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Genetic biofortification More recently, genetic biofortification, which involves enhancing the nutrition content of crops through breeding, has been promoted as a new approach to fortification, and is increasingly seen as an alternative, effective means of delivering specific micronutrients along with food. A lot of work has been done on biofortification by HarvestPlus, a CGIAR (Consultative Group for International Agricultural Research) programme.¹ Golden Rice, a variety of rice enriched with vitamin A, is the most wellknown case of a biofortified crop. Proponents of Golden Rice argue that it has the potential to be a complementary source of vitamin A, and could be a cost-effective means of reducing vitamin A deficiency (Dawe, Robertson, and Unnevehr, 2002; Stein, Sachdev, and Qaim, 2008). On the other hand, critics have argued that the levels of β-Carotene in Golden Rice are too low and do not make sufficient contribution to vitamin A requirements (Grusak, 2005). There are also economic issues involved in the adoption of Golden Rice. Its cost-effectiveness depends on its widespread adoption across Asia.
¹ For further details, see Bouis (1999, 2000), Carvalho and Vasconcelos (2013), HarvestPlus (2014), Mayer, Pfeiffer, and Beyer (2008), Meenakshi et al. (2010), Saltzman et al. (2013), Smith (2013), and Stein et al. (2008), and www.harvestplus.org.
68 Ending Malnutrition But a single seed strain is not going to be suitable for the diverse agroecological conditions in which rice is produced across Asia.
Golden Rice has met with great resistance from research and civil society groups opposed to genetically modified seeds. Very few Asian countries have legal frameworks in place for testing and introduction of transgenic food crops. This has resulted in long delays in the widespread adoption of Golden Rice even to deal with vitamin A deficiencies.
While Golden Rice has faced obstacles due to being a genetically modified crop, several other biofortified crops have been developed through conventional open pollination and other plant-breeding methods. Some of these have already been released for production while many others are at different stages of development. Rich in β-Carotene, the Orange Sweet Potato has been successfully introduced in Mozambique and Uganda to deal with vitamin A deficiencies. Biofortified Orange Sweet Potato accounts for about 56 percent of the area cultivated with sweet potato in Mozambique, and about 44 percent of the area cultivated with sweet potato in Uganda. HarvestPlus, International Crops Research Institute for the Semi-Arid Tropics, various agricultural universities in India, and seed companies are partnering to produce crossbreeds of high-yielding pearlt millet that are rich in iron and zinc. A variety rich in iron, ICTP 8203-Fe, was released in India in 2013, and is being tested in Niger. In Bangladesh, sweet potato, tomato, pumpkin, mango, and guava enriched with vitamin A have been developed. The Bangladesh Rice Research Institute has developed rice varieties biofortified with zinc, which have already been released for production by farmers.² In March 2015, the Pakistan Agriculture Research Council released zinc-fortified varieties of wheat developed in collaboration with HarvestPlus.³ There is no independent research yet on the impact of the adoption of biofortified crops on nutritional outcomes of the population at large. A few studies, all done with the support of agencies involved in the development of biofortified crops, have shown that introduction of β-Carotene-rich Orange Sweet Potato in Mozambique and Uganda has lowered the prevalence of vitamin A deficiency among children and women who consumed the biofortified produce (Hotz et al., 2012a, 2012b). More research and evidence are needed to assess the cost-effectiveness, acceptability, and impact of biofortified crops on the overall nutrition of populations. The incorporation of biofortified crops in the agricultural and nutrition strategies of countries will require addressing several policy issues relating to the ownership and control of the technology, the cost of seeds to farmers, cost at which other complementary inputs (like fertilizers, pesticides, and water) needed for ² www.harvestplus.org/sites/default/files/Bangladesh%20Statement%20at%20ICN2.pdf.
Fortification and Supplementation 69 crop production are made available to farmers, their suitability to the agroecological context, and the nutritional outcomes of their adoption.
