Rapid Responses on the BMJ: Lack of transparency in the Business of malnutrition

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Join the ongoing discussion in the BMJ about Veena Rao's personal opinion piece entitled, "Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India" click HERE   Following our complaint the  BMJ has published the following correction:  "In this online Personal View (BMJ 2012;345:e8131, doi:10.1136/bmj.e8131) the author, Veena Rao, did not declare any competing interests. She has now told us that she has been “a member of the Advisory Board on the Britannia Nutrition Foundation (a non-profit trust) since 2009.” The website of the foundation is at www.britannia.co.in/bnf/index.html.   Ms Rao has submitted a further comment but fails to mention that Britannia Nutrition Foundation is funded by Brittania Industries Ltd. 


The original article can be found on this link http://dx.doi.org/10.1136/bmj.e8131 

or Here

 Views & Reviews Personal View: Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India

 BMJ 2012; 345 doi: (Published 30 November 2012) 

 Cite as: BMJ 2012;345:e8131 

See this article in the Times of India  HERE  and pasted below (page down) 



Comment From Dr. Sailesh Gupta MD, Secretary General,  Indian Academy of Pediatrics (IAP), Dr. Satish Tiwari MD (Paediatrics) President, Indian Medico-legal and Ethics Association and Dr JP Dadhich, IBFAN

Re: Law regulating marketing of infant foods has nothing to do in furthering undernutrition in India   17 December 2012

Veena Rao’s write up on "Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India" is misleading and requires urgent clarification. We strongly refute her assertions blaming International Code of Marketing of Breast Milk Substitutes and Indian Legislation - the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992 and amended in 2003 (IMS Act), for the furthering undernutrition in India. We have following observations for submission:

1. Providing no scientific evidence to substantiate her assertion, the author proposes that the commercial promotion of complementary foods will reduce child undernutrition in India. The Lancet Series on Maternal and Child Under nutrition has clearly stated that aside from suboptimum breastfeeding which results in 1.4 million deaths and 10% of disease burden in children younger than 5 years in populations with sufficient food, education about complementary feeding is sufficient and in populations with insufficient food the provision of food supplements (with or without education) are effective measures to address stunting (1). The national guidelines on Infant and Young Child feeding, developed by Ministry of Women and Child Development, Government of India, states recommend only home-made complementary foods for infants and young children (2). The Indian Academy of Pediatrics, in its’ Infant and young child feeding guidelines (2010) recommends age specific home-made food like porridge, well mashed foods, Chopped foods and family foods (3).

2. We are not aware of any evidence of a relationship between the COMMERCIAL promotion of complementary foods and the REDUCTION in prevalence of undernutrition. Indeed the prohibition on advertisements and promotion for foods for children under 2 in India became effective only in 2004, yet the scourge of malnutrition has been present in India for many decades before the legal prohibition. Data from last three National Health and Family Surveys namely, NHFS1 (1994-95) NFHS 2(1998-99) and NFHS 3(2005-06) reported a very high prevalence of undernutrition in children (4). Moreover, a recent survey report in India has revealed that in the 100 focus districts, the prevalence of child underweight has shown a 20.3 percent decrease over a 7 year period with an average annual rate of reduction of 2.9 per cent (5). This is important to note that during this period complementary foods have remained under the purview of the IMS Act with prohibition on their promotion through advertisements and health care facilities. It again busts the myth that law on infant foods is furthering the undernutrition in India.

3. Child undernutrition in India is not merely a problem of the poor as stated by the author. An analysis of data of National Health and Family Survey 3 (NFHS 3) (4) reveals that among the children in the highest wealth index, 25.3 are stunted, 12.7% are wasted, and 19.7% are underweight. Parents of these children have a better access to markets and hence commercial infant foods.

