Death by biscuit
Malnutrition isn’t a rural worry. Worse, in Mumbai, it’s not the lack of food but craving for junk that’s proving fatal.

Sammrudhi Pawar is playing with her two-anda-half-year-old brother Siddhartha. “Do you like Maggi?” we ask. She nods. “How many times can you eat it in a day?” One hand clinging to her dress, the four-year-old bends over a low stool placed outside the Dhobi Ghat centre of the Foundation for Mother and Child Health (FMCH-India), and raises the other hand, all five fingers up.

It’s the answer you’d get from a noodleloving child anywhere in the world, except that until two years ago, that’s all Sammrudhi ate. That and biscuits dipped in milk.

Her mother Anushka Pawar, 27, says with a smile, “Aur kuch nahin khaati thi. Usko biscuit hi chaahiye the.”

The homemaker lives with the two children and her husband, who she says works in “housekeeping”, in the Ganesh Nagar area of Dhobi Ghat, Mahalaxmi.

50% Indian kids under 5 are malnourished

Once, a predominantly slum area, it now houses high-rises built by the Slum Rehabilitation Authority. The average income of a nuclear family here ranges from 20,000 to Rs 25,000. Which means the Pawars can afford to feed their kids better, if they’d agree to eat. “Anushka brought in Sammridhi when she was a year old,” says Piyasree Mukherjee, COO of FMCH, adding, “and at that time the child was far below her weight and height category.”

Malnutrition cases are alarmingly high in Ganesh Nagar, as with other urban slum pockets in Mumbai, says Mukherjee. FMCH is a non-profit that focuses on encouraging early preventive health and balanced nutrition practices within economically disadvantaged communities in Mumbai through planned interventions and access to free healthcare services.

And the reason is reliance on processed, packaged eats.

Eighty lakh Indian children under the age of five are acutely malnourished, says Dr Rupal Dalal, paediatrician and director of health at FMCH. This means they are underweight for their age and gender category. With an impaired immune system, they are at nine times more risk of death. “Even one episode of diarrhoea can be fatal in such cases,” she adds. It’s not just weight that’s affected.

Malnourished children also register stunting and poor cognitive development.

Defined by the UN’s Word Food Programme as the condition when a person does not get enough food or if the food they eat does not provide sufficient micronutrients to meet daily nutritional requirements, malnourishment leaves an imprint on growth even if the child eventually returns to normal weight. Even in cases where malnourishment is arrested within two years of birth, stunting of three to five centimetres coupled with an IQ of five to 10 points lower means the damage is done, says Dadar-based paediatrician and member of the Centre for Study of Social Change, Dr Ramesh Potdar.

If 50 per cent of Indian kids under five are malnourished, “that’s half your future generation not being able to help build the economy of a country that craves development,” according to Mukherjee.

Dose of affection

A little less than eight kilometres away from the Pawars, in Mahim, live the Chauhans, who have built themselves a small shanty on Tulsi Pipe Road. Twenty five-year-old Kali Chauhan spends the afternoon weaving baskets on a spot she finds outside her tarpaulin tent. Her three-year-old daughter Simran, clings to her as she slits bamboo with a sickle. She buries herself in her mother’s dupatta when we try to talk to her. She resurfaces, however, when a wafer seller walks past. Kali lets her pick three packets, two of which Simran devours within minutes. The third is reserved for Simran’s brother, four-year-old Badal. “I haven’t cooked today. I wasn’t feeling too well. But she must be hungry. The nalliwala will be coming soon,” she says about the vendor of deep fried flour cylinders.

Her illness doesn’t let her skip work since the family lives off daily wages. Kali’s husband Jogi will cart the baskets to Navi Mumbai, where they are sold for Rs 100 each. On a good day, he sells four. The family earns Rs 300 after deducting the cost of bamboo. Of this, Rs 60 – one-fifth of the day’s earnings – will be spent on chips.

This indulgence, coupled with persistent attack from advertisements, makes parents happy to feed their toddlers cream biscuits dunked in chai or milk and instant noodles “fortified with nutrients”.

In Phule Nagar, Powai, where migrants from UP, Bihar, Karnataka, Tamil Nadu and Maharashtra occupy shanties that line a two-metre-wide central path, 22-year-old Reeta Narendra Ladke sits in the Smiles Anganwadi which FMCH rents out for a few hours every day. Ladke, who has three children – the eldest is six – admits that during the initial years, she fed the kids Maggie and cookies. “Soft and easy to chew, these are favourites with children. They (ads on TV) say they have extra calcium, iron and minerals,” says Ladke, who had to seek medical help when one of her daughters developed white spots on her skin, a symptom of calcium deficiency.

Aspiration – “I can afford to feed my child what is shown on TV” – also prods parents into shopping at the local kirana store. And then there is the time factor. “Most mothers can’t spend hours cooking nutritious food. And with water availability limited to a few minutes each day, cooking is a task that must be completed soon,” says Dr Dalal.

Stepping in to help

At the Nutrition Rehabilitation and Research Centre, a three-year-old project initiated by the Lokmanya Tilak Municipal General Hospital in Sion, 300 fresh cases of malnutrition are registered every year. Dr Alka Jadhav, professor of paediatrics and her team of 12, including a UNICEF consultant and three nurses, cater to three inpatients a week, in addition to several walkins, mostly from Mumbai.

Once a child is identified as a patient of Severe Acute Malnutrition (SAM), s/he is put on an emergency diet of F75, a therapeutic milk product used as initial resuscitation food to fight malnutrition for 48 hours.

