Experts question iron-fortified salt as a fix for India's anaemia burden

The brief in 7 cards

1. Note1 / 7

   WHY IN NEWS?

   • A proposed expansion of double-fortified salt (DFS), with iron and iodine, has triggered debate among public health experts.
   • In November 2026, the public health collective Health for All questioned the scientific basis and safety of universal iron fortification.
   • In February 2026, the Centre temporarily stopped rice fortification under the PMGKAY and allied schemes. An IIT Kharagpur study found nutrients degraded during the two to three years rice stays in storage.
   • Experts also ask whether finger-prick blood tests in NFHS surveys overestimate anaemia.
   • The government is running the Diet and Biomarkers Survey in India (DABS-I) for a fuller picture of diet and nutrient status.
2. Note2 / 7

   HOW BIG IS THE PROBLEM, AND WHY?

   NFHS-5 (2019-21) found anaemia in 67.1% of children aged 6–59 months, 57% of women and 52.2% of pregnant women. The table sets out its main causes.

   Cause	How it leads to anaemia
   Micronutrient deficiency	The Comprehensive National Nutrition Survey (2016-18) found iron, vitamin B12 and folate deficiencies in children and adolescents
   Infections	Malaria, hookworm and tuberculosis destroy red cells, cause blood loss or create chronic inflammation
   Genetic disorders	Sickle cell disease and thalassaemia cause anaemia unrelated to diet
   Women's physiology	Menstrual blood loss, early pregnancy and higher needs during pregnancy raise risk

   Malaria-endemic tribal districts need integrated disease control. The National Sickle Cell Anaemia Elimination Mission (2023) aims to screen seven crore people.

3. Note3 / 7

   KEY CONCEPTS

   1. What is double-fortified salt?

   It is iodised salt with added iron. Because nearly every household uses salt, it can reach people without changing their diet.

   2. Why can't a haemoglobin test alone guide treatment?

   Haemoglobin shows whether someone is anaemic, not why. WHO's 2020 guidance recommends reading ferritin, a marker of iron stores, alongside inflammation markers where appropriate.

   3. Why does the body absorb so little plant iron?

   Phytates in cereals and pulses and polyphenols in tea and coffee block absorption of non-haem iron. Inflammation raises hepcidin, a hormone that also reduces absorption.

   4. What changed in Anaemia Mukt Bharat in 2026?

   Revised guidelines released in June 2026 expanded the 6×6×6 strategy to 7×7×7. That means seven beneficiary groups, seven interventions and seven institutional mechanisms. The approach also shifts from prevention towards testing, treatment and tracking.

4. Note4 / 7

   THE DEBATE ON IRON FORTIFICATION

   The table sets out the main arguments on each side.

   For wider DFS use	Against universal iron fortification
   A 2022 Cochrane review of 18 studies found DFS probably cut anaemia prevalence by about 21%	That evidence shows benefit but does not establish DFS as a stand-alone national strategy
   Salt reaches almost every household through existing iodisation supply chains	WHO advises under 5 g of salt a day, so relying on salt may clash with hypertension control
   FSSAI has set a standard for DFS	Women and children eat less salt than adult men, though they need more iron
   It is cheap and needs no change in diet	Iron-fortified rice under PDS, PM POSHAN and ICDS, plus iron-folic acid tablets, may overlap
   –	People with transfusion-dependent thalassaemia already face iron overload
   –	A 2006 Pemba trial found more serious adverse outcomes with iron supplements where malaria was endemic
   –	A 2015 Kenyan trial reported harmful changes in infants' gut bacteria after iron fortification

   This card sets out documented positions. It does not adjudicate between them.

5. Note5 / 7

   GAPS IN CURRENT INTERVENTIONS

   • Diagnosis: Routine screening checks haemoglobin but rarely identifies the cause.
   • Compliance: Stomach side effects and irregular use reduce adherence to iron-folic acid tablets under Anaemia Mukt Bharat.
   • Diet: Pulses, dairy, fruit and green vegetables remain unaffordable for many. ICMR-NIN's 2024 Dietary Guidelines stress dietary diversity.
   • Convergence: Gaps in deworming, malaria control, sanitation and safe water keep infection-related anaemia going.
   • Monitoring: UNICEF's 2025 analysis found that the causes of anaemia vary by region. This calls for district-specific responses.
6. Note6 / 7

   WAY FORWARD

   These are the article's suggestions, not adopted policy.

   • Run district-level DFS pilots measuring ferritin, haemoglobin, inflammation and total iron intake before national expansion.
   • Equip primary health centres to test ferritin, vitamin B12, folate and inflammation markers.
   • Supply pulses, millets, green vegetables and vitamin C-rich foods through PDS, anganwadis and school meals.
   • Combine deworming, malaria control, genetic screening and water and sanitation programmes.
   • Use the revised 7×7×7 framework to track beneficiaries, treatment adherence and district accountability.
   • Learn from Peru, which tracks each child and uses cash transfers. Vietnam combines iron supplements, deworming and fish sauce fortified with iron (NaFeEDTA).
7. Note7 / 7

   

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