4. The real problem lies in the fact that only 20.7% among all children 6-23 months in India receive optimal infant and young child feeding namely, Breast milk, milk, or milk products; appropriate number of food groups; and minimum times of complementary foods (4). But the promotion of commercial foods to the poor is certainly not the best and most sustainable way to address this problem. The Global Strategy for Infant and Young Child Feeding (WHO, UNICEF, 2003) recommends: “Providing sound and culture-specific nutrition counselling to mothers of young children and recommending the widest possible use of indigenous foodstuffs will help ensure that local foods are prepared and fed safely in the home.” The global strategy has suggested a very limited role for “Industrially processed complementary foods”(6). In fact one of the major causes of malnutrition is lack of health education or exaggerated health claims which promotes commercial food (unaffordable by most of the population) at the cost of homemade food (which is easily available and affordable). The primary reason for the lack of diversity is probably knowledge, but also the high prices of foods from various groups. The HUNGaMA survey report from India has reported that 93.7% mothers in studied population were not giving non-cereal foods to infants because they are expensive (5). On the other hand, Healthy Food, Healthy Child, a FAO EU Food Facility Project in Cambodia to improve dietary diversity and family feeding practices with nutrition counselling, starting with infant and young children, has shown positive results in preventing undernutrition and sickness (7).

5. Since the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992 which was amended in 2003, is regulating the marketing of infant milk substitute, infant foods and feeding bottle very effectively, we see no need either to dismantle these controls and allow commercial promotion of products for this vulnerable group or develop a separate code for marketing of complementary foods.

Dr. JP Dadhich MD (Paediatrics), National Coordinator, Breastfeeding Promotion Network of India (BPNI)  


Dr. Sailesh Gupta MD (Paediatrics) Secretary General, Indian Academy of Pediatrics (IAP)


Dr. Satish Tiwari MD (Paediatrics) President, Indian Medico-legal and Ethics Association



1. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA,Kirkwood B, Morris SS, Sachdev HP, Shekar M; Maternal and Child UndernutritionStudy Group. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008 Feb 2;371(9610):417-40

2. National guidelines on infant and young child feeding, Government of India, 2006. Available at: http://wcd.nic.in/publication/infantandyoungchildfeed.pdf

3. Infant and Young Child Feeding Chapter, Indian Academy of Pediatrics, Rajeshwari K, Bang A, Chaturvedi P, Kumar V, Yadav B, Bharadva K, Gupta S, Gupta P, Shah D, Aneja S, Dubey AP, Tiwari S, Choudhury P, Agarwal RK. Infant and young child feeding guidelines: 2010. Indian Pediatr. 2010 Dec; 47(12): 995-1004.

4. International Institute of Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS - 3), 2005-06: India: Mumbai:IIPS.

5. Naandi Foundation. Fighting Hunger and Malnutrition - The HUNGaMA Survey Report. Available at: http://hungamaforchange.org/HungamaBKDec11LR.pdf. Accessed on 17 December, 2012

6. WHO/UNICEF Global Strategy for Infant and Young Child Feeding, World Health Organization (WHO), 2002. Available at: http://www.who.int/child-adolescent-health/NUTRITION/global_strategy.htm Accessed on 17 December, 2012

7. FAO. Improved Complementary Feeding recipes diversify infants and young children's diet. Available at: http://www.youtube.com/watch?v=0rUX6F7ieVY). Accessed on 17 December, 2012

Competing interests: None declared


From Patti Rundall and Dr Arun Gupta (IBFAN)

Lack of transparency in the Business of Malnutrition

17 December 2012

Dear Editor

Veena Rao's 'Personal View' "Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India" neatly illustrates the flaws and lack of transparency in the food industry's position.

Only now, in the rapid response after prompting, does Ms Rao mention that she is on the Advisory Board of Brittania Nutrition Foundation but even then this is not considered to be a conflict of interest simply because she has not received funding from Brittania Industries Ltd. She does not say whether the Foundation receives money from Brittania Industries. [SEE NOTE about BNF funding below) 

It may be useful for BMJ readers to know that Brittania Industries' stated purpose is to `'Help people enjoy life –through healthy snacking" and "Make enjoyable food, healthy & accessible to all people, any time, anywhere - every day. " Encouraging all day snacking on 'slightly better for you' junk foods is a Top Strategic Priority that is shared with many other transnational food, marketing and media businesses as they seek to displace traditional food patterns and cultures in low and middle-income countries.


So too is the strategy to persuade mothers that the healthiest option is to get babies on to commercial processed foods, formulas and supplements as soon as possible and for as long as possible rather than continuing breastfeeding alongside infinitely cheaper and often more nutritious family foods.The fortified formulas and foods for older babies share branding with formulas for young babies (infant formulas) are often high in sugar and flavourings and the deceptive promotional micronutrient claims - which mask the risks of the products and persist illegally in India and many countries - prompt fears that breastfeeding and family foods are inadequate. While fortification of staples and therapeutic foods can be useful if handled carefully, there is no evidence that the indiscriminate commercial promotion of baby foods to all has any beneficial role to play in addressing or 'preventing' malnutrition - which is a complex global problem with many underlying root causes - most importantly poverty. Malnutrition existed way before India banned advertising of complementary foods and includes the 'double burden of malnutrition' and Non Communicable Diseases (NCDs) - the costs of which are steadily overwhelming families and governments.


