His Name is TODAY

We are guilty of many errors

and many faults,
But our worst crime is
abandoning the children,
Neglecting the fountain of life.
Many of the things we need can
wait.
The child cannot wait.
Right now is the time his bones
are being formed,
His blood is being made,
And his senses are being
developed.
To him we cannot answer
Tomorrow
His name is TODAY.
- Gabriela Mistral (1889-1957),
a Nobel laureate poetess from Chile
Acknowledgements
Advisors/Contributors
Dr. Praful Barvalia (MBBF), Dr. Krishna Behera (MBBF), Sudheendra Kulkarni, Chairman, ORF Mumbai, Dr. Shefali Batlish and Dr. Rajesh Batlish,
specialists in community medicine, Dr. Armida Fernandes (a leading Public Health activist, the founder member of NGO SNEHA and former Professor
and Head of Neonatology at Lokmanaya Tilak Municipal General Hospital (Sion-LTMG), Mumbai), Radha Vishwanathan, ORF Mumbai

Special Tanks to
Field workers/ Community volunteers Anuradha Raut, Dipesh Mane, Monika Raje
ORF team Aparna Sivakumar, Anushka Kelaskar, Damodar Pujari, Dhaval Desai, Dr. Deepesh Reddy, Janki Pandya, Karishma Makeshwar,
Payal Tiwari, Pravinbhai Darji, Rammohan Khanapurkar, Rishi Aggarwal, Dr. Sumedh Kulkarni, Vijayshree Pednekar
MBBF teamAnita Chitre, Dr. Vaishali, Dr. Vinay Sharma, Vishnu Aggarwal
Photos- Anuradha Raut, Janki Pandya, Rachel DSilva
Design- Rahil Shaikh Miya
Te authors/contributors have declared that no competing interests exist. None of the authors/contributors has fnancial (such as employment, consultancies,
stock ownership, honoraria, paid expert testimony), academic or personal relationships that has inappropriately infuenced the study design, data collection, analysis
and content of the manuscript. Authors/contributors time was partly funded by ORF.
FOREWORD
Strengthen nutrition-specifc interventions;
give equal focus to nutrition-sensitive interventions
Sudheendra Kulkarni
Chairman, Observer Research Foundation Mumbai
Tis study by Rachel DSilva, a young researcher at the Observer Research Foundation Mumbai, in collaboration
with Dr. Nitin Kothawade and Dr. Mihir Maher of the M.B. Barvalia Foundation, busts two myths. One, that
undernutrition in our country is limited to the poorest parts of rural India especially, to areas populated by
tribal communities. Two, that undernutrition has only to do with the lack of nutritious food and hence it can
be eliminated simply by providing what is lacking.
Tis is by no means the frst such study to highlight either the prevalence of undernutrition in urban slums in India or the fact that there are factors other
than intake of insufcient nutritious food causing undernutrition. Nevertheless, the afore-mentioned myths remain entrenched. Terefore, the chief
merit of this report lies in the fact that it casts the spotlight on a much-neglected problem through a fresh study based on a feld survey.
Te report also has other notable merits. Firstly, it has empirically established that the problem of undernutrition and the attendant maladies such as
stunted physical and mental development of children, poor attention in school, unsatisfactory learning outcomes, etc is more rampant in unstructured
slums than in structured slums. Tis truth is of enormous signifcance in Mumbai, where the study is based, because a large part of the nearly 65% of the
population of the metropolis that lives in slums actually lives in those newer slum clusters that are worse than slums.
If the appellation of slum itself connotes a habitat lacking in basic minimum civic amenities, the category of an unstructured slum points to something
far more wretched. A mere glance at some of the photographs in this report would provide visual proof of their wretchedness. Te population in these
unstructured slums sufers not only from food insecurity but also from survival insecurity because these are unrecognised by the government. As such
they are vulnerable to eviction and their homes liable to demolition. Even when they are not uprooted, they are ineligible to receive the modicum of civic
services that regular and recognised slum clusters get.
By highlighting the higher levels of undernutrition among children in these unstructured slums, this report has sought to draw the attention of the
government and sensitive sections of the civil society to a problem that can only be described as a national shame since it darkens the image of a prospering
India, the more so since it exists in the nations fnancial capital. A little over a decade from now, India is expected to emerge as the worlds third largest
economy, afer China and United States, with a GDP of close to $ 8 trillion, four times bigger than what it is today. Yet, in a city that symbolises this
growing prosperity in many ways, we have slum clusters with children whose tender bodies dont get the nourishment they need.
Te second noteworthy aspect of this report is that it brings to the fore the strong correlation between undernutrition among slum children and lack
of sanitation and clean drinking water. Open defecation, another national shame, is quite common in the slums of Mumbai. Tis, along with the use of
sewage-contaminated water, which too is widespread in slum clusters, causes faecally-trasmitted infections (FTIs) that hinder absorption of nutrients.
Tus, the study supports a profound and defnitive observation made by UNICEF: In hygienic conditions, much of Indias undernutrition would
disappear.
What should be done to tackle this problem efectively? Its important to remember that only a strong and sustained partnership, with the active
participation of communities and community-based organisations, can help.
As this report points out, so far the governments have focused only on nutrition-specifc interventions Mid Day Meal scheme in schools and
provision of supplementary food under the Integrated Child Development Scheme (ICDS) to children in the 0-6 age group. Tere is an urgent need to
give equal programmatic attention to nutrition-sensitive interventions good housing, access to proper sanitation, clean drinking water, pollution-free
environment, livelihoods for the poor, etc.
Tis does not mean that the governments are doing a good job even with the Mid Day Meal scheme. As this report points out (page 87) about 41% of
children consume half or less than half of the entire serving of the mid-day meal. Te unused khichdi is thrown away, leading to avoidable wastage. Tis
happens because the food given to children is monotonous. Khichdi is the only food item served repeatedly on most days of the week. (page 92) Tere
is a big gap between what is prescribed for children under the scheme and what is supplied.
Remove the contamination of corruption and callousness from the implementation of the
Mid Day Meal scheme
Tose familiar with the fawed implementation of the Mid-Day Meal scheme in Mumbai and also in many other parts of India know that it is a
victim of corruption, administrative inefciency and rampant political interference. For instance, are ministers, legislators and top bureaucratic ofcials
in Maharashtra blind not to know that the grains supplied to many Mid-Day Meal centres are of extremely poor quality dirty, full of husk, stones,
etc? Dont they know that there is a big gap between the per-meal cost ofered by the government and what it will really cost mid-day meal providers to
cover their costs from grain storage, purchase of additional 'nutritive' elements, cooking, labour, distribution and maintenance? Dont they know that
womens self-help groups and other social organisations that prepare and distribute the meal to schools rarely get their payment on time? Indeed, our
feld study revealed that one reputed organisation has an outstanding of Rs. 3 crore from the municipal corporation. With such insensitive management
of the scheme, isnt the government forcing many mid-day meal providers to cut corners and provide sub-standard and unappetising food to students?
Te solution to the problem lies clearly in removing the contamination of corruption and callousness from the implementation of the scheme, in
empowering dedicated local self-help groups, and in replicating the phenomenal success stories such as the one demonstrated by Bangalore-based
ISKCONs Akshaya Patra and Mumbai-based ISKCONs Annamrita programme. Akshaya Patra, for example, feeds nutritious meals to 1.3 million
school children across India. Its overall impact on childrens education and health is heartening increased enrolment in schools, increased attendance
in schools, reduced dropout rate, improved academic progress, improved nutritional status of students. (http://www.akshayapatra.org/impact)
In Mumbai itself, ISKCONs Annamrita project provides a wholesome mid-day meal to thousands of school children. Its common kitchen at Tardeo
maintains cleanliness standards comparable to kitchens in fve-star hotels. Examples like these show that spiritually inspired and philanthropically
supported organisations belonging to various faiths, which provide unconditional service to the nation, are critical for the success of the Mid-Day Meal
scheme and other such ambitious initiatives in Indias social sector development. Governments must support them in all possible ways.
