Why child malnutrition cannot be treated with magic foods like RUTF

Children whose distended bellies look like balloons about to burst, with oversized heads resting on shrivelled up little bones covered with a thin layer of skin suffer from a condition called Severe Acute Malnutrition (SAM). 

Like stress or depression in the case of adults, SAM is an underlying cause of 1/3rd of the total under-5 child deaths (12 lakh). In 2005, India had about 80 lakh such children. Today, the number has grown to 93.4 lakh.

National Health Policy 2017: silent on malnutrition

“India is a land of contradictions”.

This aphorism is best seen manifested in the National Health Policy 2017. The new Health Policy was expected to offer concrete and effective strategies to eradicate malnutrition from our country. 

For instance, the request for a National Nutrition Mission remains pending. The NITI Aayog too has not been allowed to set up one and it is included in the recently released draft policy only as a “suggestion”.

If allowed, the National Nutrition Mission will be set up and function on the lines of the very successful Polio Mission, and is our best bet to prevent children from dying from lack of nutrition.

The National Health Policy is also silent on the treatment of malnutrition and SAM through the use of commercial Ready to use Therapeutic Food (RUTF). If one does manage to read till the end of the document, one cannot help but be surprised by the section on implementation, which comprises of just 47 words. For the health of 125 crore Indians, the seriousness of the policy is reflected in its one paragraph on implementation. Another ‘jumla’?

The National Health Policy 2017 was termed a ‘milestone’ by the Health Minister because it revised and released after a gap of 14 years. Perhaps, the minister ought to realise that the National Nutrition Policy has not been revised since 1993, which means, if he can come up with a new Nutrition Policy, he can truly promote it as a ‘landmark’.

Myth of Malnutrition being a Myth

Keen observers of the child health sector would recall that in the run-up to the general election in 2014, the present Chairman of NITI Aayog, Arvind Panagariya, had proudly called the malnutrition in India a myth in this EPW article. Briefly put, Panagariya assured that the figures were inflated.

In the analysis of Panagariya’s conclusion in this column, senior health journalist Pramit Bhattacharya had written that, “Panagariya’s argument is this: India’s malnutrition figures are inflated because Indians are genetically predisposed to being smaller. To establish his hypothesis, he cites the example of poorer nations of sub-Saharan Africa, which have much higher child mortality rates compared to India but outperform India when it comes to nutritional outcomes. Since malnutrition in India is not leading to as many deaths as in Africa, the malnutrition standards are wrong, he argues.”

One wonders what Panagariya has to say about the increased number of SAM children now that he is the head of the planning arm of the government. In fact, a BJP minister shared the new SAM figures just a month ago. One hopes that the deniers of malnutrition in India will now stop acting like ostriches!

One also hopes that the minister and the NITI Aayog will not entertain scatter-brained ideas like the “Nanaji ki Thali”, a nutrition strategy being pushed by some RSS bigwigs. Though it might be in line with their principle of “One Nation, One Culture”, it will wreak havoc on child health and nutrition in India.

Magic food isn’t the answer

A month ago, 16 leading health experts, former health secretaries, paediatricians and activists, of the country wrote a letter to the Health Minister JP Nadda, highlighting their concerns on the subject of child undernutrition and efforts to eradicate it.

One of their main concerns is the government’s lack of clear guidelines on the use of RUTF or Ready to use Therapeutic Food.

RUTF is a high-sugar, high-energy and high-fat product comprising of peanut paste. The RUTF product being used in Indian states like Rajasthan and Odisha contains 500 calories, with sugar and fatty content being as much as half of the source of calories while the protein share is just 10-12%.

The other major problem with such products is that they are not edible without being mixed with water and in many cases of children suffering from SAM, the risk of water-borne diseases is too high to allow the use of water in their diet.

It is worth remembering that if the families of such children were economically strong to afford clean water they would probably not suffer from SAM in the first place.

The TATA MIT Centre is working on a milk-based, locally produced (made with indigenous ingredients like gram flour) RUTF product, but they are still at the testing stage.

In any case, the assumption that milk can be a substitute for people who cannot afford clean water betrays a total disconnect with India’s ground realities. SAM is prevalent usually among communities that live on the margins, in remote forests, drought-stricken regions, and sometimes even in dense slums.

Child-undernutrition needs to be understood as an intergenerational disease. Simply put, unhealthy, low-weight, young mothers cannot be expected to give birth to healthy children. With regard to SAM, the strategy of the government seems to be to let the state governments decide as they please.

The few hundred Nutrition Rehabilitation Centres (NRC) that were opened in the last decade have now become defunct and are usually found empty. The government has failed to create an enabling environment for poor parents to stay with their children in the NRC; they are usually daily-wage earners, and the reason most give for not using the NRCs is that they cannot afford to skip even a day’s work.

No more quick fixes

Thus, as the letter by concerned health experts advises, what India needs today is a urgent framing of a “local evidence based policy that seeks to reduce burden of severe wasting in a sustainable manner instead of focusing upon distractive and uncertain “quick fixes”.”

A government study published in 2016 after screening over 1,00,000 children between 6 months and 5 years of age found 1.1% of them had SAM. On these SAM-affected children, commercial RUTF treatments (locally-produced and centrally produced) were tried, in addition to home augmented foods (like khichdi). The results showed “that the differences between home augmented foods group and commercial RUTF group were not significant”.

The study proved that overall impact across all three approaches is low, “with only 57% children recovering even after a prolonged period (up to 4 months) of intervention”. And even if one considers 57% to be a good success rate, the study showed that this recovery was extremely short-lived and most children relapsed into SAM after “4 months of stopping treatment”.

Based on this study, it is obvious that SAM cannot be treated with magic foods like RUTF. What it needs is a transformation in the way we treat public health in our country.

The strategy needs to be a holistic one that addresses difficult issues like “sustainability, food security; protecting, promoting and supporting breastfeeding and optimal complementary feeding; preventing early child bearing; strengthening preventive and curative health systems, especially the capacity of frontline workers; enhancing literacy; and improving water supply and sanitation”, urges the letter to the Health Minister.

But is the government even listening? A first step will be a clear policy on the use of RUTF in India.