Potential impacts of iron biofortification in India
Alexander J. Steina,*, J.V. Meenakshib, Matin Qaimc, Penelope Nesteld,
H.P.S. Sachdeve, Zulfiqar A. Bhuttaf
aUniversity of Hohenheim, Agricultural Economics and Social Sciences, Inst. 490b, 70593 Stuttgart, Germany
bHarvestPlus, International Food Policy Research Institute, Washington, DC, USA
cDepartment of Agricultural Economics and Rural Development, Georg-August University of Goettingen, Goettingen, Germany
dInstitute of Human Nutrition, Southampton General Hospital, Southampton, UK
ePediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi, India
fPaediatrics and Child Health, Aga Khan University, Karachi, Pakistan
Available online 21 February 2008
Iron deficiency is a widespread nutrition and health problem in developing countries, causing impairments in physical activity
and cognitive development, as well as maternal mortality. Although food fortification and supplementation programmes have been
effective in some countries, their overall success remains limited. Biofortification, that is, breeding food crops for higher
micronutrient content, is a relatively new approach, which has been gaining international attention recently. We propose a method-
ology for ex ante impact assessment of iron biofortification, building on a disability-adjusted life years (DALYs) framework. This
methodology is applied in an Indian context. Using a large and representative data set of household food consumption, the likely
effects of iron-rich rice and wheat varieties are simulated for different target groups and regions. These varieties, which are being
developed by an international public research consortium, based on conventional breeding techniques, might be ready for local
distribution within the next couple of years. The results indicate sizeable potential health benefits. Depending on the underlying
assumptions, the disease burden associated with iron deficiency could be reduced by 19e58%. Due to the relatively low
institutional cost to reach the target population, the expected cost-effectiveness of iron biofortification compares favourably
with other micronutrient interventions. Nonetheless, biofortification should not be seen as a substitute for other interventions.
Each approach has its particular strengths, so they complement one another.
? 2008 Elsevier Ltd. All rights reserved.
Keywords: Iron deficiency; Biofortification; DALYs; Impact assessment; India; Cost-effectiveness analysis
Despite recent progress in the fight against hunger
and malnutrition in many countries, global food and
nutrition security is still a far-away goal. An estimated
820 million people in developing countries are
undernourished (FAO, 2006). Many more suffer from
specific deficiencies in certain micronutrients: 2 billion
people are anaemic, many due to iron deficiency
(WHO, 2007), 2 billion are iodine deficient and approx-
imately 140 million children are vitamin A deficient
(ACC/SCN, 2004). Unlike undersupply in terms of
* Corresponding author. Fax: þ49 1212510497805.
E-mail address: email@example.com (A.J. Stein).
0277-9536/$ - see front matter ? 2008 Elsevier Ltd. All rights reserved.
Social Science & Medicine 66 (2008) 1797e1808
macronutrients, micronutrient deficiencies are not al-
ways apparent immediately,which is whythe term ‘hid-
den hunger’ is also used. The health consequences can
be severe, however, and include higher susceptibility to
infectious diseases, impaired physical and cognitive
development and increased mortality rates, especially
among women and children due to their higher require-
ments. For instance, in India 85 million children and 26
million women are affected by iron deficiency anaemia
(IDA); for men the number is estimated at 14 million.
