Creative Solutions For Child Malnutrition in South Asia

Although it's a subject I have often written about, this particular post about fighting child malnutrition is inspired by a recent email from Col. Pavan Nair, an Army officer turned social activist, and a patriotic Indian with a deep sense of service to those in the greatest need in his country and its neighborhood.

In 2009, the Indian government banned the import of Plumpy'Nut nutrient bar by UNICEF to treat moderate to severe acute malnutrition among Indian children. Defending the government action, Mr. Shreeranjan, the joint secretary of the Ministry of Women and Child Development, told the Reuters that "Nothing should come behind our back. Nothing should be done in the name of emergency when we have not declared an emergency."

Clearly, Mr. Sheeranjan does not see the food emergency that is causing almost half of India's children to be malnourished. According to UNICEF's State of the World's Children's report carried by the BBC, India has the worst indicators of child malnutrition in South Asia: 48% of under fives in India are stunted, compared to 43% in Bangladesh and 37% in Pakistan.

Meanwhile 30% of babies in India are born underweight, compared to 22% in Bangladesh and 19% in Pakistan. UNICEF calculates that 40% of all underweight babies in the world are Indian.

Malnutrition is the leading cause of death in children in developing countries, including India and Pakistan. According to World Health Organization about 60% of all deaths, occurring among children aged less than five years in developing countries, could be attributed to malnutrition.

Those who survive the trauma of early childhood malnutrition suffer various degrees of brain damage and continue to lack sufficient cognitive and motor skills later in life.

According to World Bank's HNP (Health and Nutrition) paper "India's Undernourished Children", here is some data on the scale of the problem India faces:

1. 47% of Indian children under 5 suffer from malnutrition.
2. 60 million in all, highest in the world.
3. Two million Indian children under 5 die each year.
4. At least one million of them die from low immunity attributable to malnutrition.
5. Ten million children out of the statistical range a year suffer from lack of motor and cognitive skills for the rest of their lives.
6. Most of the retardation occurs between two to three years of age.

In the face of such shocking data, what is particularly disturbing is the lack of focus in pursuing solutions to this problem that affects tens of millions of children in the developing world, especially in sub-Saharan Africa and South Asia.

If the governments, such as India, are concerned about dependence on foreign food imports, they need to have policies and plans in place to encourage development of local alternatives to what are called ready to use therapeutic food (RUTF) bars such as Plumpy'Nut made from fortified peanut paste.

Community-based therapeutic care is being pushed in Pakistan by an Agha Khan University project. It is an attempt to maximize broad impact through improved coverage, access, and cost-effectiveness of treatment for malnutrition. Such community-based nutrition packages can provide effective care to the majority of acutely malnourished children as outpatients, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. Children with SAM without medical complications are treated in an outpatient therapeutic program with ready-to-use therapeutic food and routine medications. It proposes the use of Ready-to-use Therapeutic Food (RUTF) and Fortified Supplementary food for the treatment of moderate and severe malnutrition. The advantage of these commodities is that they are ready-to-use paste which does not need to be mixed with water, thereby avoiding the risk of bacterial proliferation in case of accidental contamination.

While the advantages of the RUTF solutions such as Plumpy'Nut and Cipla's generic equivalent Nutrinut are proven, the cost of such treatment needs to be made a lot more affordable than it is. A standard Plumpy'nut treatment goes for four weeks (twice a day) at a cost of 12 Euros in Africa. India's Cipla also makes a generic version of Plumpy'Nut. It's being used in Nepal for Nepali Rupees 52 (~75 US cents) for a 500 Kcal bar. At 92 grams net weight; 12.5 grams protein; 32.86 grams lipid). It has the same nutritional content of F-100 milk formula and plumpy’Nut.