Brittania Industries is on the Board of the Global Alliance for Improved Nutrition (GAIN) and both GAIN and Brittania are on the Lead Group of the Scaling Up Nutrition (SUN) initiative, which is urging governments to enter partnerships with businesses to conquer malnutrition One could hardly think of a better public relations cover!


IBFAN has prepared a paper outlining why we can't join SUN and our fear that it will lead to low-income country dependence on inappropriate imported products and foreign 'expertise' increasing rather than decreasing malnutrition.[1] We are calling on SUN to respect the World Health Assembly recommendations and ensure that 'governance' - health policy and programme setting - is free from influence from those who stand to gain financially from decisions.


Also important are the recommendations of the Global Strategy on Infant and Young Child Feeding calling for "sound and culture-specific nutrition counselling to mothers of young children and recommending the widest possible use of indigenous foodstuffs will help ensure that local foods are prepared and fed safely in the home.” [2]


Patti Rundall, Policy Director, Baby Milk Action

Dr. Arun Gupta MD, FIAP, Regional Coordinator IBFAN Asia,

Joint Coordinators of IBFAN's Co-ordinating Council.


[1] The Scaling Up Nutrition (SUN) initiative IBFAN’s concern about the role of businesses


[2] FAO's short film about complementary feeding in Cambodia, “Improve the food security of farming families affected by volatile food prices” shows the importance of non-commercial nutrition counselling. [2]FAO EU Food Facility Project in Cambodia to improve dietary diversity and family feeding practices. http://www.youtube.com/watch?v=0rUX6F7ieVY

NOTE ADDED AFTER POSTING:  The Brittania Nutrition Foundation IS funded by BIL (Britannia Industries Limited)

See the BNF website :http://www.britannia.co.in/bnf/bnf-charter.html

" Structure and Functioning  BNF is organized as an independent entity and funded by BIL and grants/donations. The board members are recognized experts in their field. They work in the areas ranging from nutrition policy / decisions making, nutrition research, child health and social sciences. BNF board is supported by scientific advisors and partner organizations and other experts for specific programs or throughout as seen appropriate. The composition of BNF board is available under the section "BNF Board"

Competing interests: Dr Arun Gupta is employed by the Breastfeeding Promotion network of India (BPNI) and Patti Rundall is employed by Baby Milk Action- both members of the International Baby Food Action Network. Patti Rundall owns a small number of shares in the Nestle Company solely for the purpose of attending shareholder meetings.





From Dr. Brij B. Agarwal

Malnourished children and mal-administration

16 December 2012

Administrators have an important role in enhancing the health and quality of life of those they administer. They contribute as an implementer, idea generator and opinion maker. The realities of the world we live in, weigh their opinion favorably and as actionable.

Health and nutrition issues plaguing the future of humanity are a recipe of a failed society. Hence the scholastically sound view expressed by the author needs a dispassionate deliberation as it raises some concerns. Communication should impress a point rather than merely be impressive. The opening paragraph tries to impress with data but is an oxymoron. Demographically India has a higher relative population of children. We know that every sixth human is an Indian but every fifth child is an Indian. The average per capita calorie consumption is consistently falling over last two decades despite it being already low by world standards. India is emerging as an economy yet the administrators (belonging to same cadre as the author) continue to lower the income threshold for poverty (presently < 0.6 US Dollars/ day) to cover their failures. The UNICEF webpage cited by the author supporting her data, warns that the childhood malnutrition is more due to infrastructural and administrative failure than the food availability/ intake issues. It would have been desirable if an administrator had tried to address the issues that indicate the failure of system she heads rather than advocate a solution that can become a yet another milk cow for the corruption tainted Indian administration, the spine of which is Indian Administrative Services (IAS). The suspicion of having a vested agenda to pursue gets stronger due to author’s IAS background and influence peddling association with an entity that is non-profit on books but derives sustenance by patronizing from a thorough commercial entity. The patron will be the direct beneficiary as a potential provider of the complementary foods as being advocated by the author.