Although it is beyond the scope of this report, the real and lasting solution to the problems of both undernutrition and sanitation lies, to a large part,
in ensuring that every household has a good house to live in. ORFs studies on this issue clearly show that this can indeed be achieved. (See Afordable
Housing for the Poor Its IMPossible! and Slum Rehabilitation in Mumbai: Why it has failed. How it can succeed.) What we would like to emphasise here
is simply this: if the government is serious and sincere about removing hunger and undernutrition among slum children, then it must frst remove the
artifcial and irrational distinction between structured and unstructured slums, regular and irregular slums. Te status of the slum should not matter
at all for the purpose of providing basic civic amenities such as sanitation, drinking water and primary healthcare. Te very fact that the government has
allowed a slum colony to come up obliges it not to deny these amenities to the residents.
Is it beyond the capability of a resourceful city like Mumbai and other places in urban India to eliminate hunger and undernutrition, especially
among its children? Is it? Tis study is meant to provoke the governments, conscientious civil society organisations and concerned citizens to answer
this question.
I congratulate Rachel for this meticulously researched project. It combines both academic research and in-depth feld study, both of which she and her
associates from the M.B. Barvalia Foundation (MBBF) have conducted with exemplary commitment. I also express my deep appreciation for the support
extended by Dr. Praful Barvalia, chairman of MBBF, who has inspired a large number of medical workers and volunteers to work in the slum clusters
in and around Ghatkopar, where the feld study was conducted. MBBFs devoted work in these slums is a testimony to the fact that we have adhered to
WHOs dictum No survey without service.
We do hope that the fndings and recommendations in this study receive serious attention from policy-makers in central and state governments, municipal
corporation, and all other non-governmental stakeholders. Critical feedback is most welcome.
PREFACE
Lead us from the darkness and shame of malnutrition
to the light of health and happiness
Dr. Praful Barvalia M.D. (Hom)
Chairman, M.B.Barvalia Foundation & Spandan Holistic Institute
Te problem of malnutrition is a national shame. Despite impressive growth in our GDP, the level of undernutrition in the country is unacceptably
high.
- Dr. Manmohan Singh, former Prime Minister, while releasing a report on Hunger and Malnutrition in
India, on January 10, 2012
Tis lament by one who was the head of the Indian government speaks volumes about the magnitude
of the national problem and what all of us, stakeholders as well as all citizens with social conscience,
need to do. When 42% of our children are underweight and when the country has the largest number
of stunted children, the situation certainly demands urgent attention.
Malnutrition/undernutrition is a multifactorial phenomenon. In this report, Ms. Rachel DSilva has
done wonderful work not only giving us the epidemiology of the problem, but also a deeper insight
into the causative and contributory factors responsible for the genesis and growth of this malaise. More
importantly, she also ofers practical solutions. Rachel is a sensitive, sincere and conscientious researcher, and her dedication shows in this study.
We at the M.B. Barvalia Foundation (MBBF) are grateful to the Observer Research Foundation for providing this excellent opportunity for a highly
useful, collaborative study.
Slums are an integral part of urban India. In Mumbai they account for 63% of the population of the megapolis. Tere is a great divide between two
Indias within urban India. One enjoys surplus food, so much so that many rich people sufer from obesity. Te other sufers from severe deprivations.
Even among slums, unstructured slums are deprived more. Sadly, very few people have systematically worked on deprivations in unstructured slums. I
am happy to note that Rachel, along with Dr. Nitin Kothawade and Dr. Mihir Maher of MBBF, have studied this subject with sensitivity, sensibility and
compassion.

With the help of grassroots workers, the team made inroads into the slum communities at Ramabai Ambedkar Nagar and other slum clusters in and
around Ghatkopar. It organised health camps to deliver important lessons related to nutrition and hygiene. I had the good fortune to participate in a
couple of such camps. Te fndings of this team ought to be a matter of serious concern. 70% children in the unstructured slums are underweight; a
higher percentage sufers from severe undernutrition; and 51.33% are stunted. No wonder, this population is vulnerable to various infections setting up a
vicious cycle. Tere is a mushroom growth of such unstructured slums and we need to attend to the nutrition, healthcare and welfare needs of the people
in both structured and unstructured slums.
Te ORF-MBBF team has systematically studied various predisposing factors by giving a comprehensive profle of the clusters which takes into account
socio-economic factors, cleanliness, hygiene, sanitation, individual susceptibility, constitutional factors and, above all, way of living which includes
addiction and mental health. Similarly, at the childs level, specifc factors pertaining to nutrition, co-morbidities, scholastic performance and cognitive
as well as behavioral aspects have been studied. Indeed, we also need to understand maternal factors right from the frst day of conception.
As a result, the study indicates a horizontal and vertical integration of all the relevant factors in the study. Tis gives a holistic perspective to the study
as well as to its recommendations.
Analysis of the 24-hour dietary intake shows that a majority of the children fell short of meeting the expected energy level. Tis has far-reaching
implications in designing the right kind of menu for the Mid-Day Meal Scheme.
Tis study raises many incisive questions.
What is the meaning of food security without taking into account these essential micro factors?
How long will policy makers in the central, state and city governments continue to turn a Nelsons eye towards such a serious and complex issue?
How long will we continue to take palliative/superfcial measures which simply suppress the vital problem?
Te entrenched problem of hunger and malnutrition can be dealt with only when we tackle the basic health needs of the slum population, especially
womens social status and health, both mental as well as physical. Failure to do this will make the whole generation unhealthy, illness-prone and die
early. We will be guilty of this crime.
Tere is a message in this report for all the stakeholders, family and community leaders, schools, NGO, healthcare establishments, municipalities and
government agencies. Hope we all will receive the light.
Asato Ma Sat Gamaya
Tamaso Ma Jyotir Gamaya
Mrityor Ma Amritam Gamaya
Om Shanti Shanti Shanti.
Lead Us From the Unreal To Real,
Lead Us From Darkness To Light,
Lead Us From Death To Immortality,
Aum (the universal sound of God)
Let Tere Be Peace Peace Peace.
(Brihadaranyaka Upanishad 1.3.28.)




( 1.3.28).
Summary
Te State of the Worlds Children 2012 Children in an Urban World, a UNICEF report, calls to better understand the scale and nature of poverty and
exclusion afecting children in urban areas.
1
As of 2014, there are too many urban poor children living under the most challenging conditions without
access to basic services, facing constant threat of eviction, and are extremely vulnerable to disease and disaster. Severely deprived and harsh living
conditions put children at greater risk of undernutrition and co-morbidities. Added to this, many of the children who are at highest risk are lef out of
public and private programs to tackle undernutrition.
Te objective of the study is to help better targeting of the population at highest risk for impactful nutrition programmes. Tis study makes an attempt
to understand urban child undernutrition through a more precise understanding of slums, highlighting a few of these exclusion-promoting barriers
afecting children. Hence the clusters chosen for the study are a structured slum pocket and an unstructured slum pocket.
