If I am from a poor family and my mother did not eat nutritious food when she was pregnant with me; there are good chances that I will be suffering from stunting or wasting. Over 46 percent of Pakistan’s children suffer from malnutrition, the third highest number in the world. It doesn’t stop there. I then have greater chances that I may die before the age of 5 (over 45 percent of deaths below age of 5 are due to malnutrition) and by the time I am an adult, malnutrition will have affected my overall productivity and income potential. My lifetime income may decline by as much as 10 percent.
The first 1000 days of a child’s life influences the rest of their lives. The deficiency in micro-nutrients impairs a child’s physical, emotional and mental development and the damage done in the initial years of a child’s life, translates into a huge economic burden for the country through reduced and lost productivity as well as increased health care costs. A UN study estimates that Pakistan loses 2-3% of its GDP due to malnutrition. The National Nutrition Survey last conducted by the Government of Pakistan in 2011, also showed that 17% of children and 45% of females were iron deficient and 20 percent of the latter had severe iodine deficiency. The same report also found that 58 percent of Pakistan’s households were food insecure suffering from severe hunger.
One of the easiest ways for governments to prevent malnutrition is to have specific programs in place to address this. Interventions currently undertaken include emphasis on exclusive breast feeding till the baby is 6 months, micro-nutrients through supplements and food fortification. Fortification of foods is one of the most cost-effective ways to reduce malnutrition – simply fortify staple foods such as flour, cooking oil and salt with necessary nutrients. Fortified foods when consumed on a regular basis, maintain body stores of nutrients better in the long run than supplements.
This is especially important for children growing up who need a consistent supply of micro-nutrients to maintain growth and for pregnant and lactating women who need good levels of nutrients stored in their bodies.
Developed countries suffered from rickets (which leads to skeletol malformations) well into the 20th century, until it was discovered that the introduction of vitamin D into milk, food and juices helped to reduce it. A similar situation existed with goiter till the understanding that the addition of iodine into table salt helps to remove it. In the USA, since 1998, folic acid fortification is mandatory for enriched grain products, since studies have shown that it reduces by one-third, occurrences of neural tube defects in newborns.
Fortification can be started at a targeted or household level or at the general population level. Fortification at the targeted level has to focus on vulnerable groups; ensuring the availability of nutritionally fortified complementary foods for children between 6 months to 5 years and women of childbearing ages, this includes fortified staple foods as well as diary and other products fortified with vitamin D. Many projects have been started over the decades - on and off - by donor agencies and the government.
In the long run, universal fortification is more effective as it is undertaken in foods that are widely consumed; it is most easily done through legislation and make it binding for industries to fortify the products. Pakistan mandated by legislation in 1965, that all edible oils should be fortified with vitamin A. Post the 18th Amendment this law has been retained in the provincial food laws in all provinces. This approach would also be effective with salt iodization or wheat flour fortification with iron and folate.
Currently, no provincial legislation is in place for wheat flour fortification and only Sindh has legislated for the compulsory iodization of salt; Khyber Pakhtunkhwa and Baluchistan have both mandated salt iodization These are by far the most cost-effective nutritional interventions, particularly when done so by medium- to large-scale industries. However, once legislation has been passed it then requires government enforcement; which currently is poor and ineffective; consequentially most edible oil companies do not fortify, despite legislation.
There is much evidence to suggest that wheat flour fortification can improve the general populations iron deficiency. Per capita wheat consumption in Pakistan is among the highest in the world, which makes wheat an ideal staple to fortify for widespread benefits. The UK development agency, UKAID launched in September 2016, a $48m food fortification program, where nutrients – folic acid, vitamins A and D - would be added directly into staple food consumed in Pakistan this will include wheat flour, edible oils and ghee at source in mills and factories. They are working with over 1000 mills and over 100 oil producers directly. USAID have another similar program where they are providing nutrients premixes at subsidized rates to mills.
A study conducted by Pakistan Food Fortification Study team under PATH in April 2014, showed that the estimated cost of wheat flour fortification coverage to 85% of urban homes and 65% of rural homes would only cost $115m over 5 years and similar coverage of fortification of edible oils is only $17m over 5 years. In 2015, Pakistan’s Director Nutrition explained in a health meeting that it only cost Rs5 to add various vitamins to 20kg of flour, that would help iodine and other deficiencies. The government needs to make tackling malnutrition a priority and plan accordingly, because it’s not as much paucity of funds as it is a question of prioritization.
The writer is managing editor for Global Village Space magazine. A graduate of Columbia University.