Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in IndiaBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e8131 (Published 30 November 2012) Cite this as: BMJ 2012;345:e8131
- Veena Rao, adviser, Karnataka Nutrition Mission, Department of Health and Family Welfare, Government of Karnataka, Ananda Rao Circle, Bangalore 560009, India
Data continue to show stubbornly high rates of undernutrition in children in India. Almost two in five (38.4%) children under 3 years old are stunted, 19.1% wasted, and 45.9% underweight.1 Every third malnourished child in the world is from India, says the current Unicef website on India.2 India has one of the highest levels of child malnutrition in the world, more than in most countries in sub-Saharan Africa.3
The multiple causes of child undernutrition are well documented—poverty, sex inequality, poor cultural practices, and poor governance. But another important cause not articulated strongly enough is market related. At present the Indian market completely lacks affordable complementary foods for infants from poor families or for poor children during or recovering from illness. Just over half (55.8%) of children aged 6-9 months in India receive complementary foods.1 This is one of the main causes of acute undernutrition among children younger than 2 years, affecting their physical and cognitive development.
The sale of breast milk substitutes, infant foods, and complementary foods are governed by the International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Organization in 1981.4 The code advocates two evidence based practices to reduce undernutrition and infant mortality: exclusive breast feeding up to 6 months and complementary feeding after 6 months.4 5 6 It prohibits the advertising, promotion, and discounting of breast milk substitutes or bottle feeding and the provision of free samples. Although the code defines complementary food, it sets no standards about its marketing. The definition is “any food, whether manufactured or locally prepared, suitable as a complement to breast milk or to infant formula, when either become insufficient to satisfy the nutritional requirements of the infant.” Such food is also commonly called “weaning food” or “breastmilk supplement.”
In response, India passed the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992.7 The act does not define “complementary foods” or “weaning foods,” implying that they are included in the definition of “infant food.” An amendment dated 19 December 2003 puts “infant milk substitutes,” “feeding bottles,” and “infant food” into a single category.8 The result is that the prohibitions that apply to advertising and marketing of breastmilk substitutes and infant foods below the age of 6 months also apply to the complementary and weaning foods so essential for proper nutrition and health of children older than 6 months.
Thus the unintended consequence of the code and India’s act is that they deter the food industry from producing cheap, fortified complementary foods for children older than 6 months. The Indian food industry is not developing cheap complementary foods because of the marketing prohibitions and the lack of a specific mandate in the international code. It is also likely that because of this legal barrier, public health experts and civil society do not mobilise support on the matter.
The international code has had the desired positive effect on the Indian government, creating greater awareness of exclusive breast feeding up to 6 months and making it integral to child health programmes. However, the second equally critical principle, prevention of child undernutrition by initiation of complementary food after 6 months has been neglected and not accorded equal priority.
At present there is no international code for the introduction, marketing, and production of complementary foods for children older than 6 months, even though this is stipulated as a principle in the International Code of Marketing of Breast Milk Substitutes. So national governments are not sensitised adequately. Neither are they under any international obligation to formulate national codes in this vein, and this is essential if India is to improve the nutritional status of children under 2 years.
WHO’s 2001 global consultation recommends forceful advocacy of complementary feeding for infants after 6 months.9 However, these remain recommendations, without the strength of legislation, and have not resulted in any specific interventions in India.
The WHO 2001 guidelines on complementary feeding9 must be developed to formulate an international code for the promotion and production of complementary foods. This would set the necessary standards and enable national governments and civil society in India to actively advocate production and marketing. It would also remove market inequity, where expensive foods for the nutritional wellbeing of privileged children are plentiful but nothing is on the shelf for the poor.
Cite this as: BMJ 2012;345:e8131
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.