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Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8131 (Published 30 November 2012) Cite this as: BMJ 2012;345:e8131

Re: Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India

Veena Rao’s write up on "Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India" is misleading and requires urgent clarification. We strongly refute her assertions blaming International Code of Marketing of Breast Milk Substitutes and Indian Legislation - the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992 and amended in 2003 (IMS Act), for the furthering undernutrition in India. We have following observations for submission:

1. Providing no scientific evidence to substantiate her assertion, the author proposes that the commercial promotion of complementary foods will reduce child undernutrition in India. The Lancet Series on Maternal and Child Under nutrition has clearly stated that aside from suboptimum breastfeeding which results in 1.4 million deaths and 10% of disease burden in children younger than 5 years in populations with sufficient food, education about complementary feeding is sufficient and in populations with insufficient food the provision of food supplements (with or without education) are effective measures to address stunting (1). The national guidelines on Infant and Young Child feeding, developed by Ministry of Women and Child Development, Government of India, states recommend only home-made complementary foods for infants and young children (2). The Indian Academy of Pediatrics, in its’ Infant and young child feeding guidelines (2010) recommends age specific home-made food like porridge, well mashed foods, Chopped foods and family foods (3).

2. We are not aware of any evidence of a relationship between the COMMERCIAL promotion of complementary foods and the REDUCTION in prevalence of undernutrition. Indeed the prohibition on advertisements and promotion for foods for children under 2 in India became effective only in 2004, yet the scourge of malnutrition has been present in India for many decades before the legal prohibition. Data from last three National Health and Family Surveys namely, NHFS1 (1994-95) NFHS 2(1998-99) and NFHS 3(2005-06) reported a very high prevalence of undernutrition in children (4). Moreover, a recent survey report in India has revealed that in the 100 focus districts, the prevalence of child underweight has shown a 20.3 percent decrease over a 7 year period with an average annual rate of reduction of 2.9 per cent (5). This is important to note that during this period complementary foods have remained under the purview of the IMS Act with prohibition on their promotion through advertisements and health care facilities. It again busts the myth that law on infant foods is furthering the undernutrition in India.

3. Child undernutrition in India is not merely a problem of the poor as stated by the author. An analysis of data of National Health and Family Survey 3 (NFHS 3) (4) reveals that among the children in the highest wealth index, 25.3 are stunted, 12.7% are wasted, and 19.7% are underweight. Parents of these children have a better access to markets and hence commercial infant foods.

4. The real problem lies in the fact that only 20.7% among all children 6-23 months in India receive optimal infant and young child feeding namely, Breast milk, milk, or milk products; appropriate number of food groups; and minimum times of complementary foods (4). But the promotion of commercial foods to the poor is certainly not the best and most sustainable way to address this problem. The Global Strategy for Infant and Young Child Feeding (WHO, UNICEF, 2003) recommends: “Providing sound and culture-specific nutrition counselling to mothers of young children and recommending the widest possible use of indigenous foodstuffs will help ensure that local foods are prepared and fed safely in the home.” The global strategy has suggested a very limited role for “Industrially processed complementary foods”(6). In fact one of the major causes of malnutrition is lack of health education or exaggerated health claims which promotes commercial food (unaffordable by most of the population) at the cost of homemade food (which is easily available and affordable). The primary reason for the lack of diversity is probably knowledge, but also the high prices of foods from various groups. The HUNGaMA survey report from India has reported that 93.7% mothers in studied population were not giving non-cereal foods to infants because they are expensive (5). On the other hand, Healthy Food, Healthy Child, a FAO EU Food Facility Project in Cambodia to improve dietary diversity and family feeding practices with nutrition counselling, starting with infant and young children, has shown positive results in preventing undernutrition and sickness (7).

5. Since the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992 which was amended in 2003, is regulating the marketing of infant milk substitute, infant foods and feeding bottle very effectively, we see no need either to dismantle these controls and allow commercial promotion of products for this vulnerable group or develop a separate code for marketing of complementary foods.

Dr. JP Dadhich MD (Paediatrics)
National Coordinator,
Breastfeeding Promotion Network of India (BPNI)
jpdadhich@bpni.org

Dr. Sailesh Gupta MD (Paediatrics)
Secretary General,
Indian Academy of Pediatrics (IAP)
secgeniap1213@gmail.com

Dr. Satish Tiwari MD (Paediatrics)
President, Indian Medico-legal and Ethics Association
drsatishtiwari@gmail.com

References:

1. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA,Kirkwood B, Morris SS, Sachdev HP, Shekar M; Maternal and Child UndernutritionStudy Group. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008 Feb 2;371(9610):417-40
2. National guidelines on infant and young child feeding, Government of India, 2006. Available at: http://wcd.nic.in/publication/infantandyoungchildfeed.pdf
3. Infant and Young Child Feeding Chapter, Indian Academy of Pediatrics, Rajeshwari K, Bang A, Chaturvedi P, Kumar V, Yadav B, Bharadva K, Gupta S, Gupta P, Shah D, Aneja S, Dubey AP, Tiwari S, Choudhury P, Agarwal RK. Infant and young child feeding guidelines: 2010. Indian Pediatr. 2010 Dec; 47(12): 995-1004.
4. International Institute of Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS - 3), 2005-06: India: Mumbai:IIPS.
5. Naandi Foundation. Fighting Hunger and Malnutrition - The HUNGaMA Survey Report. Available at: http://hungamaforchange.org/HungamaBKDec11LR.pdf. Accessed on 17 December, 2012
6. WHO/UNICEF Global Strategy for Infant and Young Child Feeding, World Health Organization (WHO), 2002. Available at: http://www.who.int/child-adolescent-health/NUTRITION/global_strategy.htm Accessed on 17 December, 2012
7. FAO. Improved Complementary Feeding recipes diversify infants and young children's diet. Available at: http://www.youtube.com/watch?v=0rUX6F7ieVY). Accessed on 17 December, 2012

Competing interests: No competing interests

17 December 2012
JP Dadhich
Paediatrician
Sailesh Gupta,MD, Secretary General, Indian Academy of Paediatrics; Satish Tiwari, MD, President, Indian Medico-legal and Ethics Association
Breastfeeding Promotion Network of India
BP33, Pitampura, Delhi
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