Development and use of alternative nutrient-dense foods for management of acute malnutrition in India

There is increased motivation in India to develop national protocols for community-based management of acute malnutrition (CMAM) to address the unacceptably high and persistent levels of wasting in many states across the country. CMAM protocols are currently in development by the Government of India (GoI) in support of POSHAN Abhiyaan (the Government’s new flagship programme to reduce all forms of undernutrition) to enable timely and appropriate management of children with uncomplicated severe acute malnutrition (SAM) in the community and more effective follow-up of complicated SAM cases discharged from India’s nutrition rehabilitation centres (NRCs). Fundamental to the CMAM approach is the availability of therapeutic food for use in the management of uncomplicated SAM cases in the community. While the World Health Organization (WHO) recommends the use of ready-to-use-therapeutic food (RUTF) for this purpose, RUTF has so far been restricted for use in India by the GoI due to its high cost and concerns that it may replace family foods and best practices for optimal nutrition and may not be acceptable at community level. Several state governments have explored the use of alternative, locally made, nutrient-dense foods for the management of acute malnutrition, however, no national consensus has as yet been achieved on the most appropriate product to use in CMAM programming. The focus of this article is the development of an alternative nutrient-dense food by the Indian Council of Medical Research - National Institute of Nutrition (ICMR-NIN) and the National Centre of Excellence (NCoE) for the management of SAM for use in a supervised supplementary feeding programme (SSFP) in Telangana as an attempt to find a solution to this impasse.

The Indian Council of Medical Research - National Institute of Nutrition (ICMR-NIN) first carried out a review of all locally available energy and nutrient-dense foods used in the management of undernourished children in India to help inform the development of a product for use in the Telangana supervised supplementary feeding programme (SSFP).  

Methodology

Related research articles, guidelines, grey literature and available information were collated and reviewed. Information about each food product was gathered, including general information, nutrient composition, shelf life, cost and evidence of impact on the recovery of malnourished children. The nutrient value of each product was calculated using the recently revised Nutritive Value of Indian Food.¹ Based on their energy density, foods were classified as having high energy density (provides 450-550 kcal/100 g), medium energy density (provides 350-450 kcal/100 g) and low energy density (provides below 350 kcal/100 g). The suitability of foods for the management of children with severe acute malnutrition (SAM) was assessed according to energy and nutrient density, nutrient profile, palatability, safety, cost-effectiveness, shelf life and feasibility of production scale-up for large-scale provision.

Results

Forty-two food items were identified, seven (17%) of which had high energy density, 14 (33%) medium density and 14 (33%) low density; no nutritional information was available for the remaining seven nutritional products. While most products met the protein requirements of 10-12% of energy, there were concerns about the quality of protein in some products and their protein digestibility-corrected amino acid score (PDCAAS)². There were also questions regarding the type of fats used and how this may influence cost and shelf life; for example, palm oil (used in some products) is cheaper and has a longer shelf life compared to other types of fat. Half (n=21) of the food products were enriched with micronutrients and one food item was fortified with spirulina. A total of 26 out of 42 (62%) products were ready to eat without preparation. The remaining products (38%) were in the form of powder that required some cooking or the addition of warm water or milk before consumption (and therefore dependent on the quality of the milk or water added and cooking process). Information on shelf life of products was available for only eight (20%) of the products; for those with information available, shelf life (a key consideration for community use) varied between two to three and 180 days.³

Discussion

In spite of the limitations of the study, including missing information around cost, nutrient values and shelf life of some products, findings were useful in demonstrating the potential to adapt existing food products in India for use in the management of SAM children in the community. The review concluded that the quality of certain available food products could be supplemented; for example, with high-quality proteins (e.g., milk or egg protein) and multivitamin and mineral mixes, to more closely meet World Health Organization (WHO) standards for therapeutic feeding. Results were shared with state governments to support their exploration of alternative foods for the treatment of children with SAM at community level.

A supervised supplementary feeding programme (SSFP) was initiated by the Women and Child Department (WCD) of the Government of Telangana in December 2019 to tackle acute malnutrition in children aged 6-59 months in two rural districts (Asifabad and Gadwal) of the state, targeting over 6,000 children with acute malnutrition. In a joint collaboration by the Indian Council of Medical Research - National Institute of Nutrition (ICMR-NIN), Kalawati Saran Children’s Hospital (KSCH) and United Nations Children’s Fund (UNICEF) India Delhi and Hyderabad offices, a protocol for the SSFP was developed focusing on early identification of cases and community-based care for uncomplicated moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). A full list of SSFP activities is described in Table 1.

