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Plumpy Nut or indigenous foods?

By Vandana Prasad

Imported ready-to-use therapeutic foods such as Plumpy Nut are being pushed to supplant locally prepared indigenous foods in the treatment of severe acute malnutrition, ignoring the multiple causes of malnutrition and destroying the diversity of potential solutions based on locally available foods

Globally, nearly 20 million children under 5 suffer from severe acute malnutrition (SAM), a condition which contributes to 1 million child deaths annually. In India, 48% of children under 5 years of age are stunted and 43% are underweight; almost 8 million suffer from SAM.

Malnutrition is not a new problem in India, nor is SAM. Several hospitals and non-government organisations are engaged in community-based management of malnutrition using locally produced/procured and locally processed foods along with intensive nutrition education. These programmes enable parents to meet the nutritional requirements of their children with foods that are available at low cost. The Supreme Court of India has also directed the government to universalise the Integrated Child Development Services scheme and provide one hot cooked meal to children under 6 years of age, to supplement their nutrition.

The blame for the increasing number of severely malnourished children can be laid at the door of policies that have destroyed poor people’s access to food. Nonetheless, there is urgent need to ensure that these children do not die; that they recover and maintain a healthy nutritional status. The current thinking -- that a centrally produced and processed ready-to-use therapeutic food (RUTF) should supplant the locally prepared indigenous foods in treatment of SAM -- ignores the multiple causes of malnutrition and destroys the diversity of potential solutions based on locally available foods. This position paper has been drafted by Dr Vandana Prasad, Radha Holla and Dr Arun Gupta, members of the Working Group for Children Under 6 -- a joint effort of Jan Swasthya Abhiyan (People’s Health Movement-India) and the Right to Food Campaign which has been advocating for the last three years with the Indian government for decentralised and community-based strategies to combat and prevent malnutrition in children (1).

How should India approach the Management of SAM? A position paper

The number of children currently suffering from malnutrition in India is an extremely serious matter of national shame and distress. Not only has this situation persisted for far too long, it remains intractable even during the recent phase of rapid economic growth. Of late, there has been intense debate and discussion on how best to intervene to make a change that is both substantial and rapid, and various groups of experts have presented strategies to policymakers to prevent malnutrition and treat its most severe forms.

This position paper responds to a particular strategy that has been introduced at the state level without due process of discussion on its repercussions and implications: namely, the use of imported ready-to-use therapeutic foods (henceforth RUTF) for the management of SAM.

The current situation 

1 A product called Plumpy Nut has been imported for distribution to children with SAM in several states, including Madhya Pradesh, Jharkhand, Orissa, Bihar and Maharashtra under the aegis of Unicef and through the mechanism of nutrition rehabilitation centres (NRCs). There is a proposal to make it the ‘prescribed treatment’ for SAM.

2 This product is imported from a company called Nutriset in France. If produced in India, it would cost approximately US$ 40 or approximately Rs 2,000 per child per treatment (2).

3 Plumpy Nut efficacy has been demonstrated in other countries such as Malawi, Niger, Ethiopia, D R Congo and Mozambique in conditions of disaster and famine.

4 Studies demonstrating the efficacy of Plumpy Nut have been primarily conducted in disaster situations, where other community-based treatments for SAM have not existed, for example refugee camps, famines, etc. There are few studies comparing the impact of Plumpy Nut with other specific community-based treatments for SAM developed from local indigenous foods.

In juxtaposition of these facts

1 The guidelines for community and home-based treatment of SAM formulated by a large group of experts and supported by the Indian Academy of Paediatrics recommends the use of home-based food (modified from the family pot). It specifically warns that commercially available international RUTF may not be suitable, acceptable, cost-effective and sustainable (3).

2 Many locally produced/producible foods that are culturally acceptable and relatively low-cost have been used for SAM in India for many decades by reliable academic and medical institutions as well as by non-governmental groups. The accompanying table gives details of some of these mixes.

3 Several experiments are ongoing, using modified family foods to treat SAM. Jodhpur Medical College has been using a mix of energy-dense khichdi, milk, arar, dal, sugar, fruit, fruit juice and egg to treat SAM both in institutional and home settings. This is in the process of analysis and documentation. In Tamil Nadu, the Direct Nutrition Programme gives a mix of 80 gm of rice, 10 gm of dal, 2 gm of oil, 50 gm of vegetables and condiments at a total cost of Rs 1.07 to each child between two and four years of age. This provides 358.2 calories and 8.2 gm of protein per child (4). The sattu maavu listed in the table is given as a complementary food for children between six and 36 months of age, and pregnant and lactating women, and costs approximately Rs 15 per kg. Other experiments by NGOs such as Mobile Creches have used common foods including eggs, soya products and milk for demonstrable impact at a cost of Rs 8 per child per day for full day-care nutritional facilities (5).

4 These foods have been completely ignored in the haste to introduce Plumpy Nut, which, though an efficacious formula, seriously disturbs the concept of self-reliance in food security and creates unnecessary dependence on a product upon which families and communities have little control.

5 The alternative foods listed above have many additional advantages.

  • They promote local agricultural practices as they use millets and locally available foods.
  • They promote local livelihoods amongst the very families that may be harbouring children with SAM in a milieu of general poverty and food insecurity, thus conferring more than food supplementation -- an opportunity to raise economic status. They may use the agency of existing women’s groups and SHGs as well as small-scale industry.
  • By being a much more decentralised process, they allow greater community participation and control.

