According to a UNICEF report published in 2016, “Nearly half of all children in Pakistan are chronically malnourished (stunted) while 11 percent are acutely malnourished (wasted)… In the province of Punjab, while stunting is declining, wasting is increasing in more than two-thirds of the districts at an alarming rate.”Many other media and research reports in the past year, paint a similarly dire picture: the fact is, Pakistan is suffering a malnutrition epidemic of epic proportions. Yet despite knowing there is an issue, we remain far from finding a solution

As with any challenge, the first step is identifying the root causes of the problem. Simply stated, malnutrition means poor nutrition, and it occurs when one’s diet lacks essential nutrients. While malnutrition can affect anyone, young children (and pregnant women) are especially prone to falling victim. Moreover, malnutrition often occurs over long periods of time, which sometimes makes it difficult to spot, and therefore a particularly insidious ailment. Common symptoms of malnutrition include: weight loss, tiredness and lethargy, alterations in mood, loss of appetite, disinterest in food and/or fluids, and a general ‘slowing down’, e.g. taking a long time to understand and answer questions. Malnutrition can also lead to increased risk of illness and infection, slower wound healing, low mood, increased risk of falls, difficulty keeping warm, reduced energy levels, reduced muscle strength, and potential hospital admissions.

According to a lady health worker at a local hospital, “Every month, 20 to 25 new children are registered in the OTP (Outpatient Treatment Programme). This is a small BHU (Bed Hospital Unit) and that many new cases of malnutrition every week is not a good sign.” She went on to add that they try to help young mothers and children by supplementing their diets with minerals and multi-vitamins, and by giving nutrition advice for taking appropriate and adequate home-based food. “If a child is ‘severely, acutely malnourished’, we give him or her ‘Ready to Use Therapeutic Food’ (RUTF), which is used as treatment for such children internationally,” she said.

According to a World Health Organisation (WHO) report, ‘Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers’, ‘Severe Acute Malnutrition’ (SAM) is a major public health problem that affects around 20 million children across the developing world. RUTF – which is basically fortified food – has widely been accepted as the main solution, with the same formula used in most RUTFs, as well as other diets used to overcome malnutrition. Food fortification dates back to the 1920s, when adding of potassium iodide to salt as a means of preventing goitre was done in Switzerland and the United States.

According to Anne Peterson, Assistant Administrator, USAID Bureau for Global Health, “More than two billion people – mostly women and children – still suffer from micronutrient deficiencies.”She adds, “Yet, experience proves that well-designed food fortification programmes can not only dramatically improve health, they can reduce stifling national healthcare costs and boost intellectual potential and domestic productivity.”

Food fortification is designed to build up micronutrients stores in people over time and without risk, so it is a safe and efficient way of improving nutrition without making people change their eating habits. With large-scale food fortification (LSFF), regularly consumed staple foods are used to improve the micronutrient intake of adults and children. Micronutrients such as iodine, iron, zinc, calcium, Vitamin A, B-group vitamins and Vitamin D are commonly added in combinations that do not alter the appearance, taste, texture or smell of the food. This means that fortified food will not affect recipes or methods of cooking. And because many of the most vulnerable people in the world eat staple foods, food fortification has the ability to reach communities and individuals that other interventions cannot.

Food fortification has also been shown to be substantially cheaper than treatment or supplementation. For example in Jordan, the cost of fortification is 0.03 dinars (approx. US$0.04) per capita per year, whereas the cost of treating anaemia is 4.9 dinars (approx. US$7.00) per capita per year. Iron food fortification is also considered more cost effective and economically more attractive than iron supplementation. There are many iron compounds available to be used in iron fortification. Cereals represent a target food group to iron fortification programmes due to high consumption and in-vitro studies can be useful to estimate the relative iron bio-availability in large number of products in short time and with a low cost. Wheat flour baked into bread or not was the main product tested in in-vitro bioavailability studies and ferrous sulfate was the principal iron compound used in the fortification studies.

Furthermore, fortified foods contribute to an increase in iron intake which according to a study published in the Journal of Nutrition –‘Reversing Productivity Losses in Iron Deficiency: The Economic Case’ by Joseph M Hunt –and conducted in India, Indonesia, and Philippines, has shown to lead to an improvement in productivity with an increase in wages.“Food fortification is a cost-effective health intervention that works,” Sally Stansfield, Acting Director, Vaccines and Infectious Diseases for the Bill & Melinda Gates Foundation, adding that, “Correcting vitamin A and iron deficiencies alone can help reduce maternal deaths by 20%, decrease child mortality by at least 23% and increase work capacity by up to 15%.” In the early 1990s, the work productivity of 80 iron-deficient women was studied at a cotton mill in Beijing, China. Their work pace was determined by a machine and was constant throughout the study. Women who were treated with iron were able to perform their work with less cardiovascular stress and less exertion, determining the positive effects of iron fortification.

All the research points to a single conclusion: that food fortification is the best way to significantly benefit the well being of large segments of the population. In 1994, the World Bank said about fortification, “No other technology offers as large an opportunity to improve lives at such low cost and in such a short time.”Today, there are hundreds of thousands of Pakistanis who are suffering from this secret epidemic of Hidden Hunger. And while there may be other cures, including micronutrient supplements, deworming and micronutrient fortification, food fortification remains the single most effective and accepted solution. Given the size and nature of the problem, we need a massive food fortification campaign on a war footing, if we are serious about changing the current abysmal state of malnutrition in Pakistan.


The writer is a Consultant Dietitian at National Hospital & Medical Centre.