On the extreme affordability front, Bangladesh is setting an example for others to follow. Bangladeshi Nobel Laureate Mohammad Younus's Grameen, in joint venture with Danone of France, is producing a special yogurt called Shakti Doi from pure full cream milk that contains protein, vitamins, iron, calcium, zinc and other micronutrients to fulfill the nutritional requirements of children of Bangladesh and contribute in improving their health. While 'Shakti Doi' (which means 'power yogurt') is primarily intended for children, it is also appropriate for adults. The price of each 80 gram cup of yogurt is only 5 takas, equivalent to Euro 0.05 (five cents). It is an affordable price even for the poor people of Bangladesh. It's locally made and significantly cheaper than Plumpy'Nut, costing about one-tenth of the cost of solutions offered outside Bangladesh.

In his email to me, Col. Nair has proposed a solution for India with the target cost of one Indian rupee or less. His solution seeks to address protein energy malnutrition (PEM), iron deficiency anemia (IDA), and vitamin A deficiency (VAD) found among Indian children. Nair's idea is to develop a nutrient bar consisting of locally produced oats mixed with honey and crushed peanuts weighing about 15-20 grams, and fortified with iron (50%), vitamin A (75%), vitamin B6 and B12 (25% each), vitamin C (50%), vitamin E (50%), Iodine (50%), zinc (50%), and other nutrients like biotin, folic acid, calcium, sodium and potassium.

I am not a nutritionist. However, I do think Col. Nair's proposal to develop a low-cost solution to address the massive problem of child malnutrition in India and Pakistan deserves a serious look and concrete follow-up. It's an opportunity for social entrepreneurs and the corporate sector to jump in with their creative energies and dollars to meet the challenge thrown by Col. Nair. Meeting this common challenge as joint India-Pakistan effort will ensure a better future for all south Asians, and bigger future profits from a brainy, healthy and highly productive next generation of Indians and Pakistanis.

Related Links:

Persistent Hunger and Malnutrition in South Asia

Social Entrepreneurs Target India and Pakistan

Light a Candle, Don't Curse Darkness

Grinding Poverty in Resurgent India

India Tops World Hunger Chart

Food, Clothing and Shelter in India and Pakistan

Mixed Messages in Hunger Report

ActionAid's World Hunger Score Card

World Food Program in India

World Food Program Pakistan


pediatric emr said…
Great idea! I believe that we really need to have "Creative Solutions For Child Malnutrition in South Asia". I wish there will be no children will suffer in malnutrition. Anyway, thanks for sharing.

Riaz Haq said…
First beef ban, now egg ban in India:

Via @nprnews: Egg War: Why #India's Vegetarian Elite Are Accused Of Keeping Kids Hungry, Malnourished. #Jain

Why this vehement opposition to eggs? Well, the local community of Jains, which is strictly vegetarian and also powerful in the state, has previously thwarted efforts to introduce eggs in day care centers and schools. Chouhan is an upper caste Hindu man who recently became a vegetarian.

And the state of Madhya Pradesh is mostly vegetarian, as are some other states, like Karnataka, Rajasthan and Gujarat. For years, the more politically vocal vegetarians in these states have kept eggs out of school lunches and anganwadis.

But here's the thing: While these states as a whole may be mostly vegetarian, the poorest — and most malnourished — Indians generally are not. They would eat eggs, if only they could afford them, says Dipa Sinha, an economist at the Center for Equity Studies in New Delhi and an expert on India's preschool and school feeding programs.

India's free school lunch program alone reaches about 120 million of India's poorest children, and the anganwadis reach millions of younger children. So, the egg war isn't trivial.

Chouhan's office has said the chief minister is "sentimental" about keeping anganwadis egg-free. "This is a very upper caste Hindu sentiment," says Sinha.

Hindu scriptures prescribe notions of purity for people belonging to upper castes, Sinha explains. "You can't use the same spoon as someone else. You can't sit next to someone eating meat. You can't eat food cooked by someone who eats meat. And they think this is a dominant culture and that they can impose it on anyone."

The recent ban on the slaughter of bulls and bullocks in the neighboring state of Maharashtra also reflects this sentiment.

