Low compliance among the people of India has caused iron supplementation approaches there to not be effective in reducing anemia.  Fortification of foods with iron is another option, which public health programs there have mandated.  Double-fortified salt (DFS, with iron and iodine) has been the approach used, but the evidence supporting its benefit-cost ratio is limited.  Makkar and colleagues conducted a study designed to estimate the economic and health benefits of DFS, and published their results in the February 2022 issue of The Journal of Nutrition.

Data for this work were derived from national surveys of earnings and dietary iron intake.  Iron deficient anemia (IDA) was predicted using information on dietary intake, sanitation and included menstrual losses for women.  Increased wages derived from anemia reduction was the measured benefit of DFS and this value was compared with the cost of providing DFS.

Those with IDA had lower wages than those without IDA, and addition of DFS was predicted to reduce IDA from 10.6% to 0.7% in men, and from 23.8% to 20.9% in women.  The cost benefit analysis indicated that the estimated ratio was 4.2:1 at a national level.  The conclusion derived from these data was that the improvement in wages associated with DFS was cost effective, and it should be used throughout India to reduce IDA.

In an editorial, Schultink points out that the major driver of the benefit observed with DFS use was an increase in wages for men, and that the benefit for women (who are more prone to IDA) was much less positive.  They noted that the benefit for women obtained with improved sanitation was much more effective than DFS.  Schultink suggested that the benefit-cost analysis should be performed among those receiving government food distributions so as to inform the Indian government and to be applicable in other countries where similar food distribution programs are used.


Sanchit Makkar, Sumedha Minocha, Kishor Govinda Bhat, Anjaly Teresa John, Sumathi Swaminathan, Tinku Thomas, M G Venkatesh Mannar, Anura V Kurpad, Iron Fortification through Universal Distribution of Double-Fortified Salt Can Increase Wages and Be Cost-Effective: An Ex-Ante Modeling Study in India, The Journal of Nutrition, Volume 152, Issue 2, February 2022, Pages 597–611, https://doi.org/10.1093/jn/nxab378.

Jan Werner Schultink, Using Double-Fortified Salt to Reduce Iron Deficiency Anemia in India, The Journal of Nutrition, Volume 152, Issue 2, February 2022, Pages 375–376, https://doi.org/10.1093/jn/nxab422.

Images via canva.com.