The Maharashtra government has put on hold its plans to supply ready-to-use therapeutic food products to severely malnourished children in rural government-run crèches called anganwadis. The government announced this decision in the Bombay High Court on September 13, during a hearing of a writ petition against the state’s tender calling for bids for such therapeutic foods.

As the name suggests, therapeutic foods are medicinal products. They are not to be confused with the controversial “ready-to-cook” mixes that are set to replace hot cooked meals for three million children in the age group of three to six years in Maharashtra.

On July 17, the state government called for bids for the supply of therapeutic foods despite two central ministries stating that this is in violation of national guidelines.

In recent years, the World Health Organisation and United Nation’s Children Fund have been promoting therapeutic foods as a short-term treatment for severe acute malnutrition in children. But most studies in India have not found them to be significantly more effective than home-cooked food. Besides, they are also more expensive to produce.

On August 28, the Union Ministry of Women and Child Development sent letters to state governments reminding them that the use of therapeutic foods to tackle malnutrition is “not an accepted policy” of the Government of India. These guidelines were laid down by the Union Ministry of Health in 2009.

Ignoring these guidelines, the Maharashtra government issued a tender calling for bids worth Rs 38 crore for the production and supply of “Energy Dense Nutritious Food” – another term for ready-to-use therapeutic food. The tender said this would cover 85,000 severely malnourished children under the Integrated Child Development Services, a four-decades old nationwide scheme, which aims to boost child nutrition and health. The scheme is funded by the Centre and must, therefore, run in compliance with central government guidelines. The Union Ministry of Women and Child Development supervises this scheme.

On Monday, officials at Maharashtra’s Women and Child Development Department said that they had not received the Union ministry’s letter. “We are continuing with the process of examining the bids that we have got for the tender,” said a senior department official who did not wish to be identified.

On Wednesday, however, the state informed the High Court that it was putting the tender on hold.

“If the state government had not stayed the tender on its own, chances are the court would have stayed it anyway, because two central ministries are very clear about their stance,” said Dr Abhay Shukla, national co-convener of the public health advocacy group Jan Swasthya Abhiyan.

What are therapeutic foods?

Ready-to-use therapeutic foods comprise a powdered mixture of dried milk, vegetable oil, sugar, peanut butter, vitamins and minerals embedded in a lipid rich paste. They do not need to be cooked.

Ready-to-cook mixes, on the other hand, are dry, dehydrated and micronutrient-fortified versions of regular meals, which need to be cooked for 15-20 minutes in water before consumption.

In recent years, the World Health Organisation, Unicef and a sizeable lobby in the global food industry have been promoting the use of therapeutic foods to treat severe acute malnutrition. Children with severe acute malnutrition have a very low weight for their height, and visible signs of wasting.

The Maharashtra government tender claims such children are “nine times at risk of dying” than healthy children. Since 9.4% of Maharashtra’s children under the age of five are severely malnourished, the tender claims that energy dense foods would help reduce their mortality rate. The outlay of Rs 38 crore for 85,000 children works out to Rs 12 per child per day – higher than the current spending of Rs 9 per child per day on take home rations.

But many nutritionists and activists in India are unconvinced of its benefits. “There is no scientific evidence to show that therapeutic foods are more successful in treating SAM [severe acute malnutrition] than home-based hot cooked food,” said Purnima Upadhyay, co-ordinator of the Jan Arogya Abhiyan, a network of non-profit organisations working for public health in Maharashtra. “Why spend so much money on RUTF [ready-to-use therapeutic foods] then?”

What does the research in India show?

Over the past three years, at least six Indian states have conducted Unicef-backed pilot studies on “community-based management of acute malnutrition”, which relied on treatment using therapeutic foods to pull children out of severe malnourishment.

One of the studies was conducted in Maharashtra’s Nandurbar district by the state women and child development department along with Unicef and the Tata Trust. Over 11,000 children with severe acute malnutrition were given either home-based nutritious food or therapeutic food mixes. The therapeutic food mixes were procured through the Tata Trust at the rate of Rs 70 per packet.

Maharashtra’s women and child development secretary Vinita Singal has claimed that the state’s decision to supply therapeutic foods to severely malnourished children through the new tender is based on this study.

But the study’s results have not been made public.

Rajan Sankar, senior nutrition advisor at the Tata Trust, said, “I believe the recovery rate from malnutrition was found to be slightly higher among children fed with RUTF [ready-to-use therapeutic foods] than those fed with home-based foods.”

He clarified that the recovery rate with home-based food was also quite high. “Nowadays, the general consensus seems to be that children with SAM [severe acute malnutrition] can be managed with home-based food as well,” he said.