Next, the child goes through an appetite test. It’s to measure how much s/he can eat in a single sitting. A child weighing 5 kg should be able to consume at least 15 gm of food at a time. If s/he can, the child is shifted to the F100 diet (100 kilocalories/per meal/3 days). Once completed, s/he is put on Medical Nutrition Therapy (MNT) – 100 gm per cup measuring 500 kilocalories and 14 gm of protein.

The health centre has also set up a food production unit in Dharavi’s urban health centre in collaboration with IIT’s Food Technology department to produce MNT. The process is mechanised. Ingredients like peanut butter, vegetable oil, skimmed milk, sugar and micronutrients are treated, ground, mixed and packed into cups. With the help of Society for Nutrition, Education & Health Action (SNEHA), an NGO that works with communities in Dharavi, Kandivali, Govandi and Mankhurd, two cups of the potion are delivered to every home with children for two months.

Since the success of their project launched three years ago (of 13,000 children screened, 600 had SAM, 70 per cent of whom moved to the Moderately Acute Malnourished category in 2 months), UNICEF has taken over its funding. In the case of a community project like this, even a 20 per cent prevalence drop is seen as success. The model will be presented at a conference in Brazil this year. “Eighty per cent of cases we see are due to poor food choices rather than complete lack of food,” says Jadhav.

Often, parents fail to connect the dots between a child’s failing health and that packet of nalli in their hand.

On the same street as Kali lives 22-yearold Rekha Chavda and Patru, 38. They are debating whether their 15-month-old daughter Payal should be drinking tea.

Payal is Rekha’s third child. The two daughters that were born before her died at the age of two and four months respectively. Though no doctor was willing to issue a death certificate, the blame was assigned to common cold. Two children from this 120-member Mahim shanty community fall prey to ‘cold’ every year. Last week, it claimed another victim.

Abhishek Bharadwaj, who works with Alternative Realities, puts it down to malnourishment. “A child dying from a common cold isn’t normal,” he says. Often, mothers don’t receive nutritional advice from doctors. “Doctors at most government hospitals see 100 patients a day. There’s no time to counsel mothers on what to feed the kids,” adds Dr Dalal. Where the anganwadis – intervention centres set up by the government under its Integrated Child Development Services programme where children are screened and allotted food to take care of their nutritional needs – fall short, agencies like SNEHA and FMCH step in.

At their Dhobi Ghat and Phule Nagar centres, FMCH nutritionists counsel mothers on the correct complimentary feed to give their children after six months. Cooking classes are held every week to introduce them to healthy ingredients that can be made into quick bites to replace packaged corn puffs. A costing exercise helps drive home the message that a Rs 10 junk snack a day can leave a family bereft by Rs 9,000 a year.

NGOs that run schools within the communities are also pitching in. At one school run by Muktangan at Elphinstone, preschool teachers describe the lengths to which they go to ensure that their students eat healthy. “If we see them bringing junk in their tiffins on a regular basis, we counsel their parents during PTA meetings or call them for a one-on-one,” says Gauravi Jadhav, pre-school coordinator of the NGO run by Paragon Charitable Trust. During lunch, teachers join them in eating the mid-day meal – khichdi mixed with vegetables. At Muktangan, a daily serving of fruit is mandatory for all. “When the children see everyone eating healthy foods, they are encouraged too,” Jadhav adds, referring to the common complaint most social workers in the industry have – parents also subsist on khaari and chai for breakfast and vada pav, Chinese bhel through the day.

But the adults seem to have other problems to address. At Phule Nagar, where a sample survey conducted by FMCH in May this year found 46 per cent children ill with fever/cold and cough and/or diarrhoea during a five-day period, a middle-aged woman points to a group of men spending their afternoon playing cards. “The government should stop this first, or shut down alcohol shops.”

To determine a child’s nutritional status, its status is compared to a health reference (child of same sex and age). International standards are defined by the National Centre for Health Statistics (NCHS). The information log allows for a small range of deviations from the ideal height and weight at a particular age. Using this deviation and a formula, experts calculate the Z-score of the child – a weight for height comparison against the healthy child.


Biscuits: Have refined flour and hydrogenated fats, added soda to make them crisp. Causes constipation, has empty calories.

Instant Noodles: Have refined flour, preservatives. Causes constipation and loss of appetite.

Spiced Corn Puffs: Burn on heating, like plastic. Have added colour and preservatives, decreases absorption of nutrients from other foods. High in salt and oil.

Nalli and Spiced Wafers: Have excess oil and salt. Fried in leftover and reused oils. Packaged in unhygienic conditions. Causes tummy infection.

Chocolate: Reduces calcium absorption, hunger.

See pics:

1. Sammrudhi Pawar is playing with her two-anda-half-year-old brother Siddhartha.

2. Anthropometric (proportion of body and hence growth) measurements, including circumference of head and muscle mass on limbs, indicate a child’s physical development

3. Basket maker Kali Chauhan and her husband earn about Rs 300 a day. Of this, Rs 60 is often spent on chips for their 3-year-old daughter Simran and son Badal, 4

4. FMCH conducts weekly cooking demos at its Phule Nagar and Dhobi Ghat centres where moms are taught to make spinach sheera, gajar soup among other healthy, tasty snacks

5. Residents of Ganesh Nagar, Dhobi Ghat, Varsha Deepak Jadhav’s one-and-a-half-year-old son Tanay is underweight and short for his age. Unlike his friends, he is unable to string words to form a phrase. FMCH nutritionists, who he visits, put it down to his low birth weight (1.45 kg instead of 2). Jadhav, owing to morning sickness, survived on a diet of biscuits and fruits through her pregnancy. Tanay too was fed biscuits dipped in milk till a few months ago.

41% of Maharashtra’s children under age 2 are stunted

About 16.3 % have been identified as severely underweight