While most Hindus today don't eat beef, Hindus belonging to lower castes, including Dalits (considered the lowest in India's caste hierarchy), do rely on this meat as a regular source of protein, as do Christians and Muslims. Dalit scholars have called this ban an effort to impose upper-caste Hindu values on the lower caste minorities.


"We opened it, and one of the letters in that box was from a girl in [fourth grade]," says Sinha. "It was a Dalit girl, who said, 'Thank you very much. I got to eat an egg in my life for the first time.' "

"Wherever eggs are introduced, attendance goes up," says Sinha. "It's very popular, because children don't get it at home."

Eggs are also an easy way to provide much-needed protein and fat to malnourished children, says Sachin Jain, the food rights activist. They are easy to procure locally, and storage and transportation aren't a problem. "No ... vegetarian food item is that good a source of protein," he says.

Milk, which comes close and is often touted as a good alternative by vegetarians like Chouhan, comes with many complications. It is often diluted by suppliers and is easy to contaminate, says Jain. It also requires more infrastructure to store and transport to remote rural areas.

"I am a vegetarian," adds Jain. "I have never touched an egg. But I have other sources of fat and protein, like ghee (clarified butter) and milk. Tribals, Dalits and other poor people don't have these options. They can't afford these things. Then, eggs become a very good option for them."

"We still have very high malnutrition," says Dipa Sinha. "Every third Indian child is malnourished."

This context is crucial in this discussion, she says, "because the best interest of the child is what should be driving policy. I think this (ban on eggs) is a big setback."
Riaz Haq said…
#Pakistan fights #malnutrition with mass #food-fortifying program. #cereals #wheat #oil #ghee #fortification

UK aid funding supports ambitious project adding nutrients to everyday foods such as bread and oil, to reduce disastrous long-term impact of poor nutrition

A new programme of fortification of everyday foods such as bread and oil is being rolled out in Pakistan in an attempt to tackle chronic and widespread malnutrition.

The food fortification programme, which is backed with $48m (£36m) of funding from the UK’s Department for International Development (DfID), will see nutrients added directly to wheat flour, edible oils and ghee at source in mills and factories.


The programme is aimed mainly at changing the health of women and children. Palmer says this is because of the disastrous long-term impact of poor health in mothers. “Stunting is inter-generational. If you are poor and your mother is stunted, it could take a few generations to iron out, which perpetuates inequalities.

“Recurrent and early childbearing reduces a woman’s nutritional status and there are taboos around women eating certain food. For example, they might be told they can’t eat much eggs or meat in pregnancy, which are foods that are rich in protein and iron that they need. Women may eat less nutritious food than other family members and they often can’t access healthcare.”

Joel Spicer, president of Micronutrient Initiative, which is working with Mott MacDonald, says the high levels of malnutrition are having a devastating impact on Pakistan’s development.

“Our work is taking place in the context of a malnutrition crisis in Pakistan, where nearly half of children are stunted and won’t be able to participate in the economy,” he says. “Stunted kids are at a disadvantage cognitively as well as often being the height of a child two or even four years younger. If a child doesn’t get [enough] nutrition in the first 1,000 days, their brain and immune system don’t develop.

“When these children become adults they are more susceptible to communicable diseases, they are generating less money for their families – and the overall net effect on GDP is 3% a year for Pakistan. So it is a much cheaper problem to fix than to allow to continue.”

Fortification of cereals directly at source, where they are produced, is done in almost 90 countries worldwide. Similar tactics have been used successfully in Jordan and Iran in recent years.

Spicer says the project is an ambitious one. “We are aiming to work with over a thousand mills directly as well as around 100 oil producers. That is why [this project] is so exciting – it will reach 57% of the population through wheat flour and 72% through ghee, in a country with some of the highest rates of malnutrition in the world.”

Spicer believes the world could do more to tackle the issue of child malnutrition. Globally, one in four children still suffers from stunting even though levels of hunger have fallen by a third in the past 15 years.