Evidently, though there are few formal studies documenting their efficacy there are some, along with plenty of anecdotal evidence of success. The very fact that these pre-existing attempts have not been properly studied, analysed and documented by research and expert bodies on nutrition is a matter of concern. It is hard to explain why it has been permitted for a somewhat alien product to be introduced on such a large scale without investigating the relative merits and demerits of the ready-to-use foods that we have been using in such prestigious institutes as mentioned above. It would not have been either difficult or time-consuming to study these further for a few months before arriving at a suitable strategy for SAM that includes supplementary food.

Perhaps it leads us to our longstanding recommendation and demand: that the country needs to develop a well-discussed and debated policy on child nutrition rather than having to combat each contingency as it arises. This policy necessarily needs to keep in mind that supplementary nutrition is one, though important, part of the multi-pronged strategy to bring about overall food security for children and families, and the best supplementary nutrition would be one that promotes self-reliance, decentralisation, community participation and is low-cost and culturally acceptable. An imported or centrally prepared very expensive food that displaces other locally producible options can hardly hope to fulfil these criteria and should be abandoned in favour of the ‘right’ product. Adequate thought, planning and research should go into developing such policies rather than succumbing to various pressures in haste and allowing unsustainable processes that may prove difficult to reverse and will cause long-term harm to the very communities and families whose children we aim to ‘treat’. We also need to continuously remind ourselves of the comprehensive set of strategies that will bring about the ultimate goal of child health, nutrition and wellbeing through services of general care, health and nutrition in an environment of overall food, economic and social security.

Name of mix Composition and calorific value Developed by Locally prepared by State
Davangere Mix Laddus made of equal quantities of groundnut, roasted Bengal gram, jaggery and ragi. 100 gm gives 400 calories and 15 gm of protein Medical College, Davangere Women’s groups Karnataka
Shakti Nutrimix Rice, wheat, whole gram (chana), groundnut, sugar, salt, cardamom, black pepper, vitamins and minerals. Each 100 gm of mix provides 10.4 gm of protein, 5.3 gm of fat, and 402 calories Shibpur People’s Care Organisation, 23/1 Baze Shibpur Road, Shibpur, Howrah/Village and PO Tapan, Dt Dakshin Dinajpur Women’s groups West Bengal
Nutrimix Wheat (400 gm), rice (400 gm), gram (75 gm), moong (75 gm), groundnut (50 gm); sprouted, dried, roasted and powdered. Two heaped spoons in a glass of water or milk with sugar twice a day Development Research Communication and Service Centre, 58 A, Dharmotala Road
Bosepur, Kasba
Kolkata  700 042
Women’s groups West Bengal
Nutrimix Wheat/rice and Bengal gram/moong in ratio of 4:1. Used for treating SAM, for preparing F 75, F 100, as starter and catch-up foods. Each 100 gm cooked provides 120-150 kilocalories and protein 2-3 gm. Can be made more energy-dense by adding seasonal fruits, and micronutrient-rich by adding electrolyte mineral solution CINI (Child In Need Institute), Kolkata Women’s groups West Bengal
LAPSI Green millet, peanut, jaggery. Successfully used for quick recovery from SAM Bharat Agro Industries Foundation and CAPART   Maharashtra
SAT Mix Roasted and ground rice, wheat, black gram and sugar in ratio 1:1:1:2. Provides 380 calories per 100 gm Sree Avittom Thirunal Hospital   Kerala
MIX   National Institute of Nutrition, Hyderabad   Andhra Pradesh
HCCM (high-calorie cereal milk)   Christian Medical College, Vellore   Tamil Nadu
Sattu maavu (Anuradha K Rajivan, ‘History of Direct Nutrition Programmes in Tamil Nadu’, www.righttofoodindia.org/) Wheat flour 42%, maize flour 10%,
malted ragi flour 5%,
Bengal gram flour 12%, jaggery 30%,
vitamin pre-mix 1%.
100 gm provides protein 9-10% and calories 360
Nutrition Monitoring Programme (state programme)   Tamil Nadu

NB: Shelf life is not a necessary condition for these locally produced ready-to-eat foods as they are prepared in quantities needed by local women’s groups under the supervision of the respective hospital or NGO

(Dr Vandana Prasad is a community paediatrician and the Founding Secretary and National Convenor of the Public Health Resource Network. Her special areas of interest are child health and nutrition. She has been closely associated with many national health movements such as the People’s Health Movement and the Right to Food Campaign. This position paper for the Working Group for Children Under 6 was first published in the journal Social Medicine (Vol 4, No 1, March 2009))

Endnotes
1 ‘Working Group for Children Under 6, Strategies For Children Under 6’, special article, Economic and Political Weekly, December 29, 2007
2 1 sachet is 92 gm. Treatment for SAM requires 90 sachets per child of 10 kg. (Nutriset site: http://www.nutriset.fr/index.php?option=com_content&task=view&id=30&Itemid=28) Each kilo of RUTF costs approximately US$ 4. (Powerpoint presentation by Steve Jarrett, Unicef,  September 20, 2008: ‘Ready-to-Use Therapeutic Foods (RUTF): Addressing the Situation of Children With Severe Acute Malnutrition -- Production in India’)
3 Gupta, P, Kapil, U, et al, ‘National Workshop on Development of Guidelines for Effective Home-based Care and Treatment of Children Suffering from Severe Acute Malnutrition’, Indian Paediatrics, Vol 43, February 17, 2006
4 Ibid
5 Working paper Mobile Creches, ‘Impact of Strategies for Children Under 6 on Malnutrition; Evidence from Two Microstudies’, 2008

Infochange News & Features, July 2012