A structured slum here means a registered permanent slum that receives government services such as piped water, sanitation and health services. An
unstructured slum here means an unregistered, non-tenured, informal, unauthorised colony occupying private or otherwise non-residential public land,
resettlement colonies, squatter settlements etc.
2
As per Census 2011, 65.7% slums fall into recognised (not notifed/non-legalised) and identifed (not
notifed/non-legalised) category in India. Tese are mostly unstructured slums.
Firstly, this report describes challenges to undernutrition in urban areas. Social profles of the slum clusters structured and unstructured chosen for
the study are then portrayed within the framework of their access to basic services. Results of the study have proved higher prevalence of undernutrition
in unstructured slums. Further, the fndings of the study have shown, higher percentage of children are underweight and stunted among those who
have to live in tent type shelters as compared to children living in concrete homes. Te impact of lack of access to proper sanitation facility is
evident through the fndings that show higher number of undernourished children among those who have to defecate in the open.
1 UNICEF, State of the Worlds Children 2012, Children in an Urban World,ActionPutting Children frst in an Urban World, pg 4, in UNICEF Website, retrieved on 12 August
2013, <www.unicef.org/sowc/fles/SOWC_2012-Main_Report_EN_21Dec2011.pdf>
2 Banerjee, Joya (2010): Child Health and Immunization Status in an Unregistered Mumbai Slum, Dissertation, Boston Massachusetts. Viewed on 13 August 2013,
<www.hsph.harvard.edu/women-and-health.../fles/.../banerjee_thesis.pdf>
Similar is the case with respect to access to the basic necessity of piped water supply or safe water and its relation to undernutrition. Overall the fndings
lend empirical evidence to speedily target the population at highest risk in order to win the battle against child undernutrition in slums. Te study thus
demonstrates the need to tackle a whole ecosystem of issues which impact child undernutrition not just regulating their food intake.
An important recommendation of the study is that health services in the slums must be revamped to tackle malnutrition.Tere is a need for extending
the responsibility of primary health services to tackle malnutrition among children of all ages both in the structured and unstructured slums. Immediate
steps need to be taken by Primary Health Centre (PHC) and private clinics in the vicinity to deal with Severe Acute Malnutrition (SAM) and Moderate
Acute Malnutrition (MAM) in an integrated manner. Anganwadi services such as supplementary nutrition and pre-school education must be
extended to all unauthorised, illegal slums. Health education, health services such as immunisation, health check-up and referral services must be
provided in convergence with public health systems.
It also recommends that the Municipal School Health Programme must be enhanced through partnerships. Te existing School Health Programmes
(SHP) in municipal schools for children in 1st, 3rd, 5th, 7th and 9th standards must be enhanced through partnerships with NGOs having expertise in
the treatment of nutrient defciencies, refractive problems and mental disabilities.
An urgent recommendation is made for improvement of the School Mid Day Meal programme. Te management of Mid Day Meals is a top
down approach and much needs to change with respect to this approach. It needs to become more community-based, with the involvement of local
philanthropy, community kitchens, CBOs and religious food charities. Te much-needed improvements in the design of the Mid Day Meal scheme, in
terms of variety, making the meal attractive and appealing and, including local menus in the diet can be made with inputs from all or any of the above
mentioned organisations.
Te study recommends provision of civic amenities for unauthrorised or unstructured slums provision of more toilets, sanitation system, piped
water supply, primary health and nutrition services to residents of unstructured slums will make a big diference to the nutrition outcomes of
children living there.
In short the fndings of this study show the impact of environmental and social factors - namely, type of shelter - structured or unstructured, access
to proper sanitation, safe water and household food security on childrens nutrition status. Tey demonstrate the need to urgently focus on nutrition-
sensitive interventions such as agriculture and food security, social safety nets, early child development, maternal mental health, womens empowerment,
water and sanitation, children protection, classroom education, health and family planning services that can go a long way in creating nutrition and food
secure generations.
TABLE OF CONTENTS
1 INTRODUCTION 15
Literature review
Aim of the study
Objectives
Need for the study
Limitations of the study
2 MATERIALS AND METHODS 29
Study design
Instruments used in the study
Methodology adopted in the conduct of the study
Method of data collection
Defnition and details of measurement of study variables
Analysis used for the study
3 CHALLENGES TO CHILD NUTRITION IN SLUMS 41
Challenges to child nutrition in slums
Te inadequacy of social safety nets
4 PROFILE OF CLUSTERS SELECTED FOR THE STUDY 46
5 FINDINGS 64
Profles of undernourished children...
... And their mothers
Nutrition status of children
Nutrition status of children based on age and gender
Clinical signs of nutritional defciencies and associated co-morbidities
Mental health and behavioural issues
Impact of environmental factors on nutrition status
6 24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUMS) 83
Te Mid Day Meal scheme in Mumbai
Recommendations on nutrition and diet
Improving the 6-day Cyclic Menu of the mid day meal
7 RECOMMENDATIONS 104
8 ANNEXURES 113
ANNEXURE A : A comparison of growth scales
ANNEXURE B : Marwaha et al. nationwide reference data for height, weight and body mass index of Indian schoolchildren
ANNEXURE C : List of fndings on clinical signs of nutritional defciencies and associated co-morbidities
ANNEXURE D : Te Lancet Series on Nutrition
ANNEXURE E : Questionnaires
ANNEXURE F : Recommended Dietary Allowances for Indians
ANNEXURE G: Maternal Health and Nutrition Interventions in Maharashtra
ANNEXURE H: List of Abbreviations
Chapter 1.
Introduction
17
T
he prevalence of child malnutrition and undernutrition in Mumbai, Indias fnancial capital, is an unconscionable crime and is the result of
the interplay of several complex issues. Tis report titled Mumbais Shame How undernutrition and poor sanitation are stunting the growth
of children in Mumbais structured and unstructured slums, is a cross-sectional study of undernutrition in two slum clusters structured and
unstructured - in suburban Mumbai. Te aim of this study is to highlight the preponderance of undernutrition in the heart of Mumbai as a silent
emergency and to press for urgent action to tackle the nutrition-specifc and nutrition-sensitive components that can quickly reverse this deprivation.
Slums have various levels of deprivations.
3
It may be easier to understand structured slums as those that have legal status and have legal access to civic
amenities. It is difcult to draw a clear cut understanding of unstructured slums as it may involve having to deal with security of land tenure, local
political declarations of a dwellings authorised or unauthorised status; besides, a number of pavement dwellers, residents of railway properties living in
tents may fall out of this category. Hence, a workable defnition of unstructured slums has been employed here: those slums whose residents do not have
access to public toilets and where residents may have to defecate in the open, those slums that do not have access to piped water, and those slums that are
not covered by government health services. Slums having these characteristics generally have less permanent, tent-type shelters.
Without prejudice to the medical specifcities of the related conditions of 'undernutrition' and 'malnutrition', and the specifc interventions to tackle
them, our study calls for a multi-pronged approach to tackling the problem.
3 Urban Basic Services in Slums, Mumbai City Development Plan 2005-2006
18
INTRODUCTION
Notably, the study underscores that a persons nutritional status does not depend on food availability alone. Nutrition security implies physical, economic
and social access to balanced diet, clean drinking water, safe environment, and health care (preventive and curative) and the education and awareness
that are needed to utilise these services.
4
Furthermore, the body needs and uses nutrition to fght infections. Hence, a disease-producing ecosystem that
keeps causing infection in children will also seriously undermine their ability to absorb nutrition and, therefore, their nutritional status
5
.