Supplementation The June 2013 issue of The Lancet, as part of its Maternal and Child Nutrition Series, argued that nutritional supplements provide a rapid and cost-effective means of dealing with micronutrient deficiencies.⁴ In the issue, Bhutta et al. (2013) argued that, unlike conventional strategies based on breastfeeding and provision of nutritious foods through lunch or noon-meal schemes and other social protection programmes targeting pregnant women, lactating women, and children, considerable evidence based on randomized control trials show the benefits of supplements in reducing the incidence of stunting.
Their detailed analysis of quantitative evidence on the effects of supplements on nutritional outcomes suggested that a total investment of US$ 9.6 billion on ten nutrition-related interventions in thirty-four focus countries would reduce mortality among children aged less than 5 years by about 15 percent.
This finding was used to make the argument that a supplementation-based strategy to deal with maternal and child malnutrition is promisingly costeffective.
While supplementation-led interventions may be appropriate in some contexts, especially in the short term, or in the face of emergencies such as conflicts or natural disasters, exclusive focus on micronutrient supplementation distracts from addressing the deeper causes of malnutrition, and undermines the development of sustainable long-term solutions to micronutrient deficiencies. The case for a supplement-led strategy for dealing with micronutrient deficiencies is problematic on various grounds.
As pointed out by Pinstrup-Andersen (2013) in a comment on Maternal and Child Nutrition series papers in The Lancet, the fixation on randomized control trials as the only legitimate evidence is misplaced as it is impossible to apply such methods to testing food systems.
An exclusive focus on micronutrient supplementation without addressing the fundamental causes of malnutrition, particularly those related to the food system, can be extremely problematic and render nutrition policies ineffective. In most cases, micronutrient supplementation cannot be very effective without adequate food. Providing micronutrients without adequate food can even have negative effects.
Also, while the beneficial effects of some forms of supplementation – for example, iron supplementation among pregnant women – are well established, the evidence is much less clear in many cases. For example, the efficacy of maternal and neonatal vitamin A supplementation has been ⁴ www.thelancet.com/series/maternal-and-child-nutrition.
70 Ending Malnutrition questioned, and the recent recommendations for inclusion of early neonatal vitamin A supplementation in nutrition programmes have been severely criticized.⁵ Additionally, focusing on supplements often favours reliance on and involvement of the biochemical and pharmaceutical industries, which would develop a vested interest in discouraging alternative long-term options for addressing malnutrition on a more affordable and sustainable basis. If the supplements are produced domestically – which may be better for the national economy – time and resources will be needed to establish local manufacturing systems, distribution systems, and regulatory structures. However, such efforts to develop national capacities are likely to be thwarted by international trade, investment, and intellectual property rights agreements and regulations driven by powerful corporate lobbies.
In view of these problems, the role of supplements is best limited to dealing with specific, short-term requirements such as providing iron and folic acid supplements during the period of pregnancy.
Ending malnutrition: Diet-based or supplementation-led?
In the recent policy literature on nutrition, a distinction is often made between nutrition-specific interventions and nutrition-sensitive interventions. Nutrition-specific interventions are based on different forms of supplementation. Addressing specific forms of malnutrition is their primary objective. Nutrition-sensitive interventions, on the other hand, are multisectoral interventions with varied primary objectives – for example, alleviation of poverty, development of agriculture, improving educational attainments, or improving access to water, sanitation, and health facilities – that are designed so as to result in improved nutrition as a side effect.
UNICEF (1990) developed a conceptual framework on causes of malnutrition in 1990. The framework identified the basic causes (the socioeconomic and political contexts), underlying causes (food insecurity, inadequate health care, unhealthy household environment), and immediate causes (inadequate dietary intake and diseases) of malnutrition, and was used to develop UNICEF’s multisectoral strategy on malnutrition among women and children. This was one of the first attempts to conceptualize multisectoral linkages of nutrition, and has been adapted and widely used to guide the nutrition strategies of many agencies worldwide (see chapter 6).