While there is a clear correlation between hidden
hunger and poverty, it is well-recognised that economic
development and income growth alone are unlikely to
control micronutrient malnutrition in the near future
(Haddad, Alderman, Appleton, Song, & Yohannes,
2003). Direct micronutrient interventions e such as
industrial fortification of foods, pharmaceutical supple-
mentation or the promotion of dietary diversification e
have been designed and implemented in many
countries. Economic evaluations of such interventions
show that, in most cases, benefitecost ratios are favour-
able (Behrman, Alderman, & Hoddinott, 2004; Horton,
1999; Horton & Ross, 2003). Yet, except for iodised
salt, their coverage and overall success in developing
countries have been limited (ACC/SCN, 2004). For
instance, supplementation programmes may have low
compliance because of presumed side effects (Jefferds,
2002), their success may be limited by inadequate
supply of supplements, cultural beliefs or the need to
adhere to a daily regimen (Galloway et al., 2002), and
those most in need of the supplements, i.e. women
from poor and uneducated backgrounds, are often least
likely to be covered by related health services
(Pallikadavath, Foss, & Stones, 2004). Moreover, these
programmes involve large recurring expenditures,
which many developing countries cannot incur. Some
of these problems also apply to food fortification
programmes. Building on existing distribution channels
for processed foodstuffs, institutional costs are lower,
but coverage rates among the needy are often low,
too, because the poor and malnourished typically
consume locally produced foods and tend to purchase
few processed products. In India, the percentage of
wheat and rice that is marketed outside of the local
community is only around 30e35% (Government of
India, various issues), indicating that much of rural
consumption is locally sourced.
Over the last 10 years, a new agriculture-based
approach has evolved, in which staple food crops are
bred for higher amounts of micronutrients in the edible
parts. This strategy has been termed ‘biofortification’
(Bouis, 2002). Because the prevalence of micronutrient
deficiencies is highest among the poor, who often
cannot afford sufficient amounts of vegetables, fruits,
and livestock products, biofortified staple crops may
improve their nutrition and health status precisely
because the micronutrients are embodied in the staples
themselves. In principle, once such crops are developed
and disseminated, they automatically become part of
the food chain, with farmers reproducing biofortified
seeds themselves for home consumption and local mar-
kets. However,since biofortifiedcrops have hardly been
released so far, their actual impacts remain uncertain,
and a comprehensive methodology for ex ante impact
assessment is not available.
There are two previous papers that deal with the
potential economic impact of biofortification in
some detail e both focus on the special case of
Golden Rice in the Philippines. Dawe, Robertson,
and Unnevehr (2002) used a regional food consump-
tion data set to measure the potential nutritional effect
of Golden Rice by analysing likely improvements in
vitamin A intake. Thus, they analysed the impact
from ‘field to fork’. Yet, in the case of biofortified
crops, it is necessary to go further and also map the
impact from ‘fork to fitness’ (i.e. to physical and men-
tal health). This was done by Zimmermann and Qaim
(2004), who projected the actual health effects of
Golden Rice by computing an expected reduction in
the disease burden of vitamin A deficiency. However,
they used highly aggregated national average vitamin
A intake data, neglecting the distribution of individual
intakes; use of average intakes can lead to a serious
bias (Murphy & Poos, 2002).
The present article improves on the existing litera-
ture by developing a methodology to project the impact
of iron biofortified crops all the way from ‘field to fork
to fitness’, based on more comprehensive data and
refined methodologies. To measure the burden of iron
deficiency, we build on the concept of ‘disability-
adjusted life years’ (DALYs). This burden is calculated
with and without biofortification, so that the difference
is the reduction in the disease burden through bioforti-
fication, expressed in the number of DALYs saved.
Besides impact, we also analyse the cost-effectiveness
of iron biofortification, which allows comparison of
its efficiency with other public health interventions.
This also addresses a research gap, as detailed cost-
effectiveness estimates of biofortification with iron
and zinc are not available (Ma et al., 2007).1
1Similar research as described here for iron biofortification has re-
cently been carried out for zinc biofortification by Stein et al. (2007).
A.J. Stein et al. / Social Science & Medicine 66 (2008) 1797e1808
under the Grand Challenges in Global Health Initiative.
Thus, soon developing countries will have access to
micronutrient-rich lines, which they can use in their
national breeding programmes. With more information
becoming available, further economic studies are
needed to analyse the potentials and constraints in
specific situations and at the macro level.
We gratefully acknowledge financial support of the
German Research Foundation (DFG) and HarvestPlus.
The authors thank Rekha Sharma for sharing her com-
putations and for assistance with the NSS data. They
also thank Gerard Barry and Ivan Ortiz Monasterio
for helpful discussions and comments.
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