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Open Statement from India on the Lancet Series on Nutrition, 2013

An open statement was released on June 24 by a group of renowned scientists and policy makers from India, expressing their concerns over future policy decisions based on the Lancet Series on Nutrition, 2013. Signed by Prof. H.P.S. Sachdev, Dr. Arun Gupta, Prof. Umesh Kapil, Dr. Panna Choudhury, Prof. A.P. Dubey, Dr. Mira Shiva, and Dr. C.P. Bansal, the statement has the purpose of warning the Indian Government and other stakeholders not to allow the series to become an opportunity for the commercial exploitation of malnutrition.

The statement questions the prioritization of interventions in the series, which ‘has been achieved through several assumptions and imputations, which are brittle and sensitive to alternative philosophies and effect size inputs’ and which has ‘excluded or ignored relevant, contemporary, and high quality evidence’. They recommend that the appropriateness of the interventions be revisited according to national contexts.

The group also highlights conflicts of interest of persons who participated in the elaboration of the series, which should be considered when interpreting the results of the papers.

STATEMENT (PDF Version)

For further information, please contact the authors directly in the email addresses and telephones provided below.

STATEMENT
June 24, 2014

Policy Implications of Lancet Series on Nutrition, 2013: Guard against Commercial Exploitation of Malnutrition

We appreciate the challenging and demanding work put in by the Maternal and Child Nutrition Study Group authors in preparing the Lancet Series on Nutrition, 2013. We also applaud the primary objective of strong advocacy that “the post-2015 sustainable development agenda must put addressing all forms of malnutrition at the top of its goals”. However, we have substantial reservations about some broad issues and the specific solutions being promoted, which are briefly summarized below. Our sole intent is to caution the Indian Government along with other stakeholders and to catalyze 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.

The conflict of interest of the leader of the series and some other authors, particularly influential links with the food products and micronutrient industry, merit serious consideration while interpreting the recommendations. In the current era, policy decisions and recommendations in advanced countries (for example USA) and international agencies (World Health Organization) are arrived at by a transparent process involving only individuals with

no conflict of interest.

Prioritization of interventions has been achieved through several assumptions and imputations, which are brittle and sensitive to alternative philosophies and effect size inputs; prioritization 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 modeled while prioritizing ten most important interventions (Chapter 2). This produces bias for the selection of product based solutions (particularly Ready to Use Therapeutic or Supplementary Foods 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 modeled and negative trials of zinc supplementation on growth (from South Asia) have been excluded. The modeling basis for management of Moderate Acute Malnutrition (MAM) as the fifth most effective intervention is unclear. Further, the text in the section on Acute Malnutrition will create intense pressure for introducing specific products marketed by multinational corporations (RUTF and RUSF) without supporting high quality evidence. A just published Cochrane Review concludes “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 in the Parliament of India of not utilizing commercial RUTF for community treatment of severe malnutrition.

In the zeal for advocacy, safety concerns with some interventions, particularly in some heterogeneous groups, have receded in the background; these must constitute an integral part of the decision making process. For example, the recently reported increased risk of diarrhea, bloody diarrhea and chest indrawing with multiple micronutrient supplementation in children and the potential risk in some situations of increased perinatal and neonatal mortality and large for gestational age babies with multiple micronutrient supplementation in pregnant women.

The call for engaging with the “private sector” and unregulated marketing of commercial foods for preventing malnutrition in children raises serious concerns. The inherent conflict of interest will ensure that commercial considerations override sustainable nutritional goals.

The rapidly escalating burden of overnutrition has been chronicled but has not received the same in depth attention and modeling, particularly for exploring relevant interventions. In view of the immediate and long-term health and economic consequences, urgent remedial measures also need to be instituted for overnutrition in the Indian context.

We make a fervent appeal for an active consideration of our above stated concerns by the Government of India while taking any policy decisions based on the Lancet Series on Nutrition, 2013.

Prof. H.P.S. Sachdev,
(Former, National President Indian Academy of Pediatrics and Senior Consultant Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, B-16 Qutab Institutional Area, New Delhi 110016; E-mail: hpssachdev@gmail.com; Tel: 09810104400)

Dr. Arun Gupta,
(Member – Prime Minister’s Council on India’s Nutrition Challenges, Regional Coordinator – IBFAN Asia, Central coordinator, Breastfeeding Promotion Network of India (BPNI), and Convener-Alliance against Conflict of Interest (AACI); E-mail: arun@ibfanasia.org; Tel: 09899676306)

Prof. Umesh Kapil,
(Former, National President, Indian Association of Preventive and Social Medicine and Professor, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029; E-mail: umeshkapil@gmail.com; Tel: 09810609340)

Dr. Panna Choudhury,
(Executive Director, Indian Academy of Pediatrics, Vice Chairman Child Health Foundation, and Former, National President Indian Academy of Pediatrics; E-mail:pannachoudhury@gmail.com; Tel: 09810806979)

Prof. A.P. Dubey,
(Chairperson, Indian Academy of Pediatrics, Sub-Specialty Chapter on Nutrition; E-mail:apdubey52@gmail.com; Tel: 09968604303)

Dr. Mira Shiva,
(Initiative for Health and Equity in Society and Member National Authority Women’s Empowerment, E-mail: mirashiva@yahoo.com; Tel: 09810582028)

Dr. C.P. Bansal,
(National President, Indian Academy of Pediatrics; E-mail: cpbansal@gmail.com; Tel: 09827063677)

Image: Hyderabad, India. Photograph: Mahesh Kumar A/AP (via The Guardian)

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