Table 1: Activities of the Telangana state SSFP

* All children are assessed for history of morbidity but only SAM children have a detailed medical assessment. If a MAM child is sick, he or she will be referred to nearest primary healthcare centre.

Product development

ICMR-NIN worked closely with the Government of Telangana to develop a new nutrient-dense food that could be used in the SSFP for the community-based management of SAM and MAM cases. The aim was to develop a product that would have the treatment advantages of ready-to-use-therapeutic food (RUTF) (effective treatment for recovery), while being tailor-made to children in the India context and acceptable at community level, and which could be produced locally and therefore at lower cost.

Based on findings of the review of existing food-based products, a decision was made to adapt the widely accepted food product for Telangana state already used as the take-home ration (THR) for all children aged 6 to 36 months under the government Integrated Child Development Services (ICDS) programme Balamrutham (meaning "child elixir"). An improved version of this product, Balamrutham+, was developed to improve its energy, protein and nutrient density (Table 2. Compared to Balamrutham (still routinely given to all children as a THR except SAM and MAM children who are catered for under this programme), Balamrutham+ has more skimmed milk powder (SMP), oil, added groundnuts and rice flakes to improve taste, and less wheat to reduce phytate content (Table 3). Rice flakes were used to reflect local dietary patterns in Telangana to ensure product acceptability. Balamrutham+ has lower milk protein compared to WHO therapeutic food recommendations; however, in the SSFP protocol, 200 ml milk and one egg per day are also provided to children with SAM which, together with the Balamrutham+ ration, meets protein requirements. The micronutrient profile of Balamrutham+ remained largely unchanged compared to Balamrutham, given that the original product already met Government of India (GoI) guidelines for THR and additional micronutrients, such as vitamin A and iron, are delivered separately through other blanket national nutritional programmes integrated into the SSFP. Balamrutham+ is a powder that requires dissolving in equal amounts of lukewarm water to provide a paste; we see no disadvantage of adding water to Balamrutham+ feeds, given that water must be given alongside all ready-to-use therapeutic foods (RUTFs), as long as the added water is procured from a safe source.

The product was finalised following an acceptability study of two possible recipes among MAM children and their mothers in the community. Both Balamrutham and Balamrutham+ are developed by a state-owned subsidiary, Telangana foods, under the WCD of the Government of Telangana. The product is distributed in 1 kg packets with packaging designed by UNICEF, with clear pictorial guidelines on handling for community health workers and caregivers. It has a shelf life of three months. The cost of producing Balamrutham+ is about 100 India Rupees per kilogram of final product (including the cost of packaging); twice that of the THR given to all children. However, this is much lower than commercially prepared food items due to the exclusive use of locally procured foods and government subsidies on the raw ingredients used, given the use of the product under social welfare schemes.

Feeds are given to children under five years old as per the SSFP dietary protocol of 75 kcal per kg of body weight of child for MAM and 125 kcal per kg body weight for SAM (dosed using 30 ml scoops). Feeds are given on site at Anganwadi centres for children older than 36 months and as a THR for those aged 6-35 months (as children in the younger age group do not attend Anganwadi centres). Dosage of Balamrutham+ and frequency are described in Table 4.

Programme outcomes

The original plan was to initiate the SSFP in both Gadwal and Asifabad districts from February 2020 (with full geographical coverage) and later scale up to 10 districts. However, manufacturing issues with Balamrutham+ meant that SSFP was implemented in only one block (of the proposed four) in Gadwal district in March 2020. A total of 497 children were recruited to the programme, of which 153 (31%) were SAM and 344 (69%) MAM; 58.5% were boys. The target for the programme was set at a 50% recovery rate for SAM and MAM children combined (using discharge criteria in Table 1), decided based on results of a study by Bhandhari et al (2016). The intention was to follow children up for the full duration of the programme to assess progress towards the target recovery rate and therefore feasibility of the use of Balamrutham+ within this programme. However, data could only be collected for two weeks due to the impact of the COVID-19 pandemic. For MAM children, after two weeks of food supplementation, 22.3% reached the discharge criteria (weight-for-height (WFH) z-score -2 SD or more). This was higher in younger children (6 to 35 months) compared to older children (over 36 months) (26.2% vs 18.2% recovery rate at the end of two weeks). As expected, recovery rates at the end of two weeks were lower for SAM children; 17.7% reached the criteria for MAM (WFH between -2SD and -3SD) and no SAM children met the discharge criteria. A higher proportion of younger SAM children aged 6-35 months met the MAM criteria compared to older children (over 36 months) (20.4% vs 11.4%).

