Background
Double-fortified salt (DFS): Common salt fortified with both iodine and iron to address micronutrient deficiencies through regular consumption.
Anaemia burden: NFHS-5 found more than half of Indian women and around two-thirds of young children anaemic.
Policy rationale: Salt is consumed across households, making it a convenient vehicle for delivering iron. However, convenience does not establish effectiveness.
Features / Concerns
Conflict with salt reduction targets
Indians consume nearly twice the WHO-recommended 5 grams of salt per day.
Around one-third of adults have hypertension.
India’s NCD action plan aims to reduce salt consumption by 30%, creating a conflict between salt reduction and DFS delivery.
Unequal consumption patterns
Adult men consume more salt, while women and young children consume less.
Consequently, vulnerable groups with higher iron requirements may receive inadequate iron through DFS.
Poor iron absorption
DFS contains non-haem iron, which is less readily absorbed by the body.
Phytates in cereals and pulses, polyphenols in tea and coffee, and calcium in milk further reduce absorption.
Impact of infections
During infection and inflammation, the hormone hepcidin restricts iron absorption.
Thus, iron fortification may be least effective in populations facing high infectious disease burdens.
Risk of iron overload
The human body has no regulated mechanism to eliminate excess iron.
Excess accumulation can cause oxidative stress and is associated with metabolic complications.
People with beta-thalassaemia, particularly those receiving repeated blood transfusions, face additional risks of iron overload. Sickle cell disease is also prevalent in several tribal regions.
Challenges in universal screening
The PDS reaches approximately 800 million beneficiaries, making individual screening for inherited blood disorders before DFS distribution difficult.
Overlapping fortification programmes:
Fortified rice is already distributed through PDS, PM POSHAN and ICDS.
This operates alongside iron supplementation programmes without adequate assessment of cumulative iron exposure.
Challenges
Multifactorial nature of anaemia
Anaemia is not exclusively caused by iron deficiency.
Globally, around half of anaemia cases are attributable to iron deficiency.
India’s Comprehensive National Nutrition Survey (2016–18) also found that iron deficiency explained only a part of anaemia among children and adolescents.
Multiple underlying causes
Nutritional deficiencies: Folate, vitamin B12, protein and vitamin A deficiencies.
Infections: Malaria, hookworm, chronic inflammation and poor sanitation.
Genetic factors: Haemoglobinopathies such as beta-thalassaemia and sickle cell disease.
Other factors: Early marriage, adolescent pregnancy and menstrual blood loss.
Limitations of Anaemia Mukt Bharat
The revised 7x7x7 strategy continues to rely heavily on iron-folic acid supplementation.
Irregular consumption and poor compliance limit its effectiveness.
Evidence from international experiences
Tanzania (Pemba trial, 2006): Iron and folic acid supplementation among children in a malaria-endemic region was associated with increased hospitalisations and deaths.
Kenya (2015): Iron-fortified foods altered infants’ gut microbiota towards potentially harmful bacteria and increased diarrhoeal episodes.
Peru: Child anaemia declined substantially through beneficiary tracking, cash transfers and regional accountability, although COVID-19 disrupted progress.
Vietnam: Anaemia among women declined through weekly iron-folic acid supplementation, deworming and fortified fish sauce containing better-absorbed NaFeEDTA iron, alongside improvements in income and dietary diversity.
Implementation challenges
Supervised clinical trials may not reflect household cooking losses, variable consumption and uneven iron intake.
Affordable access to eggs, dairy, green vegetables and millets remains limited for many households.
Deworming, malaria control and sanitation receive inadequate attention in anaemia interventions.
Way Forward
District-level pilot projects: The Health Ministry should undertake monitored district pilots before national expansion, particularly in malaria-endemic and haemoglobinopathy-prone regions.
Scientific monitoring: Assess haemoglobin, ferritin, inflammation and total iron exposure to determine actual health outcomes and risks.
Targeted fortification: Prioritise vulnerable and iron-deficient populations instead of adopting universal fortification. Use scientifically validated, better-absorbed iron compounds.
Strengthening diagnostics: Expand screening to identify different causes of anaemia, including nutritional deficiencies, infections and inherited blood disorders.
Diversified nutrition: Improve affordability and accessibility of eggs, dairy products, green vegetables, millets and other nutrient-rich foods.
Conclusion
Anaemia is a multifactorial public health challenge requiring a comprehensive, evidence-based and targeted response. Double-fortified salt may offer a convenient delivery mechanism, but its effectiveness and safety need further assessment. India should prioritise district-level evidence, nutritional diversity, better diagnostics and control of infections before considering nationwide expansion.