Even a perfunctory understanding of the defnition of nutrition security brings the realisation that there is still a large section of population of this
country who are nutritionally insecure. Tey are spread across the vast expanse of the country. In the urban context, it is easiest to identify them from
amongst two broad categories, slum inhabitants and the homeless population.
One can get an idea of the gross number of persons who are likely to be nutritionally insecure by looking at the available data. Roughly 1.37 crore
households, or 17.4% of urban Indian households or one in every six urban Indian residents lived in slums in 2011 as per the National Slum Census.
6

Te population of slum dwellers in Mumbai city, as per the 2011 census, is a staggering 8 million people, which is about 63% of the citys population.
Malnutrition fgures pointed out in various studies both at the national level and at the international level tell their own story. On the Global Hunger
Index 2012 released by the International Food Policy Research Institute (IFPRI), India ranked as low as 65th among 79 countries, alongside Bangladesh
and Timor-Leste which are ranked 68th and 73rd respectively as countries with a high proportion of underweight
7
children. Te most recent National
Family Health Survey (NFHS-3, 2005-6) reported stunting in 40%, wasting in 17%, and low weight for age in 33% of urban children under 5 years. In
the same survey, 47% of children from Mumbai's slum areas were said to be stunted, 16% were wasted, and 36% had low weight for age.
4 Ibid
5 Neeraj Hatekar, Sanjay Rode, Truth About Hunger and Disease in Mumbai Malnourishment among slum children, Economic and Political Weekly, Oct 2003
6 Slums Census of India, censusindia.gov.in/2011-Documents/On_Slums-2011Final.ppt
7 Underweight is a low weight for age ratio (acute malnutrition) and a largely reversible malady if conditions for better absorption of nutrition are created for the individuals.
Stunting is a low height for age ratio (chronic malnutrition) a slowing of skeletal growth, indicating a long-term malnutrition status arising out of extended periods of low
food intake and infections.
Wasting is low weight for height ratio (Acute and/or chronic malnutrition) the result of recent rapid weight loss or a failure to gain weight due to acute infection and/or inad-
equate dietary intake.
19
Te Maharashtra Comprehensive Nutrition Survey 2012, (CNSM 2012) is the frst ever state-specifc nutrition survey with a focus on infants and
children under two years and their mothers. Tis used a representative sample of urban and rural children under two years of age from each of the six
administrative divisions of Maharashtra - namely, Amravati, Aurangabad, Konkan, Nagpur, Nashik and Pune. It showed an improvement in stunting,
wasting and underweight fgures as from NFHS-3 to CNSM 2012. Stunting was reduced from 39 % to 22.8 %, wasting was reduced from 19.9 % to 15.5
% and underweight from 29.6 % to 21. 8 %.
8
Tis improvement was due to several initiatives under National Rural Health Mission, the expansion of the Anganwadi network and the eforts of the
Maharashtra Malnutrition Mission. As part of the Malnutrition Mission the focus was on improving coverage, survey and weighing of all children,
specially lef out and marginalised children and regular grading and identifcation of underweight children. Other eforts taken on mission mode were
close interaction with Anganwadi workers, Supervisors, Auxilliary Nurse Midwife (ANM), community based management of malnourished children
and raising awareness about the importance of 10 essential interventions e.g. breast feeding, weaning, etc. 'Model anganwadi', 'muthhi bhar dhanya'
model for donation of foodgrains by the village community, adoption of malnourished children by village functionaries was taken up. Maharashtra also
took up major micro-nutrient drives through NRHM, e.g. vitamin-A and de-worming, iron and folic acid (IFA) tablets etc. Alongside there were also
major improvements in maternal health through schemes like Janani & Shishu Suraksha Karyakram.
Te data from the ICDS Urban project, January-March 2013, shows sustained reduction and control of malnutrition in slums through the ICDS project.
Tere is reduction in Moderate Underweight (MUW) and Severe Underweight (SUW) categories from 21.83 % to 20.97 %. Te latest malnutrition
fgures released by the state government suggest that 11% of 52.53 lakh children under fve years under ICDS are underweight
9
. Commendable though
this may be, this data has its limitations and does not provide a comprehensive picture. It is important to note that this data does not include those areas
8 UNICEF(2012): Comprehensive Nutrition Survey in Maharashtra (CNSM) 2012 in Rajmata Jijau Mother Child, Health and Nutrition Mission, Government of Maharashtra
Website, retrieved on 12 August 2013,<www.nutritionmissionmah.gov.in/Pdf/CNSM_FinalFactsheet_Booklet.pdf>
Children in Maharashtra: - An Atlas of Social Indicators UNICEF, in UNICEF Website, retrieved on 12 August 2013, <http://www.unicef.org/india/resources_7955.htm>
9 11% of kids under fve in state underweight, Indian Express, Wednesday Feb 12, 2014
20
INTRODUCTION
that are not covered by ICDS projects, particularly the unstructured slums, and it does not include older children over six years living in slums who may
be vulnerable to undernutrition and other morbidities, and hence in need of urgent attention.
10
Here is where the collaborative study by the Observer Research Foundation, a public policy think tank, and MB Barvalia Foundations (MBBF)
Spandan Holistic Institute, makes a signifcant contribution to the discourse on nutrition insecurity in Mumbais slums. Te study looks at children of
school going age from a recognised or structured slum that receives a gamut of municipal services from health posts and schools to water supply, and
those from an unstructured, unauthorised squatter settlement where municipal services are unavailable. Te study fndings show that children from
unstructured slums are more vulnerable and at greater risk of being nutrition insecure. In other words, several factors such as water supply, sanitation
and housing impact childrens nutrition status. And the issue of undernutrition cannot be tackled without attending to these basic amenities.
Earlier studies on the prevalence of malnutrition
Malnutrition was seen as a rural problem until several studies pointed to its prevalence in urban areas all over India. Studies conducted between 1980-
2000 by Dr. Shanti Gosh, paediatrician, and Dr. Dheeraj Shah, senior lecturer, University College of Medical Sciences and GTB Hospital, New Delhi,
on the nutritional problems in urban slum children revealed inadequate food intake caused by improper infant feeding practices, lack of exclusive
breastfeeding, late introduction of solid mushy foods, dilution of milk, poor caloric and nutritional content of food, inequitable inter and intra-familial
distribution, age and gender diferences as factors contributing to poor nutritional status of urban slum children.
Te study listed illness caused by poor environmental and housing conditions, lack of hygiene and sanitation facilities, inadequate access and utilisation
of healthcare and poor hygiene conditions as factors exacerbating the problem of malnutrition. Deleterious caring practices resulting from any or all of
issues such as absence of responsible adult caregiver, lack of knowledge regarding food requirements, traditional beliefs, low parental literacy and poverty
were also seen to contribute to the problem.
10 ICDS Urban Project Ranking January 2013 & ICDS Urban Project Ranking March 2013, in Rajmata Jijau Mother Child, Health and Nutrition Mission, Government of Maha-
rashtra Website, retrieved on 12 August 2013, <http://www.nutritionmissionmah.gov.in/Site/Common/reports.aspx> Integrated Child Development Scheme (ICDS) aims at
providing services to pre-school children in an integrated manner so as to ensure proper growth and development of children in rural, tribal and slum areas. ICDS is a centrally
sponsored government scheme.
21
In terms of social sector support the study identifed serious gaps such as lack of reach and co-ordination of public sector services, inadequate training and
supervision of service providers in nutritional counselling and compromised efciency of services and programmes (Urban ICDS, Public Distribution
System (PDS) and others) contributing to the inadequate targeting of the population.