“We estimate that $2bn a year in funding would prevent 50 million children from stunting. But the world spends $14.5bn a day on energy subsidies, so you have to conclude that malnutrition is a political choice.”

In June, Save the Children warned that little progress has been made on curbing malnutrition, particularly in sub-Saharan Africa and south Asia. Rates have actually increased since 2000 in 13 countries, including Papua New Guinea and Eritrea.

Launching the project, the head of DfID Pakistan, Joanna Reid, said: “Food fortification is a safe, cost-effective way of decreasing micronutrient deficiencies. That is why the British people, through UK aid, are investing in the food fortification programme. We believe that this programme will benefit millions in Pakistan.”
Riaz Haq said…
Pakistani Universities Promoting Moringa to Fight Malnutrition

Aga Khan University and Sindh Agriculture University are jointly promoting Moringa tree planting in Pakistan's Thar desert to fight malnutrition, according to multiple media reports. Moringa has gained popularity as superfood in the West in recent years. People of drought-stricken Tharparkar have been suffering from malnutrition and disease in the middle of a long-running drought in the region. Sindh Agriculture University, Tando Jam, and the Aga Khan University will plant 40,000 moringa tree seedlings in Matiari, a rural district in central Sindh, in an effort to improve the health of malnourished mothers, children and adolescents in the area. The moringa tree plantation campaign has been funded by the Prince Sadruddin Aga Khan Fund for the Environment, a $10 million fund dedicated to practical solutions to environmental problems.
Riaz Haq said…
Pakistan: A win-win thanks to flatbread

More than half of the women and children in Pakistan lack adequate levels of essential micronutrients such as iron, zinc, folic acid, vitamin A and vitamin D. Poor nutrition and micronutrient deficiencies in childhood have profound effects on immunity, growth and cognitive development.

WFP’s Chakki project aims to combat malnutrition and stunting (lower height for age), by targeting the small-scale local mills where most people buy their flour. People like Tahir have learnt how to add micro-nutrients (iron, zinc, folic acid, vitamin B12) that are essential to good nutrition, especially in pregnant and breastfeeding women, children and adolescents.

Talking about his customers, Tahir says: “Many are highly educated people, so they quickly understand that the small price increase of 6 PKR (equivalent to US$0.04) per 20 kg is worth it. I spend a little longer convincing sceptics who are not familiar with the positive impact fortified flour will have on their diet. However, they usually decide to give it a try when they learn about the benefits, and they end up coming back to purchase more.”

Just a few steps away from Tahir’s mill lies local meeting spot Quetta Akbar Café and Hotel. After hearing from Tahir about the value of using fortified flour, owner Anwar Khan shifted to using fortified flour too. The price of one chapati increased from 12 to 15 PKR, equivalent to a US$ 0.02 increase, but customer feedback on taste and texture is very positive. Some also mention that the bread stays softer for longer. Since May this year, posters placed on the café's walls educate customers about the added value of using fortified flour. And both Tahir and Anwar enjoy talking to people about fortification and getting feedback.


ISLAMABAD – The National Fortification Alliance (NFA) of Pakistan, with technical support from the United Nations World Food Programme (WFP) and funding from the Australian Government launched a pilot project to fight malnutrition by fortifying wheat flour in Islamabad and Rawalpindi. This project will support chakkis (small-scale grinders) to mill flour that is rich in micronutrients that are key to keeping families healthy.

“Given the extent of the consumption of wheat from chakkis, this project will provide a firm basis to reach nutritionally vulnerable populations and provide them with essential nutrients, which is another step WFP is taking to curb malnutrition in Pakistan,” said WFP Country Representative, Finbarr Curran at the launch of this programme today.

Dr. Baseer Achakzai from the National Fortification Alliance, Ministry of National Health Services, Regulation and Coordination also participated in the launch.

Almost half of Pakistan’s population suffers from micronutrient deficiencies which can lead to poor child growth, anaemia and many other health issues. Reducing these deficiencies is a high priority for the Government of Pakistan.

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