Debate over ‘therapeutic food’: can it solve the malnutrition problem?

Following a central government notification, Maharashtra stopped the implementation of a plan to treat severely malnourished children with an energy dense nutritious food paste. An explanation of an old argument over RUTF, which has come back under the spotlight over the past few months

Written by Tabassum Barnagarwala | Updated: November 1, 2017 9:40 am
Underprivileged tribal children in Dhundelwadi in Dahanu tehsil of Pune district. Prashant Nadkar/Express Archive

The Union Ministry of Women and Child Development (WCD) issued a notification to states and Union Territories at the end of August, clarifying that “use of ready-to-use therapeutic food (RUTF) for management of malnutrition is not an accepted policy of the Government of India”, and asked that this advice “be strictly complied with”.

The concept of therapeutic food has long been a subject of debate in India. The Global Hunger Index report 2017 put India at number 100 in a list of 119 countries, and the National Family Health Survey-4 (2015-16) found 35.7% children aged less than five years were underweight, and 38.4% were stunted. The need for combating malnutrition is evident — however, to what extent can therapeutic food do this job?

What is ready-to-use therapeutic food?
Ready-to-use therapeutic food (RUTF), also referred to as energy dense nutritious food (EDNF), is a medical intervention to improve the nutrition intake of children suffering from Severe Acute Malnutrition (SAM). RUTF is a packaged paste of peanuts, oil, sugar, vitamins, milk powder and mineral supplements, which contains 520-550 kilocalories of energy per 100 g. Additional ingredients may include nuts, legumes, grains and sweeteners to improve the taste. The paste is given to children aged between six months and six years, usually after a doctor’s prescription. Each packet of the paste costs Rs 25 and has a shelf life of two years. A child can be given three packets daily for a month.

RUTF use is common in Africa, where the incidence of malnutrition among children is high. In India, the global collaborative Scaling Up Nutrition (SUN) movement has tied up with Maharashtra, Uttar Pradesh and Jharkhand to promote therapeutic food as a solution to malnourishment. Pilot projects to treat SAM children with RUTF have been undertaken in all three states and in Bihar.

How does the Indian government view RUTF?
On August 28, the Union Ministry of Women and Child Development (WCD) wrote to states and UTs that “Enough evidence is not available for use of RUTF vis-à-vis other interventions for the management of SAM. Concerns have also been raised that the use of RUTF may replace nutritional best practices and family foods that children would normally be eating, impacting negatively on continued breastfeeding in children older than six months…”

Recently purchased RUTF packets at an anganwadi in Maharashtra’s Nandurbar district. The state government has stopped the distribution of these packets. Express

Earlier on August 18, Union Health Minister Jagat Prakash Nadda wrote to Nutrition Advocacy in Public Interest (NAPI), a nutrition think tank, that a SAM Alliance formed under the Department of Biotechnology, Indian Council of Medical Research and the Health Ministry to assess the benefits of RUTF had found that therapeutic food was only “temporarily helpful in nutritional rehabilitation”. Nadda stressed that “RUTF may not benefit a common household in developing appropriate food habits for children against home augmented food.”

The Health Ministry had, in fact, stressed as early as in 2009 that the use of RUTF was not an accepted policy of the government. And in 2013, the Centre had asked Jharkhand to stop distributing RUTF to malnourished kids.

Following the August 28 WCD Ministry notification, Maharashtra halted the tendering process to procure RUTF for 83,120 SAM children at a cost of Rs 32.66 crore. But the state WCD Department, which had intended to launch RUTF in anganwadis, wrote to the Centre, asking it to reconsider its assessment of therapeutic food. The debate, in essence, is over concerns whether RUTF would be efficacious and beneficial in a country like India, with its varying food habits and high incidence of malnutrition.

But haven’t the benefits of RUTF been demonstrated in studies?
A smallscale study in Mumbai’s Sion Hospital put RUTF’s efficacy at 65-70 per cent. The hospital runs a Nutrition Rehabilitation and Training Centre, which receives 30 children every day with nutrition deficiency. “We have treated children aged six months and above with multi-nutrient paste (RUTF). Children who have consumed it regularly have come out of SAM,” Dr Alka Jadhav, Head of the Paediatrics department, said. She carried out a similar study in Jawhar, a region in the tribal Palghar district, which is infamous for its high malnutrition rates, and reached the same results.

The United Nations Children’s Fund (UNICEF) supports community-based management along with RUTF. In 2013, a UNICEF report observed that if properly used, “RUTF is safe, cost-effective, and has saved hundreds of thousands of children’s lives.” UNICEF data show around 20 million children worldwide suffer from SAM, of which 10-15 per cent received treatment through RUTF.

The UNICEF has expanded its supplier base to reduce the cost of RUTF. India is one of 16 countries where local manufacturers have been given UNICEF accreditation — two manufacturers have so far been empanelled. Research in The Lancet found malnourished children ran a nine times higher risk of death than normal children; the UNICEF report said RUTF contains all nutrients needed for the recovery of such SAM children.

What are the other concerns about RUTF?
Cost is a major concern. RUTF is a medical intervention, and at Rs 25 per packet, a single child’s treatment with three RUTF doses a day will cost Rs 2,250 a month. Given that well over a third of all children aged under five years are stunted or underweight, the implementation of an RUTF regime will impose a massive financial burden on the government.

A small study by Janarth Adivasi Vikas Sanstha in tribal Nandurbar district showed that children who were given RUTF found it too heavy to eat anything else afterward. Also, once RUTF was stopped, children often slipped back into malnutrition. There is no largescale study of post-RUTF treated children in India so far, but health activists say it cannot be a permanent solution. A Cochrane study from 2013 argued that the benefits of RUTF needed more intensive research — “RUTF may improve recovery slightly, but we do not know whether RUTF improves relapse, death or weight gain as the quality of evidence was very low”, the study said.

So where is this situation headed now?
The Health Ministry is working to develop guidelines and a toolkit for early childhood development that would encourage frontline workers to counsel families on nutrition and feeding practices. The Ministry’s SAM Alliance research observed that management of SAM children “involves family-centric approach instead of food-centric approach”. Handholding of families of SAM children is essential for optimal childcare practices, along with adequate hygiene and sanitation.

Pradip Prabhu, who moved Bombay High Court in August against the Maharashtra government’s decision to initiate RUTF, said rural and tribal families can only consume traditional food, and children must not be driven away from hot cooked meals. “Dependence on therapeutic food cannot be permanent. Children will stop consuming home cooked meals if anganwadis regularly give SAM kids RUTF,” Prabhu said.

Activists from Narmada Bachao Andolan (NBA), who have questioned the implementation of RUTF, said not all children given RUTF emerge out of malnutrition. “A more holistic solution is needed, which includes counselling on breastfeeding and family planning to ensure low birth weight babies are not born, and proper functioning of anganwadis so that at least regular meals are provided to children,” said Latika Rajput of the NBA.

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