Marketing Nutrition – Warning towards commercial exploitation

THE high-profile India launch of The Lancet 2013 series on “Maternal and Child Nutrition” on June 28 generated the much-needed debate on what exactly constitutes India’s nutrition needs and goals. The first series, comprising five papers, was published in The Lancet in 2008.

The latest series identifies a set of “ten proven nutrition-specific interventions”, which, according to the authors, “if scaled up from the present population coverage to cover 90 per cent of the need would eliminate about 900,000 deaths of children younger than five years in the 34 high nutrition burden countries, where 90 per cent of the world’s stunted children live”. The effects of these interventions have been calculated in these countries across Asia, Africa and West Asia, and they reinforce the importance of early nutrition in the health of children, that is, the first 1,000 days between pregnancy and 24 months, in preventing under-nutrition in mother and child. This, the authors say, is the crucial period to lay the foundation for good health as neglect of maternal, newborn and child nutrition can have irreversible consequences in the current and next generations.

The new series seeks to establish that under-nutrition has important consequences for economic development and that stunting of growth and vitamin and micronutrient deficiencies could have adverse effects on the child’s survival. It also say that obesity among adults and children is emerging as an additional burden affecting both rich and poor populations. It recommends nutrition-sensitive and nutrition-specific interventions and argues that programmes in agriculture, cash transfers, and early child development have shown to improve nutritional and developmental outcomes in children. The private sector, it says, is an important force in shaping nutritional outcomes.

Authored by a consortium of scientists led by Robert E. Black of the Johns Hopkins Bloomberg School of Public Health, the 2013 series claims to have addressed “country priorities to strengthen nutrition”, a concern reflected in the 2008 series on “Maternal and Child Undernutrition”, and ignored by donors and agencies. Unfortunately, the latest series also derives its own understanding of the prioritisation of interventions by countries and argues for a strong component of questionable initiatives involving the private sector in preventing malnutrition.

Scaling up nutrition

Understandably, the approaches and the remedies offered by the series have been questioned by experts in the paediatric sector in India. One such initiative, which the series actively propagates, is the Scaling up Nutrition initiative, or SUN, a policy brief released at the spring meetings of the World Bank and the International Monetary Fund in April 2010. On the subject of raising resources, both public and private, the authors emphasise that SUN is a crucial driver of these needed actions and that support for it must remain strong. This movement was launched at the United Nations General Assembly in September 2010 even though it has no direct association with the U.N.

Interestingly, the authors have declared that they have no conflict of interests. Black and Venkatesh Mannar, president of the Micronutrient Initiative, have declared that they serve on a committee of a multinational baby food manufacturer, the Nestle Creating Shared Value Advisory Committee. Black was on the board of the Micronutrient Initiative and Vitamin Angels.

“As long as it is declared and there is no influence in the studies, and private corporations do not influence the authors, there is nothing wrong,” Venkatesh Mannar told Frontlineabout the conflict of interests, a point raised by paediatricians and health experts. He said SUN was like a club, and India could join it if it saw value in it.

The series claims to be guided by a new framework that shows how to achieve optimum foetal and child growth. This framework shows the dietary, behavioural and health determinants of optimum nutrition, growth and development and how they are affected by underlying food security, care-giving resources and environmental conditions, which are in turn shaped by economic and social conditions, national and global contexts, resources and governance. It then talks about nutrition-specific and nutrition-sensitive interventions that could purportedly address the underlying determinants of malnutrition.

It is surprising that the framework chooses to find all the solutions for malnutrition within the narrow confines of nutrition alone while discounting other major determinants, including purchasing power, food safety nets, access to clean drinking water, health care, sanitation and, above all, access to wholesome food. The report does not talk about rise in food prices, both in the national and international context, which itself is a major determinant of what people are able to consume.

In fact, one of the lead authors negates the link between purchasing power and access to food. The series also does not underscore the importance of increased government spending on the social sector, especially in India where spending is one of the lowest not only in the world but also in South Asia. In fact, rather than advocate a strong government influence in policymaking and spending, the series exhorts the private sector to step in more actively.

Complementary food advocated 
Looking at the determinants of stunting and overweight, the series advocates complementary food and also mineral and vitamin supplementation. It acknowledges wider environmental factors, such as unsanitary conditions, leading to diarrhoea, which could be a cause of stunting. Interestingly, in the same vein, child overweight receives disproportionate importance in the report without a critical look at the links between formula feeding and childhood obesity.

Whether deficits are in utero or occur post-conception in the first 1,000 days of the baby’s birth, the push for complementary feeding of a certain kind is apparent in the report, but there is no suggestion for an alternative that questions the economic determinants that have led to deficits in essential food in people’s lives.

In fact, the series emphasises that “treatment strategies for severe acute malnutrition with recommended packages of care and ready-to-use therapeutic foods [RUTF] are well established, but further evidence is needed for prevention and management strategies for moderate acute malnutrition in population settings, especially in infants younger than six months”. Peculiarly, while discussing “community-based management of Severe Acute Malnutrition”, the authors observe that no significant differences in mortality were seen among children who had been given RUTF and those who had been given standard care.

The problem is that the series tries to strike a balance by recommending breastfeeding along with the delivery of an infant and young child nutrition package, complementary feeding and micronutrient supplements. Even Union Minister for Rural Development Jairam Ramesh, who presided over the launch, offered segmented and fragmented solutions to a problem that needs a holistic and systemic correction beginning with greater investment in basic determinants. However, he cautioned against placing emphasis on nutrition-sensitive agriculture as it could unwittingly pave the way for hazardous genetically modified foods.