Dr. Shanti Ghosh and Dr. Dheeraj Shah advocated that sustainable behavioural change and health practices are required to tackle malnutrition. As
mitigating factors the study recommended that community-based peer counselling eforts more efectively reach target audience, more number of
mobile crches and anganwadis be made available, and dedicated volunteers be trained to carry out nutrition education and behaviour change. Te
efective use of mass media to communicate nutrition messages was advocated. Importantly, the study recommended an integrated strategy to improve
food accessibility which would include interventions for income generation, eliminating discriminatory labour policies, improving PDS, improving
personal hygiene, environmental sanitation and health-seeking behaviour, involvement of community leaders, non-governmental oganisations (NGOs)
and community-based organisations (CBOs).
A study on the nutritional status of adolescent girls of a slum community of Varanasi found Chronic Energy Defciency
11
in 51% and stunting in 10%
as per WHO standards.
12
A study in 2001 on the nutritional status of children residing in squatter settlements on pavements and along roadsides of Jaipur city as determined by
anthropometry found that on the whole, considering both the age categories and the sexes, only 25.3% of the sample under study could be categorised
as normal, while the rest of the children sufered from varying degrees of malnutrition. Te data also revealed that there were a higher percentage of
underweight children in the older age group.
13
11 Chronic Energy Defciency: A sustained period of caloric deprivation
12 N Singh, CP Mishra(2001): Nutritional status of adolescent girls of a slum community of Varanasi, India J Public Health; 45:128-134
13 Goyle, Anuradha, N Shekhawat, H Saraf, P Jain & S Vyas (2001): Nutritional Status of Children Residing in Squatter Settlements on Pavements and Along Roadsides of Jaipur City
as Determined by Anthropometry, Anthropologist, 7(3): 193-196 (2005).Viewed on 13 August 2013(www.krepublishers.com/...2005...3...2005...3-193-196-2005.../Anth-07-...)
22
INTRODUCTION
A World Bank study
14
in 2005 identifed dietary diversifcation, better anaemia control, vitamin A doses, and universal access to iodised salt as some
initiatives that could rapidly reduce micronutrient defciencies. Te Integrated Child Development Scheme (ICDS) has only partly succeeded in targeting
the communities most vulnerable to the problem of malnutrition. Of relevance to the context of the ORF-MBBF study is a comment that excessive focus
on providing food supplementation has taken much energy and resources away from modifying child care behaviour and education.
A 2007 study
15
on nutrition surveillance titled Nutrition Surveillance in 1-6 years old Children in Urban Slums of A City in Northern India on dietary
intake and other factors associated with nutrition, found that 57.4% of the children were malnourished. Whats more, the intake of calories decreases
signifcantly as the nutrition status of the children deteriorates - less than 16% of the undernourished children were consuming not more than 90% of
the recommended calories intake.
Many studies on malnutrition among 0-36 month-old children emphasise on immunisation, the criticality of breast feeding to improving nutrition status
of children, and providing micronutrient supplements etc. Nourishing our FutureTackling Child Malnutrition in Urban Slums
16
, is one such report
undertaken by Piramal Healthcare and Dasra, a philanthropic organisation in Mumbai. Te report looks at interventions in tackling malnutrition by
training community volunteers, public health workers, better advocacy, enhancing access to healthcare by improving health posts and anganwadis and
maps and assesses the work of other NGOs in the feld, highlighting best practices by showcasing the work of SNEHA, SMILE, Apnalaya, Mobile Creche
and others .
14 Michele Gragnolati, Meera Shekar, Monica Das Gupta, Caryn Bredenkamp and Yi-Kyoung Lee, Indias Undernourished Children: A Call for Reform and Action, Te World Bank,
August 2005
15 Goel, Manish Kumar, R Mishra, D R Gaur, A Das(2007): Nutrition Surveillance In 1-6 Years Old Children in Urban Slums Of A City In Northern India, Te Internet Journal of
Epidemiology, Vol 5 Number 1, DOI:10.5580/164f
16 http://www.dasra.org/pdf/NOURISHING_OUR_FUTURE.pdf
23
Te situation in the slums of Mumbai, however, is not very diferent from the rest of the
country. Te study by Dr. Neeraj Hatekar, Professor of Econometrics, University of Mumbai
and Sanjay Rode, Department of Economics, University of Mumbai, titled Truth About
Hunger and Disease in Mumbai Malnourishment among slum children
17
, estimated that
750 children in the 0-5 years category die due to malnutrition in Mumbai. From the point
of view of our study, it is signifcant that Hatekar and Rode studied the nutrition status
of tribal children in Jawhar taluka of Tane district of Maharashtra as well as the slums
of Kurla, Matunga and Dadar in Mumbai and commented that conditions of child
healthcare, maternal nutrition, access to clean drinking water and other amenities as
well as access to adequate food are no better in urban slums than in tribal villages.
In the ten years that have passed what is the situation? In 2010, taking cognisance of a news report that 16 children had died of malnutrition in one slum
in Mumbai, a team from the National Commission for Protection of Child Rights (NCPCR) did a study in the slums of Govandi in the north-east and
Malad in the western suburbs of Mumbai to evaluate the functioning of the ICDS in these areas. In its report
18
submitted in March 2011, doctors Dinesh
Laroia, Yogesh Dube and Shaifali Avasthi commented on the poor infrastructure in the anganwadi centres, lack of availability of clean toilets, potable
water, leaking roofs, all indicating poor resource allocation for these facilities in the anganwadis provided by the government.
Signifcantly, the NCPCR team commented on the inadequacy of resources for providing breakfast and snacks to children as a result of which the Self-
Help Groups (SHGs)
19
were fnding it difcult to continue to supply food of the desired quality. Te months take-home rations (THR) for children were
supplied to the parents on one single day, making it difcult to monitor the impact on the childrens health. Te one-time hand-out also negated the
opportunity to interact and train the parents on a day-to-day basis. Te ICDS project was as severely short stafed then as it continues to be now. Tere
17 Neeraj Hatekar, Sanjay Rode, Truth About Hunger and Disease in Mumbai Malnourishment among slum children, Economic and Political Weekly Oct 2003
18 Govandi Nagar North East and Malad West visit Report, Mumbai, Maharashtra 11th March, 2011 ncpcr.gov.in/view_fle.php?fd=125
19 A Self Help Group (SHG) is a small, economically homogeneous afnity group of rural/urban/tribal poor voluntarily coming together to save small amounts regularly, which
are deposited in a common fund to meet members emergency needs and to make small interest-bearing loans to their members. Tey also address their common problems and
undertake income generating activities. SHGs are also sometimes referred to as mahila mandals (womens groups).
Hatekar and Rode in their 2003 study titled
'Truth About Hunger and Disease in Mumbai
Malnourishment among slum children'
commented that conditions of child healthcare,
maternal nutrition, access to clean drinking
water and other amenities as well as access to
adequate food are no better in urban slums than
in tribal villages of Maharashtra.
24
INTRODUCTION
was no apparent mechanism to track cases of Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) nor any institutional support
to hospitalise cases of SAM. Te report also called for a complete overhaul of the living conditions of residents of these areas. Much of this is borne out
in our study fndings too.
A study
20
in 2012 (Das et al) supports the idea of focussing on children of younger age-groups (frst 1000 days of a childs life) for the best impact on
their long-term health prospects. Te study recommends focussing on girls education and nutrition to be able to break the intergenerational cycle of
malnutrition. Te study also raises the important issue whether growth standards should be locally tailored or refect global distributions. Refer to
Annexure A & B for a comparison of global (WHO 2006) and local (Aggarwal et al., Khadilkar et al., Marwaha et al.) growth standards.
