Context

• The National Family Health Survey-5 (NFHS-5) found that more than half of women and approximately two-thirds of young children are anaemic.
• Double-Fortified Salt (DFS), containing iodine and iron, has been proposed as a convenient solution.
• However, convenience does not guarantee effectiveness. Excessive salt consumption, risks associated with iron accumulation and the multiple causes of anaemia raise questions about the suitability of universal fortification.

The Contradiction Between Iron Fortification and Salt Reduction

• The effectiveness of DFS depends on regular salt consumption.
• However, Indians consume approximately twice the WHO-recommended five grams of salt per day.
• Nearly one in three Indian adults suffers from hypertension, while India's National Non-Communicable Disease (NCD) action plan aims for a 30% reduction in salt intake.
• DFS potentially contradicts these objectives because its delivery mechanism depends on continued salt consumption.
• Moreover, salt intake varies across population groups. Adult men generally consume more salt than women and children, meaning that those with greater iron requirements may receive smaller quantities.
• Thus, universal salt fortification may create an imbalance between nutritional requirements and actual iron consumption.

Iron as a Nutrient

• Health Risks Associated with Excessive Iron
  • International studies have raised concerns about indiscriminate iron supplementation.
  • The 2006 Pemba trial in Tanzania associated iron and folic acid supplementation among children in a malaria-endemic setting with increased hospitalisations and deaths.
  • A 2015 Kenyan trial found that iron-fortified foods altered infants' gut microbiota towards pathogenic bacteria and increased diarrhoeal infections.
  • These findings are relevant to India because several regions face malaria and inadequate sanitation.
• Haemoglobinopathies and Iron Overload
  • India has millions of beta-thalassaemia carriers, while sickle cell disease is concentrated in several tribal regions.
  • People with thalassaemia, particularly those receiving repeated blood transfusions, are vulnerable to iron overload.
  • Screening everyone before introducing fortified salt is impractical, especially considering that the Public Distribution System (PDS) reaches approximately 800 million people.
• The Problem of Cumulative Iron Exposure
  • Fortified rice is already distributed through the PDS, PM POSHAN and ICDS, while iron-folic acid tablets reach several population groups.
  • Introducing DFS could expose children and adolescents to iron through multiple government programmes simultaneously.
  • The absence of comprehensive research on cumulative iron intake makes a nationwide rollout premature.
• Iron Absorption and Dietary Limitations
  • DFS generally contains non-haem iron, whose absorption depends on dietary composition.
  • Phytates in cereals, millets and pulses, polyphenols in tea and coffee, and calcium in milk inhibit iron absorption.
  • Since fortified salt is consumed with food, much of its iron may remain unabsorbed. Furthermore, infections and inflammation increase hepcidin, a hormone that restricts iron absorption.
  • Consequently, fortification may be least effective among populations with high infection burdens.

Iron Deficiency Only in Half of Anaemia Cases

• Multiple Causes of Anaemia
  • India's Comprehensive National Nutrition Survey (2016–18) also found that iron deficiency explained only part of anaemia among children and adolescents.
  • Other important causes include:
    • Folate and vitamin B12 deficiencies, particularly among populations with limited dietary diversity.
    • Chronic inflammation, recurrent infections, malaria and hookworm.
    • Poor sanitation and inadequate hygiene.
    • Haemoglobinopathies, including thalassaemia and sickle cell disease.
    • Protein and vitamin A deficiencies.
    • Early marriage, pregnancy, adolescent undernutrition and menstrual blood loss.
  • Therefore, treating anaemia exclusively through iron fortification risks overlooking its underlying causes.

Lessons and Policy Recommendations for India

• Lessons from Peru
  • Peru achieved a double-digit reduction in child anaemia during the early 2010s through political prioritisation, individual tracking of children, iron supplementation, micronutrient powders and cash transfers.
  • However, progress reversed when COVID-19 disrupted healthcare delivery.
  • This demonstrates the importance of sustained public health services and institutional accountability.
• Lessons from Vietnam
  • Vietnam reduced anaemia among women through weekly iron-folic acid supplementation, deworming and fortified fish sauce containing NaFeEDTA, an iron compound better absorbed in phytate-rich diets.
  • Rising incomes and greater dietary diversity complemented these interventions.
  • Its experience demonstrates that fortification must be adapted to local dietary patterns and supported by broader nutritional measures.
• Policy Recommendations for India
  • India should avoid an immediate nationwide rollout of DFS and instead:
    • Conduct monitored district-level pilot programmes.
    • Measure haemoglobin, ferritin and inflammation markers.
    • Assess cumulative iron exposure across government programmes.
    • Monitor risks in malaria-endemic and haemoglobinopathy-prone regions.
    • Adopt better-absorbed iron forms and targeted fortification.
    • Strengthen diagnostics, deworming, malaria prevention and sanitation.
    • Improve affordable access to diverse and nutritious foods.

Conclusion

• India's anaemia burden requires urgent intervention, but universal iron fortification through DFS may create health risks and conflict with salt-reduction objectives.
• The experiences of Peru and Vietnam demonstrate that successful anaemia reduction requires integrated nutrition programmes, targeted supplementation and effective healthcare delivery.
• India must adopt an evidence-based strategy that addresses nutritional deficiencies, infections, sanitation and socioeconomic inequalities.
• Ultimately, anaemia is a multidimensional public health challenge, not merely a nutritional deficiency that can be corrected through an additive in the salt bottle.