The fourth and the last component of the series, which is the most problematic one, pushes SUN as the most important symbol of the increased interest in nutrition. One of the co-authors of this chapter on “The politics of reducing malnutrition: building commitment and accelerating progress” emphasised at the launch that markets and the private sector were all “around us” and they could not be wished away. While the authors were at pains to explain that the effects of SUN on the rates of under-nutrition reduction were yet to be evaluated, one of the panels within the chapter says that “SUN presents an unprecedented opportunity for coordination, collaboration, cross-learning and advocacy to catalyse sustainable nutrition gains at national and global levels”.

The series devotes considerable space to private sector engagement and emphasises the opportunity for the private sector to contribute to the acceleration of malnutrition reduction, including expansion in new private philanthropic support for development.

“As a result of these many public and private sector intersections, the interest of the public sector towards business involvement and in under-nutrition efforts has increased substantially. The SUN Business Network is one indication of this change of interest,” the authors note.

Surprisingly, even as the series calls for regulation of the private sector, especially the commercial sector, in nutrition, it assumes that it is the lack of evaluation of the effectiveness of the sector, especially the food industry, that has led to distrust and links this to the “decades-long tension related to the marketing of breast-milk substitutes in developing countries and sugar-sweetened beverages and fast foods worldwide”.

The series even quotes from a paper published in British Medical Journal (2012), which argues that the law on infant foods inhibits the marketing of complementary foods for infants, furthering malnutrition in India. The series’ own position on infant foods remains vague and inhibited, given the fact that some of its lead authors are on the boards of giant baby food manufacturers.

Leading paediatricians, health experts and those associated with the Indian Academy of Paediatrics have cautioned the government, notwithstanding the enthusiastic release of the series, to refrain from making policy based on its prescriptions. While appreciating the “challenging and demanding work put in by the series authors and advocating that the post-2015 sustainable development agenda must put addressing all forms of malnutrition at the top of its goals”, a group of seven specialists, many of whom trained at and worked in leading government hospitals, expressed reservations about some broad issues and specific solutions being promoted in the series.

“Our sole intent is to caution the Indian government along with other stakeholders and to catalyse an informed and transparent process for funding appropriate and sustainable solutions for addressing malnutrition; this series should not be allowed to become an opportunity for commercial exploitation of malnutrition,” a statement issued by them said.

Conflict of interest

They have also pointed out the conflict of interest of the leader of the series and some other authors, who have particularly influential links with the food products and micronutrient industry. The experts argue that in the current era, policy decisions and recommendations in advanced countries (for example, the United States) and international agencies (the World Health Organisation) are arrived at by a transparent process involving only individuals with no conflict of interest. They have written to the Rural Development Minister and the various Ministries concerned about their apprehensions.

They have said that the prioritisation of interventions are based on several assumptions and imputations that are brittle and not open to alternative philosophies and should, therefore, be carefully revisited in the national context.

“Important observational evidence with nutritional implications (for example, safe water supply, sanitation and hygiene, family planning, literacy and other development aspects) has not been modelled while prioritising ten most important interventions [Chapter 2]. This produces bias for the selection of product-based solutions (particularly RUTF, and ready to use supplementary foods, or RUSF, and single or multiple micronutrients). For some interventions, the computed-effect estimates have excluded or ignored relevant, contemporary and high-quality evidence. For example, the estimate of the null effect of mega-dose Vitamin A supplement on child mortality from a trial on million subjects in Uttar Pradesh has not been aptly modelled, and negative trials of zinc supplementation on growth (from South Asia) have been excluded. The modelling basis for management of moderate acute malnutrition (MAM) as the fifth most effective intervention is unclear,” they say.

Serious issues

One of the panellists at the India launch, Vinod K. Paul, chair, Department of Paediatrics at the All India Institute of Medical Sciences (AIIMS), said that there were serious problems with four of the 10 interventions, including the advocacy of zinc supplementation, which would not be passed by the scientific community in India. Other panellists pointed out that nutrition-specific interventions did not go very far and that bio-physiological dimensions needed to be studied. Vinod Paul suggested the constitution of a high-level scientific commission for a holistic understanding of nutrition.

The experts have pointed out that the section on acute malnutrition will create intense pressure to introduce into the country specific products marketed by multinational corporations (RUTF and RUSF). They also quote from a recently published Cochrane Review, which concludes that “current evidence is limited; either RUTF or standard diet such as flour porridge can be used to treat severely malnourished children at home. Decisions should be based on availability, cost and practicality.” It would, therefore, be prudent to adhere to the government’s stated position of not using RUTF for community treatment of severe malnutrition.

“In the zeal for advocacy, safety concerns with some interventions, particularly in some heterogeneous groups, have receded. These must constitute an integral part of the decision-making process,” they have pointed out.

The disproportionate positioning of SUN as a global leader in nutrition received special criticism. The series authors were constrained to clarify that India was not bound to be a signatory to the movement. They were also at pains to explain that it was a voluntary movement and had little to do with the U.N. Arun Gupta, member, Prime Minister’s Council on India’s Nutrition Challenges and regional coordinator, International Baby Food Action Network Asia, said that the second series somehow squarely projected SUN, which has acquired the status of a movement. “Business,” he said, was at the heart of SUN’s strategy and was embedded in its principles.

While acknowledging that violations of the International Code of Marketing of Breast-milk Substitutes has created distrust of commercial interests, the paper limits this distrust to “some groups of the nutrition community”, and states that this distrust can result in missing the “opportunity” to rope in the private sector. Nutrition and the food industry are big business and developing countries such as India are big markets. In such a scenario it is up to sovereign governments to frame their own policies on the basis of unbiased scientific evidence where there is not the slightest hint of a conflict of interest.

Likewise, partially informed and uninformed debates too obfuscate much of the real issues, which lie not in targeted nutrition-specific or nutrition-sensitive interventions but in more government spending on crucial social sectors that form the basis of goo

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