A series of investigative media reports also brought to light general trends in child malnutrition in Mumbai
21
. Tey pointed out that a healthy meal is
more out of reach for girls. Tese reports also revealed that children in slums are malnourished not because their parents cant aford to feed them but
because their meals lack nutrition, ofen consisting of only wafers and tofees. Besides, malnutrition among large sections of the citys urban poor is
rampant as many do not see it as a problem, being largely ignorant of its prevalence.
A study
22
by three doctors of community medicine from Maharashtra, Saiprasad Bhavsar, Mahajan Hemant and Rajan Kulkarni, on poor nutritional
status and frequent infections, state that malnutrition is a vicious cycle, where a malnourished child has poor disease fghting ability and this lower
immunity makes the child more susceptible to malnutrition. Te study emphasises the need to improve the knowledge level of mothers on the nutritional
needs of their children and good child rearing practices; improving eating patterns by introducing non-expensive, culturally-acceptable nutritious
20 Sushmita Das, Ujwala Bapat, Neena Shah More, Glyn Alcock, Armida Fernandez & David Osrin, Nutritional Status of Young Children in Mumbai Slums: A follow-up
anthropometric study, Nutrition Journal 2012
21 'Where the young lives waste away', Hindustan Times, Oct 29, 2012; 'Tey get to eat, but its all junk food', Hindustan Times, Oct 30, 2012; 'Healthy meal: more out of reach for
girls', Hindustan Times, Oct 31, 2012
22 Saiprasad Bhavsar, Mahajan Hemant and Rajan Kulkarni, Maternal and Environmental Factors Afecting the Nutritional Status of Children in Mumbai Urban Slums, International
Journal of Scientifc and Research Publications, Vol 2, Issue 11 November 2012
25
recipes; better water treatment practices, etc. In the context of the ORF-MBBF study, this study (Saiprasad Bhavsar et al.) establishes the interplay
between children having poor nutrition status and their prevailing poor environmental conditions lack of proper housing, open defecation practices,
and no access to clean tap water etc.
Is there a correlation between better sanitation conditions and levels of undernutrition? Robert Chambers, with the Institute of Development Studies,
University of Sussex, UK and Gregor von Medeazza, with UNICEF India say that
23
sanitation and hygiene have been a blind spot for those dealing with
undernutrition and that in hygienic conditions much of Indias undernutrition would disappear. Te dramatic presentation of diarrhoea has drawn the
attention away from other less visible and less researched faecally-transmitted infections (FTIs).

Te essay titled Sanitation and Stunting in India: Undernutritions Blind Spot shows that there
are diverse non-diarrhoeal FTIs that hinder the absorption of nutrients, even without the
child seeming sick. But given that the resulting undernutrition has serious efects on health,
exposing the child to opportunistic diseases such as pneumonia, it should come as no
surprise that this is the underlying cause of about half the deaths of children under-ve
from infectious diseases in conditions like those in rural India, thereby echoing Hatekar
and Rode.
Te data gathered in the course of the ORF-MBBF study from Mumbais suburbs clearly
establishes the correlation between nutritional status and environmental factors and makes
a strong recommendation for an integrated approach to solving the problem of undernutrition.
For a global perspective, the ORF-MBBF report has taken a look at publications on maternal and child nutrition by Te Lancet, a leading international
Robert Chambers and Gregor von Medeazza, say
that sanitation and hygiene have been blind
spots and that in hygienic conditions much of
Indias undernutrition would disappear. Te
dramatic presentation of diarrhoea has drawn
the attention away from other less visible and
less researchable faecally-transmitted infections
(FTIs).
23 Robert Chambers, Gregor von Medeazza , Sanitation and Stunting in India: Undernutritions Blind Spot, Economic & Political Weekly June 22, 2013
26
INTRODUCTION
journal in general medicine. In 2008 Te Lancet series on maternal and child nutrition had quantifed the problem and its long and short-term impact.
Five years later, in 2013, the journal published a series assessing national progress and the international eforts towards previous recommendations. Te
Lancet Series 2013, while stating that nutrition is crucial to both individual and national development, strengthens the evidence base that good nutrition
is a fundamental driver of a wide range of development goals. Te point that malnutrition has a negative impact on school enrolment and grade
attainment of children aged 5 to 11 years has been validated by the experts and their reports
24
, which were referred to as part of our literature review.
Te ORF-MBBF study has also found a signifcant correlation between undernutrition
and academic underperformance; however, relying on school records alone for measuring
performance was not seen as being a sound yardstick for assessing any cognitive problems
in children. An in-depth and separate study into this issue is warranted given the staggering
implications this has for the individual and the nation.
Rightly terming it as an unfnished agenda, Te Lancet 2013 Series on Maternal and Child
Nutrition states that:
Te number of stunted children has decreased from 253 million in 1990 to 165 million in 2011; 165 million children with stunted growth have
compromised cognitive development and physical capabilities;
At least 8% is reduced from a nations economic advancement because of productivity losses, losses due to poorer cognition from reduced schooling;
Te prevalence of wasting globally was 8% in 2011;
More than half the resources to be spent in Scaling Up Nutrition initiatives (See Annexure D) will be borne by India and Indonesia.
Investing in nutrition is investing in the future
of the country It creates stronger communities
with a healthier, smarter and more productive
population.
Save the Children International
24 Neeraj Hatekar, Sanjay Rode, Quietly Tey Die: A Study Of Malnourishment Related Deaths In Mumbai, Department of Economics, University of Mumbai, working Paper 2003
27
Aim of the study
Te aim of the study is to compare undernutrition among children and adolescents across structured and unstructured urban slums located in
Mumbais Suburbs. Tis is a cross-sectional descriptive epidemiological study that looks at undernutrition through diverse factors impacting it. Along
with nutritional and overall health status, type of shelter, food insecurity, access to closed sanitary facility and access to piped water supply have been
taken into consideration.
Objectives
To assess the nutritional status of children in terms of anthropometry
25
, clinical signs of nutritional defciencies and associated co-morbidities;
To study the impact of the income and occupation of parents and household food insufciency on the nutritional status of the children;
To establish correlation between access to sanitation, access to water supply, and type of shelter and nutrition outcomes;
To evaluate and understand dietary intake patterns;
Need for the study
Experience from previous studies shows that nutrition of children in squatter settlements or unstructured slums is ofen overlooked. Importantly, despite
civic facilities, the nutrition status in structured slums also fairs poorly. Hence this study was carried out to compare undernutrition among children and
adolescents across 'structured' and urban slums.
26
25 Anthropometry is the use of body measurements such as weight, height and mid-upper arm circumference (MUAC), in combination with age and sex, to gauge growth or
failure to grow.
26 Banerjee, Joya (2010): Child Health and Immunization Status in an Unregistered Mumbai Slum, Dissertation, Boston Massachusetts. Viewed on 13 August 2013,
<www.hsph.harvard.edu/women-and-health.../fles/.../banerjee_thesis.pdf>
Mundu Bahalen, Grace & R.B Bhagat (2008): Slum conditions in Mumbai with Reference to the access of Civic Amenities, IIPS Mumbai, ENVIS center, Volume 5, No. 1.
Viewed on 13 August 2013.(www.iipsenvis.nic.in/newsletters/vol5no1/page_3.htim)
Mumbai City Development Plan 2005-2006 ,Urban Basic Services in Slums, Viewed on 19 November 2013, (www.mcgm.gov.in/.../Urban%20Basic%20Services%20in%20
Slums.pdf)
28
INTRODUCTION
Interventions in nutrition have always been more nutrition-specifc like promotion of
Infant and Young Child Feeding (IYCF) practices, for example. Not undermining their
importance however, nutrition-sensitive interventions like improvements in sanitation,
for example, have not received enough focus.