Upadhyay questioned the government’s reliance on an unpublished study. “The government claims it finds the study useful, but if the results are not yet in the public domain, how can they implement RUTF [ready-to-use therapeutic foods] in the state?” she asked.

Other research studies in India have thrown up contentious results.

A study commissioned by the Union government in 2016 compared the impact of three different kinds of foods on nearly 900 children with severe acute malnutrition in Delhi, Udaipur and Vellore. One group was fed commercially-produced therapeutic foods, another group was given therapeutic foods produced locally at a small scale, and a third group was fed “home-augmented” food. Home augmenting involves ensuring that vulnerable families get more quantities of required food grains and vegetables than they may be able to afford, and teaching them how to cook them while retaining their nutrients.

At the end of four months, the researchers found no significant difference between the effectiveness of commercial therapeutic food mixes and home-augmented foods. Locally-made therapeutic foods were more effective in bringing about recovery than home-augmented foods.

Do the benefits justify the costs?

In August, a group of nutritionists under the banner of the Nutrition Advocacy in Public Interest sent letters to Maharashtra Chief Minister Devendra Fadnavis as well as the chief secretaries of all states. “The research clearly shows that choice of dietary product is largely irrelevant for sustained recovery [from malnutrition],” the letter said, while pointing out that therapeutic food mixes would be a strain on the state exchequer with no promise of successful treatment.

Since the purported benefits of therapeutic foods do not seem to justify the costs, right-to-food activists believe that their promotion is backed by vested commercial interests.

On August 14, Transparency Market Research – a global business research agency – published a report that reveals that the global therapeutic foods market, dominated by several multinational companies, is expected to reach a valuation of $829.3 million by 2025. This is largely because the therapeutic foods market is increasingly foraying into African and Asia-Pacific nations through major humanitarian organisations like Unicef.

Two international collectives promoting therapeutic foods in India are Scaling Up Nutrition and the Global Alliance for Improved Nutrition. While the first includes members from food industry giants like Britannia, Pepsi, Unilever and Amul, the Global Alliance for Improved Nutrition is chaired by the former managing director of Britannia, Vinita Bali.

According to Dr Ashwani Mahajan, the co-convener of the Swadeshi Jagran Manch, this nexus of food industry influencers is promoting market-led approaches to tackling malnutrition. “Such approaches are misleading and undermine local, biodiverse and sustainable food cultures,” he said in a letter to Union Women and Child Development minister Maneka Gandhi dated August 23.

Members of the therapeutic foods industry, meanwhile, claim it is being unfairly maligned. Children with severe acute malnutrition are “too weak to process normal food and are at the risk of death”, said Akshat Khandelwal, the managing director of NuFlower Foods and Nutrition, an Indian company which primarily supplies therapeutic foods to countries in East Africa and Asia for humanitarian projects. Given as a one-time nutrition therapy over eight to 12 weeks, therapeutic foods could help save the lives of 94 lakh severely malnourished children in India, he said.

NuFlower supplied therapeutic foods for Rajasthan’s pilot community-based malnutrition management programme, called Poshan, in 2015-’16. Khandelwal pointed out that unlike the Centre’s three-city study, where only 900 children were tested, Rajasthan’s Poshan programme fed therapeutic foods to nearly 10,000 severely malnourished children. At the end of 13 weeks, the Poshan results found that 78% of them had recovered.

“RUTF [ready-to-use therapeutic foods] is only meant to bring them out of the danger zone, after which they should ideally be put in some sort of a supplementary nutrition programme to keep them stable,” Khandelwal said.

Centre versus State

It is unclear whether Maharashtra was planning to introduce therapeutic foods as a temporary curative measure, or as a replacement for the take-home rations that children are given as supplementary nutrition under the Integrated Child Development Scheme. Either way, this violates national guidelines.

Senior officials in the state’s women and child development department were not available for comment, despite several visits to their office. Emailed questions by went unanswered.

The Union government’s view is clear.

On August 18, in a response to an advocacy organisation, health minister JP Nadda said pilot projects in India had shown ready-to-use therapeutic foods are “temporarily helpful” for severely malnourished children, but may not help families develop “appropriate food habits for children”.

The letter sent by the Union Ministry of Women and Child Development cautioned states against therapeutic foods, saying it could “replace nutritional best practices and family foods that children would normally be eating”. It could negatively impact continued breastfeeding of infants and undermine “sustainable solutions for improving food availability and dietary diversity”.

Corrections and clarifications: An earlier version of this story erroneously stated that the government had announced its decision during the hearing of a writ petition filed by Jan Swasthya Abhiyan.