Need and Significance of an Ayurvedic Ready to Use Therapeutic Food (RUTF) in Children of Under 5 years Age : A Review

Introduction

SAM (Severe Acute Malnutrition) is a major morbidity factor of children less than 5 years of age and by all means is eligible to be counted as a national concern. It is diagnosed when the child has any one of the following criteria: weight for height (W/H) Z score <-3 SD, Mid upper arm circumference (MUAC < 115mm, bipedal oedema or visible severe wasting [1]. According to National Family Health Survey 4 (NFHS 4), 7.5% of the under 5 children are severely wasted, 38.4 % are stunted and 35.7% are underweight [2].

Whereas acute cases with complications require institutional care; uncomplicated cases where appetite is retained, is managed by community based nutrition programme. Screening of SAM cases among this age group, giving energy dense Ready To Use Therapeutic Food (RUTF) in therapeutic doses for short term, through community outreach programme, till they recover normal growth status and appetite level, is the most plausible solution [3].

Most of the evidence obtained from studies involving use of RUTFs are generated from African subcontinent [4]. Though Asian [5] countries also had employed RUTFs for tackling SAM, more indigenous, culturally acceptable and locally manufactured formulas should be evaluated to generate ample evidence for developing an effective remedy. Ayurveda, the traditional Indian medical practice, is a valuable source of such nutritional alternatives, especially as its theoretical framework stresses on right nutrition as the key goal for a healthy life [6].

Ayurveda has effective RUTF options that are not known widely. This short review article tries to explore all the possibilities and challenges involved in figuring out a safe, cost effective and palatable Ayurvedic RUTF.

Conceptualization

Ayurveda hypothesises the symptom of under nutrition as ‘Karshya’. Karshya is an Apatarpana Janya Vyadhi (diseases arising due to malnutrition), so its management is to be done by using Santarpana (proper nourishing) or Brumhana Chikitsa. Brumhana refers to the phenomenon of healthy growth of the body tissues with respect to the normal growth parameters. This nourishment can be achieved through either medicine or food or both. Of these, medicine plays better role in enhancing the metabolism and thereby aiding nutrition. There exists a general rule that medicines meant to improve nutritional process should enhance appetite and should be carminative and light in texture, as the persons who will need nourishment will be emaciated with suboptimal digestive and assimilative capacity. Ayurveda corrects the digestive capacity of the individual and make the body fit to absorb nutrients along with supplementation of deficient nutrients. Deworming medicines and doing procedure with such properties are also beneficial.

Feasibility

Ayurvedic RUTF-Options

There are therapeutic medicinal and therapeutic food preparations in Ayurveda. Modaka/leha/vataka [7] is a certain category which is prepared using high contents of ‘ghee’ and jaggery added with medicinal powders during different levels of preparation. Most of them aim at supplementation of energy in a disease debilitated stage. There are instructions to use them along with food or take in an amount capable of replacing a meal.

Impact of Ayurdvedic RUTF Options on Malnutrition

Many studies have been conducted on the efficacy of modakas and similar formulations in managing nutritional deficits and improving weight gain [9]. Most studies done in malnutrition were meant to evaluate the efficacy of nutritive supplements in increasing body mass. Mainly two types of preparations were tested. Modaka and medicated enema (basti). Basti is out of the scope of this review. Among the studies, Sivamodaka of the Prem Prakash Vyas study exhibited the highest efficacy in increasing body weight statistically.

Prinana Modaka was used in two studies and Godhumadi modaka in one. In both studies, the sample size was small and hence the results cannot be considered statistically significant. In Nirali Joshi study, 2011, using Prinana Modaka and Godhumadi modaka conducted in 10 & 11 children in 2 groups, the mean weight gain was 5.56 and 6.73 respectively. The Sandip Lad et al study (2015) which used Prinana modaka and Balya biscuit respectively in two groups comprising of 20 and 22 children showed a mean weight gain of 5.3 and 6.73 respectively.

Though the balya biscuit exhibited a better performance in terms of mean weight gain, the presence of elements like Iron and Calcium in crude form makes the product fall under sceptical shadow of heavy metal toxicity.

The above said studies suggest that locally available and culturally acceptable products were used as complementary feeds and they had been found efficient, though a statistically significant result is still being awaited.

Challenges

Shelf life: Classically prepared churna (powders),vataka and modaka claims a shelf life of 2 months [14]. Manufacturing and dispensing and intake should happen within the time frame. Addition of preservatives may be employed to increase the shelf life. Shelf-life defined for Churna according to Rule 161-B, Drugs and Cosmetics Act is 2 years. Stability study is essential to impart evidence on how quality of a drug differs with time under influence of variety of environmental factors such as, temperature, humidity and light [15].

Moisture content: Controlling moisture content in the finished product and checking fungal growth can be solved by using air tight containers which is packed in size adjusted sachets. This aids in dispensing too.

Heavy metal toxicity: Often, Ayurvedic medicines incorporate various minerals and metals into their formulations. They are supposed to undergo Sodhana/ purification therapies suggested in the context. Even though, on further evaluation, many of them exhibit heavy metal contents exceeding the permissible limits [16]. Strict monitoring and adherence to GMP guidelines for AYUSH drugs can assure safety.

Dose fixing: All the medicines for pediatric age group is age and purpose specific. (Table 2) Additional to age, the appetite and potency of drug are considered [17].

Conclusion

Considering the gravity of malnutrition as a growing concern in the nation despite all measures undertaken by the Government to improve the nutritional status of the children, new safe and cost effective, indigenous ready to use therapeutic foods should be manufactured. Ayurveda’s rich pool of empirically proven formulations can be evaluated scientifically for serving the purpose. The philosophy involved in that is to aid the body in gaining optimum appetite and thereby promoting adequate uptake and absorption of macro and micro-nutrients and maintain a steady growth pattern. The trials conducted in field, so far has put forward a couple of effective formulations named “modakas” which is the combination of food and medicine.

Once the concerns regarding shelf life, heavy metal toxicity, calorie value, dose and content specification as per UNICEF guidelines had been properly addressed, the concept of Ayurvedic RUTF can be considered feasible.

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