More recently, the Scaling Up Nutrition (SUN) movement’s Framework for Action paper called for combining the scaling up of nutrition-specific interventions with broader multisectoral approaches (SUN, 2009). This approach has been widely accepted by many international agencies as well ⁵ See, for example, Haider and Bhutta (2015) and Mason et al. (2015).
Fortification and Supplementation 71 as countries. The World Bank’s paper on multisectoral approaches towards nutrition builds upon the SUN Framework for Action to develop guidelines for making the World Bank’s interventions in various sectors nutritionsensitive (Alderman et al., 2013). USAID’s 2014 Multisectoral Nutrition Strategy identifies scaling up “effective, integrated nutrition-specific and sensitive interventions, programs, and systems across humanitarian and development contexts” as its strategic objective (USAID, 2014). DFID’s position paper on undernutrition talks of a two-pronged strategy to deal with child stunting: first, scaling up nutrition specific interventions, and second, to use nutrition-sensitive interventions to deal with residual child stunting that cannot be eradicated merely by nutrition-specific interventions (DFID, 2011).
Although recognizing the complementary role of nutrition-sensitive multisectoral interventions, most of these recent approaches give primacy to nutrition-specific interventions. Concrete, actionable strategies with precise estimates of costs are presented for nutrition-specific interventions. On the other hand, nutrition-sensitive interventions in other areas, including in food systems, are presented as complementary strategies, typically without specific budgetary commitments. This misplaced emphasis on supplementation needs to be corrected.
It is important that nutrition strategies are based on the centrality of food systems in providing nutrition. Good nutrition requires, first and foremost, ensuring availability of and access to more diverse diets and nutritious foods. In most cases, micronutrients can be delivered cost-effectively and sustainably through diverse and adequately nutritious diets. This requires that food systems are developed to make available a diverse variety of foods;
that social protection systems are put in place to ensure everyone has access to adequate and nutritious foods; that access to safe water, and improved sanitation and basic health care, are available for all.
Where necessary, and where cost-effective technologies are easily available, the nutrient content of food may be enhanced through fortification.
Certain types of regulated fortification – salt iodization, for example – are an essential component of the strategy to make food systems nutritionsensitive. Regulated fortification can be used for specific problems such as iodine deficiency, for which solutions are easily available and impacts well established. Greater evidence is needed to assess the cost implications, efficacy and impact of new approaches like genetic biofortification.
Supplementation may also be necessary at times as an urgent short-term solution when specific categories of people (for example, pregnant women and infants) are severely nutrient-deficient and immediate interventions are needed. Some micronutrients, such as iron and folic acid, are commonly delivered to pregnant women through supplements in both rich and poor countries. Supplementation can be used selectively in such contexts, though 72 Ending Malnutrition these have to be accompanied with simultaneous interventions to ensure adequate food intake.
Box 4.2 ICN2 Framework for Action: Selective use of fortification and supplementation The ICN2 Framework for Action provides a useful guide in this respect. With a clear focus on developing “sustainable food systems promoting healthy diets”, the Framework for Action suggests selective use of fortification and supplementation for dealing with anaemia among pregnant and menstruating women and young children, and zinc supplementation to prevent diarrhoea among children.
Recommended actions to address anaemia in women of reproductive age
• Recommendation 42: Improve intake of micronutrients through consumption of nutrient-dense foods, especially foods rich in iron, where necessary, through fortification and supplementation strategies, and promote healthy and diversified diets.
• Recommendation 43: Provide daily iron and folic acid and other micronutrient supplementation to pregnant women as part of antenatal care; and intermittent iron and folic acid supplementation to menstruating women where the prevalence of anaemia is 20% or higher, and deworming, where appropriate.
Recommended actions in the health services to improve nutrition
• Recommendation 47: Provide zinc supplementation to reduce the duration and severity of diarrhoea, and to prevent subsequent episodes in children.
• Recommendation 48: Provide iron and, among others, vitamin A supplementation for pre-school children to reduce the risk of anaemia.