research is being conducted to strengthen corn tortillas on a home and industrial scale [22].

6.3 Biofortification

Biofortification is a method that increases the nutrient density of food crops through conventional plant breeding, enhanced agronomic practises, and/or current biotechnology without sacrificing any consumer or farmer-preferred trait [23]. It is acknowledged as a nutrition-sensitive agriculture strategy that has the potential to significantly minimize vitamin and mineral deficiencies [24, 25, 26]. Zinc biofortification of beans, cowpeas, and pearl millet, as well as provitamin A carotenoid biofortification of cassava, maize, rice, and sweet potato, are all ongoing and at various stages of development. The biological process by which biofortified crops improve nutritional status is straightforward: biofortified crops are more nutrient-dense than conventional crops. Individuals will consume [27] and absorb [28] more micronutrients by eating biofortified crops than by eating the same amount of non-biofortified crops, assuming comparable micronutrient bioavailability [29] and retention [30] following heating or processing and storage. Consumption of biofortified staple crops can increase micronutrient intake in communities with a diet deficient in these nutrients.

6.4 Dietary diversification

Increasing dietary diversity is one of the most effective strategies for preventing hidden hunger on a long-term basis [31]. Even when socioeconomic factors are controlled for, dietary diversity is related to improved child nutritional outcomes [32]. In the long run, dietary diversification promotes a balanced and appropriate intake of macronutrients (carbohydrates, lipids, and protein); necessary micronutrients; and additional food-derived compounds such as dietary fiber. The majority of people may receive adequate nutrition from a mix of cereals, legumes, fruits, vegetables, and animal-source foods. Certain populations, such as pregnant women, may require supplements [33]. Effective solutions for promoting dietary diversity include food-based tactics such as home gardening and educating people about proper infant and young child feeding practises, food preparation, and nutrient-saving storage and preservation methods. Several low-cost, food-based approaches for improving micronutrient status can be advocated at the community level. Culturally relevant dietary adjustments should be established to assist individuals in identifying concrete measures that can increase both food supply and micronutrient absorption. This information must be distributed to the public using conventional methods of communication.

6.5 Community-based interventions for micronutrient status improvement

• Promoting exclusive breastfeeding for newborns up to 6 months of age and continuing breastfeeding for older infants

• Identifying and promoting the use of culturally suitable micronutrient-dense weaning foods.

• Identifying and promoting the use of traditional green-leafed vegetables and fruits to increase dietary diversity.

• Micronutrient preservation in fruits and vegetables by solar drying or canning processes.

• Promoting kitchen gardening and small animal husbandry.

• Increasing year-round access to micronutrient-dense foods.

Numerous issues confront developing nations, including health care, education, sanitation, water supply, and housing. As a result, focusing exclusively on a specific vitamin shortfall or technique will not be the most effective way to reduce micronutrient deficiencies. Complementary public health measures that can help minimize micronutrient deficiency include deworming, malaria prevention, increased access to safe drinking water and sanitation, and childhood immunization. Successful plans address all of these issues holistically and cooperatively, with full political commitment.

7. Conclusions

India ranks 102 out of 116 countries in the Global Hunger Index 2021. While eliminating malnutrition in India would be tough, it is not impossible. Achieving a sustainable end to hunger needs prompt action. Over 2 billion people, or one-third of the world’s population, are malnourished. Malnutrition and micronutrient deficiencies have a significant impact on child and mother mortality, mental impairment, and workforce productivity. The current paradigm of seeing food security only through the lens of energy security must change. Simply pumping grains to satisfy hunger will not provide nutrition and health. The objective should be to ensure that the diet is balanced in terms of macro-and micronutrients. To maintain MN security, laboratory, clinical, and community-based (operations) studies are required. A balanced approach of food fortification, dietary diversity, biofortification, and supplementation aided in the early detection and treatment of clinical deficiencies. A fortification program’s performance can be judged in terms of its public health effects and sustainability. The mechanism for extension must be robust. Support from the media is critical for raising awareness and promoting compliance. Large-scale initiatives including food fortification, dietary diversity, biofortification, and micronutrient supplementation are making significant headway in lowering the morbidity and mortality associated with micronutrient deficiencies. Current programs must be enhanced and work on their effective implementation must be done to ensure that they reach the poor. While targeted legislation must be enacted to rein in the proliferation of schemes, the judiciary must be an active player in the debate on nutritional justice for the people.

Acknowledgments

We pay our profound sense of gratitude to Dr. Satish Kumar Yadav for his assistance, encouragement, and insightful advice throughout in constructing this book chapter. We also apologize for not citing the research papers of all the authors that helped me in better understanding this topic.

Conflict of interest

Authors declare no conflict of interest.