27
Hence, our study was carried out to
establish the social aspects of the problem for targeting these interventions.
Children from unstructured slums may have diferent nutrition status from children of structured slums on account of being exposed to harsher living
conditions. Hence, the study was carried out to explain the nature and patterns of undernutrition and types of morbidities more precisely across the two
clusters.
Limitations of the study
Tis study is restricted to children who reside in slums, who attended the health camp conducted by the ORF-MBBF team of doctors. Te age group
chosen for the study is of school going children between 3 and 12 years; those below 3 years have not been included. Te most popularly used Indian
growth charts Khadilkar et al., does not have reference weight and height for children below fve years; hence the Marwaha et al., 2011 growth charts
have been used. (See Annexure A for comparison of growth assessment scales). Street children, living under the open skies, have not been considered.
27 Ramesh, Jairam (28 June 2013):Political class has been neglecting sanitation, Economic Times, Viewed on 13 August 2013(http://articles.economictimes.indiatimes.com/2013-
06-28/news/40255980_1_defecation-child-nutrition-sanitation-ministry)
Chambers, Robert &, Medeazza, Gregor von (2013): Sanitation and Stunting in India: Undernutritions Blind Spot, Economic and Political Weekly, Vol - XLVIII No. 25, 22 June
2013
Te Lancet (2013): Maternal and Child Nutrition - Executive Summary of the Lancet Maternal and Child Nutrition Series. Viewed on 19 September 2013
Nutrition-sensitive interventions like
improvements in sanitation for example, have
not received enough focus.
Chapter 2.
MATERIALS AND METHODS
31
Study Design
Te study was undertaken to assess the nutritional and anthropometric profle of the children who attended health camps from both structured and
unstructured settlements, in the heart of the megacity, within the municipal limits of Greater Mumbai, at Ghatkopar. Te study population was selected
from a structured and an unstructured slum - namely, Mata Ramabai Ambedkar Nagar and Indian Oil Nagar and neighbouring squatter colonies. Te
sample of 300 children selected is representative of the reference population i.e. an urban slum in a megacity. Te convenient sample of 300 children is
drawn from the age group of 3-12 years of both genders who attended the health camps conducted by ORF-MBBF on February 21, 2013 in the structured
slum. Similarly children who attended medical check-ups from the unstructured slum were also chosen for the study. Children whose parents did not
give consent were excluded from the study.
Te consent of community leaders was obtained with assistance from the Spandan Holistic Institute, a local NGO run by MBBF. Te questionnaire for
the study was refned for easy administration. Te feld study was conducted from January 21, 2013 to May 31, 2013.
As per the study titled 'Nutritional Status of Children Residing in Squatter Settlements on Pavements and Along Roadsides of Jaipur City as Determined
by Anthropometry' the prevalence of malnutrition/undernutrition in squatter slums was about 75%.
30
Keeping this as an approximate estimate of the
parameter, a two-tailed alpha error of 0.05 was established. With a view to make an acceptable deviation of 5% on either side, (acceptable 95%C.I, 70-80),
the mean acceptable sample size worked out to be 288. It was decided to round of the sample size to 300 to increase the precision of study and make
inter-group comparisons possible.
Te time and place of interviewing and examining the decided groups was identifed in consultation with them, depending on the availability and
keeping in view minimum interference on their work/activities.
30 Goyle, Anuradha, N Shekhawat, H Saraf, P Jain & S Vyas (2001): Nutritional Status of Children Residing in Squatter Settlements on Pavements and Along Roadsides of Jai-
pur City as Determined by Anthropometry, Anthropologist, 7(3): 193-196 (2005).Viewed on 13 August 2013 (www.krepublishers.com/...2005...3...2005...3-193-196-2005.../
Anth-07-...)
32
MATERIALS AND METHODS
In conformity with the WHO recommendation of no survey without service, all subjects examined in the camp and detected to be having evidence
of any medical problem were referred to the nearest health centre for further evaluation by the examining doctors. Following the data collection, an
educational drive was also initiated by ORF-MBBF to create awareness among the population about health, nutrition and sanitation issues.
A pilot study was undertaken on a total of 25 randomly selected children with a view to standardise the entire methodology of data collection as explained
earlier in this chapter. Te results of the pilot study have not been included in the analysis of the main study.
Instruments used in the study
Te instruments used in the present study were broadly of two types:
Physical instruments
Questionnaire
Tools/physical instruments
Te instruments used in the study included a portable weighing machine, height scale and growth charts for nutritional status published by Marwaha et
al. (2011).
All the instruments were calibrated and standardised for their precision throughout the period of the data collection.
Questionnaire
A detailed questionnaire was developed to record the data regarding various socio-demographic variables including access to clean drinking water
and sanitation, details about results of physical examination to identify underlying morbidity and record of nutritional intake by 24-hour dietary recall
method. Te questionnaire is attached as Annexure E.
33
Methodology adopted in the conduct of the study
Before commencement of the feld surveys, all the interviewers and medical staf were trained and briefed about the method of examination, recording
of observations and administration of questionnaire to ensure uniformity and reduce observer bias and for the importance of standardisation with
respect to equipment used for measurement. Te data collection from the study subjects broadly consisted of two types of procedures interviewer-
administered questionnaire and physical examination. Te time selected for undertaking the interviews and physical examination was generally between
10 am and 4 pm.
Method of data collection
Te selected children were interviewed by Raut A, Mane D, Raje M and DSilva R. Te answers to the questionnaires were sought through these personal
interviews. Te questionnaire was administered in Hindi and Marathi and the responses entered in the forms in English. Te interview was undertaken
later on in the childrens households ensuring adequate privacy and with their consent. At the start of the study, initial rapport was established with the
children and their immediate families to ensure that they were at ease during the entire process. Tey were informed of the scope of the study and were
assured that the information they give would be kept confdential. Te data on the various study variables was then recorded in the questionnaire. Te
questionnaire included assessment of environmental and socio-economic variables. Te details of methodology of recording these measurements are
discussed under the heading Defnition and details of measurement of study variables.
Defnition and details of measurement of study variables
Age
Age was recorded to the nearest completed year (6 months and above being rounded of to the next year and less than six months to the previous year).
Educational Status (Class)
Educational status was recorded as the class in which the subject is studying and name of the school was also noted.
34
MATERIALS AND METHODS
Socio-economic status and parents occupation
Broad income groups were made based on net family income: Rs. 5,000 and below, Rs. 5,000 to 10,000, Rs. 10,000 to 20,000 per month. In the present
study, socio-economic status was noted in terms of these three categories.
Te occupation of both the parents was considered and endorsed as such - namely, drivers, ofce clerks, BMC staf, salesmen, domestic help, peons,
casual labourers, masons and sanitation workers. Te income of both parents was estimated on the basis of type and nature of occupation.
Family size
Te size of the childrens immediate family consisting of parents and siblings was recorded.
Type of shelter
Type of shelter of the families, that is, tent structure or permanent concrete home was recorded.
Access to sanitary facility
Information on the type of sanitary facility used by the children, that is, closed or open sanitary facility, was recorded. Availability of toilets within the
home was also recorded.
Access to piped water supply
Information on the type of water supply to the dwelling, whether piped water supply close to home or sourcing from private sources in water cans at a
cost, was recorded.