Being an Indian, I am not un-surprised even an iota’s bit, as it is a common practice for the top Indian policy makers/ administrators to accept post-retirement sinecures that come to them because of their public service/IAS based profile and are offered as a barter for their influence and loyality. Such influence holders can potentially shift the social fulcrum beyond a tipping point. The numerical handicap of these lobbyists is no true handicap, as we know that a small fraction of committed minority opinion can lead to evolution of social consensus in their favor over a very short time frame.[1] We as medical scientists should have an healthy contempt for the opinion makers who hide their failure by touting convenient statistics and displaying concerns that point towards a sincere self-interest.

Dr. Brij B. Agarwal



1. Xie J, Sreenivasan S, Korniss G, Zhang W, Lim C, Szymanski BK. Phys Rev E Stat Nonlin Social consensus through the influence of committed minorities. Soft Matter Phys. 2011 Jul;84(1 Pt 1):011130.

Competing interests: None declared

Brij B. Agarwal , General Surgeon

Nayan Agarwal, Krishna A. Agarwal

University College of Medical Sciences & Vardhman Mahavir Medical College, Dr. Agarwal's surgery, New Delhi, India., Dr. Agarwal's Surgery & Yoga, F-81 Street# 4, Virender Nagar, New Delhi-110058. India



Response from Veena Rao prompted by questions from BMJ editors: 

Re: Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India  15 December 2012

Though not in fact a competing interest, but can be viewed as a potential competing interest: I have been member of the Advisory Board on the Britannia Nutrition Foundation,(BNF) (a non profit trust) since 2009. The Charter of the Trust is at  http://www.britannia.co.in/bnf/bnf-charter.html.

The activities of the Trust have nothing to do with any activities of Britannia Industries in any manner. There is no conflict of interest or competing interest in what I have written in the article and the Charter of the Trust upon which I am expected to advise. I have no financial relationship with the Britannia Industries, do not own any shares, am not associated with any production, commercial or marketing activities of the Company, do not promote their products at any forum, or receive any commissions or payments from them. Neither Britannia Industries or BNF have not been involved in any manner with the writing or content ot this article, or my decision to publish this article. The article contains my considered and personal view as an administrator who has worked on the subject in government, based on public good and national interest. This view was first stated in my book 'Malnutrition, and Emergency, What it Costs the Nation', (February 2008) written much before I accepted being advisor to BNF.

I am also associated with educational and training institutions, and international agencies. I will be happy to provide more details on request. With this, I declare that I have received no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years , no other relationships or activities that could appear to have influenced the submitted work.

Competing interests: Advisor, Britannia Nutrition Foundation


Note: As  above, Ms Rao fails to mention that Brittania Nutrition Foundation IS funded by Britannia Industries Limited.

Former bureaucrat pushes for allowing baby foods marketing
Rema Nagarajan, TNN | Dec 20, 2012

NEW DELHI: In a recent British Medical Journal article, a former joint secretary of the department of women and child development claimed that the Indian law that bars marketing of complementary foods for children over 6 months is one of the main causes of acute under nutrition among young children. The article has raised the hackles of nutrition experts who point out that there was no evidence to show that commercially produced complementary food would reduce under nutrition in India. They also pointed out that the former joint secretary, Veena Rao, who retired in 2009 as secretary to the Government of India, wrote the article without declaring the obvious conflict of interest, that she is currently on the advisory board of food company Britannia's, Britannia Nutrition Foundation. 
"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. This is one of the main causes of acute under nutrition among children younger than 2 years, affecting their physical and cognitive development," stated Rao's article. Nutrition experts pointed out that the Global Strategy for Infant and Young Child Feeding of the WHO and UNICEF recommended sound and culture-specific nutrition with the widest possible use of indigenous foodstuffs which would help ensure that local foods were prepared and fed safely at home. 
After the International Baby Food Action Network, a worldwide network of organisations working to reduce infant and child mortality, Breast Feeding Promotion Network of India and the Indian Academy of Paediatrics wrote to the BMJ criticising the article, Rao responded by stating: "Though not in fact a competing interest, but can be viewed as a potential competing interest: I have been member of the Advisory Board on the Britannia Nutrition Foundation,(BNF) (a non-profit trust) since 2009." She claimed that she had no financial relationship with the Britannia industries and was not associated with promoting their products or any commercial or marketing activities. 


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