Adaptations and impact of COVID-19 on the SSFP programme and next steps

As a result of lockdown measures imposed due to the COVID-19 pandemic, Anganwadi Centres were initially closed which prevented access to growth monitoring and feeding services. Once re-opened, services resumed but with less regular follow up of admitted children and reduced programme monitoring. In response, SSFP protocols have been adapted, for example through adoption of mid-upper arm circumference (MUAC) for growth monitoring and admissions (using admission criteria MUAC <11.5 cm for SAM and <12.5 cm for MAM) and implementation of a separate strategy for follow-up visits in designated COVID-19 containment zones. For monitoring, mobile phone applications are being used to enter data, with adaptations to allow for the collection of MUAC.

Subsequent to the pilot study, the SSFP was rolled out in all planned blocks in Gadwal and Asifabad districts according to original state plans, in spite of COVID-19 interruptions. Throughout August 2020, virtual capacity building was carried out for frontline workers of both districts to support COVID-19 related programme adaptations. Plans are being made to repeat the study in programme areas using MUAC-only criteria, with revised COVID-19 protocols and follow-up for the full length of stay. The manufacturing of Balamrutham+ has now been scaled up to meet the needs of MAM and SAM children across Telangana state, and the government aims to fulfil its commitment by scaling up the SSFP across districts state-wide.

The use of therapeutic foods for acute malnutrition has evolved over several decades, yet uncertainty remains in India concerning the best products to use in the community context. This is due both to a lack of consensus in the scientific community in India on the most effective product to use, and policy decisions taken by the Government of India (GoI), which can largely be attributed to a lack of convergence among the stakeholders concerned. The effort outlined in this article aims to bridge this gap in consensus by examining the benefits of adapting existing acceptable, affordable and therefore sustainable food products to meet the required standards for therapeutic feeding in the community in the context of a state-level supervised supplementary feeding programme (SSFP). The experiences of using an adapted product in the SSFP were significantly compromised by the impact of the COVID-19 pandemic in the early stages, however, what data is available shows encouraging initial results. The programme has since been scaled up according to state government plans and adaptations are currently being made to ensure the continuation of the programme in the current context, which may help make this programme more resilient in emergency situations. The experiences described in this article can be used to inform other states in India in the future implementation of community management of acute malnutrition programming, based on the forthcoming GoI guidelines.

Bhandari N, Mohan SB, Bose A et al. for the Study Group (2016). Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Global Health 2016;1:e000144.

Kulkarni, B. & Mamidi, R.S. Nutrition rehabilitation of children with severe acute malnutrition: Revisiting studies undertaken by the National Institute of Nutrition. Indian J. Med. Res. 150, 139-152 (2019).

FAO and WHO (2018) Joint FAO/WHO food standards programme codex committee on nutrition and foods for special dietary uses fortieth session, Berlin, Germany 26-30 November 2018. Proposed draft guidelines for ready-to-use therapeutic foods.

WHO, UNICEF, WFP, UN Standing Committee on Nutrition (2007). Community-based management of severe acute malnutrition: a joint statement. Available from: www.who.int/maternal_child_adolescent/documents/a91065/en

Table 2: Balamrutham plus (+) nutrients and fortification for 100 grams of product

Table 3: Balamrutham plus (+) ingredients for 150 grams and 100 grams of product

Table 4: Number of packets (given per week) and scoops per feed for MAM and SAM children

Note: This is for packets weighing one kilogram. For every one scoop of feed (30 g), one scoop of water is to be added.

Key: MAM = moderate acute malnutrition; SAM = severe acute malnutrition.