Method of water purifcation
Information on the method of purifcation of water for drinking purpose - whether boiled, fltered, strained through cloth or any other method of
purifcation, was recorded.
35
Food insecurity
Information on food insecurity faced by the children on certain days, months or occasions was recorded was the child deprived of a meal for no choice
of his/hers?
Nutritional data
Te data on nutritional security was collected on a survey form for the structured slum to record dietary intake by the 24-hour dietary recall method. Te
services of a nutritional consultant were requisitioned to accord calorifc value of all food items consumed and estimate net caloric intake and net protein
intake. Te nutritionists report is presented under the title 24-hour Dietary Intake Findings and Recommendations on Diet (Children of structured
slums) which contrasts the actual diet consumed with the ideal diet.
Anthropometric measurements
Te anthropometrical measurements recorded during the study were the weight and height of each child. Te recording of all the anthropometric
measurements was done with the children only wearing minimum clothing and without sweater or shoes, and was conducted on the guidelines issued
by the WHO.
31
Weight
Body weight was measured to the nearest kilogram using a portable weighing machine, which was calibrated and zero error correction done periodically
during the study. Since the interviews and examinations were carried out in the normal working hours, it also ensured that the subjects had emptied their
bowels but neither they were on empty stomach. Tis ensured that recording was done accurately when the subjects were relaxed.
Height
Height was recorded afer recording the weight, with the subject standing erect against a height scale fxed to the wall.
31 Training course and other tools, WHO - Te WHO Multicentre Growth Reference Study MGRS, Viewed on 19 September 2013( http://www.who.int/childgrowth/training/
en/)
36
MATERIALS AND METHODS
Vaccination and medical history
Te medical examination and vaccination history was recorded by medical ofcers and trained medical social workers hired as per the proforma enclosed
as Annexure E. Te medical social workers were trained by the medical ofcers in the survey team in observing presence of poor nutrition-related and
other clinical signs and symptoms of illnesses. All abnormal fndings were reviewed and validated by the qualifed doctors.
Co-morbidities, mental health and over-all behaviour
Te occurrence and frequency of infections, morbid conditions, poor appetite, poor memory, poor scholastic performance and overall behaviour was
recorded as reported by the subjects and their parents during investigation.
Analysis used for the study
Te prevalence of undernutrition was found out from the study. Te weight-for-age and height-for-age growth charts for nutritional status published by
Marwaha et al (2011) was used as an instrument in this study. All children with weight-for-age Z-score, < minus (-) 2 or below 3rd percentile were taken
as underweight and those above 3rd percentile were taken as normal. All children with height-for-age Z-score, < minus (-) 2 or below 3rd percentile were
taken as stunted and those above 3rd percentile were taken as normal.
32
Te sofware used was open epi, available at www.openepi.com
33
.Tables within the sofware used were Epi Info 7.
32 Marwaha, Raman Kumar, N Tandon, M A Ganie, R Kanwar, C Shivprasad, A Sabharwal, K Bhadra, A Narang (2011): Nationwide reference data for height, weight and body
mass index of Indian schoolchildren, NMJI, Vol. 24, No. 5
Sachdev, H.P.S. (1995): Addressing Child Malnutrition: Some Basic Issues. NFI Bulletin. Vol 16 No. 4.
33 www.openepi.com is free and open source website for epidemiologic statistics. Epi Info 7 is a free sofware tool for public health statistics.
37
Data collected by 24-hours dietary recall
34
of food intake of children from the structured slum was analysed based on Recommended Dietary Allowances
for Indians based on age and gender, by the National Institute of Nutrition, Hyderabad.
35
(See Annexure F)
Total energy and total protein consumed were calculated from the available data.
Te selected group of children for research (3 to 12 years) was further divided into three sub-groups as per their growth and nutritional requirements.
Below 6 years (preschool group) Early growth period; average growth of height by 6-7 cms/year and average growth of weight by 1.5-3 kgs/year.
7-9 years Latent growth periods.
10 years and above Adolescent phase; second highest growth spurt afer infancy.
Food pyramid: based on the food pyramid the actual diet was compared with ideal diet
As per the food pyramid,
One serving of cereals was taken as 30 gms.
One serving of pulses was taken as 30 gms.
One serving of egg, fsh, and meats were taken as 100 gms.
One serving of vegetable was taken as 100 gms.
One serving of milk was taken as 150 ml.
One serving of fruits was taken as 100 gms.
Ideal servings:-
34 24-hours dietary recall is a retrospective method of dietary assessment where an individual is interviewed about their food and beverage consumption during a defned period
of time, typically the previous day or the preceding 24 hours.
35 Recommended Dietary Allowances for Indians available online at http://www.ninindia.org/index.asp
38
MATERIALS AND METHODS
Cereal group items like roti, chapatti, phulka, bhakri, bread, poha, upma, idli, dosa, etc., should be consumed at the rate of 6 to 8 servings/day.
2-3 servings per day of protein-rich food group which includes egg, fsh and meat should be included.
3-5 servings/ day of vegetable food group should be consumed.
Around 2-4 serving/day of fruits and vegetable food group should be included.
Milk and milk products food group should be consumed at the rate of 2-3 servings/day.
Oil, fats and sweets should be consumed sparingly.
Grading system for milk, vegetable and fruit intake: A special grading system was created to calculate intake of milk, vegetable and fruit based on
requirement as per the food pyramid.
Grade Milk intake Vegetables intake Fruits intake
Grade A 1 or 1 and serving/day 2 servings/day 2 servings/day
Grade B to 1 serving/day 1 serving/day 1 serving/day
Grade C less than serving or no milk/day serving or no vegetables/day No fruits
Note: 1 cup of tea was considered as serving
1 glass of milk/day was given Grade A
Limitations: As per the 24-hour diet recall, the diet taken for a single day was recorded. Tere is possibility of variance in quantity of food actually
consumed and the quantity recorded.
ORF-MBBF researchers at work
ORF-MBBF researchers at work
Chapter 3.
CHALLENGES TO CHILD
NUTRITION IN SLUMS
42
CHALLENGES TO CHILD NUTRITION IN SLUMS
Tere are huge disparities in Human Development Indices
for slum and non-slum population on social and health parameters
like literacy rate, sex ratio and morbidity rates on account of costs,
stress and space. As per the Mumbai Human Development
Report 2009, slums have higher mortality rate between the frst
and ffh birthdays, which is twice as high as for those in non-
slum areas, i.e. eight versus four.
Lack of access to potable piped water supply for slum
dwellers leads to greater proportion of income spent on buying
water and fghting water-borne and water-washed diseases.
A closer look at the problem clearly points out certain
factors that have perpetuated undernutrition over the decades,
and the scenario has remained more or less unchanged.
Inadequate sanitation system in
slums: Tere is an average one toilet
seat per 81 persons in the slums, in
some areas it is as high as one toilet
seat per 273 persons and the lowest at
one toilet seat per 58 persons.
SLUMS
As per Census 2011, Municipal Corporation
of Greater Mumbai has 41.3 % Slum
Households. About 62% of the population
lives in slums and slum-like habitats
Overcrowding and
congestion in slums: As
per the Census 2011, 62%
population in slums occupy
only 8% of all the land in the
city.
Te slum environment is not conducive to mental wellbeing. It
results in dysfunctional behavior and other problems. As per Mumbai
Human Development Report, 2009, alcohol use is higher at 36% in
slums as compared to 29% in non-slum areas. Tobacco use is much
higher in slums with 9% of women and 46% of men using it in some
form compared to 4% and 35% respectively in non-slum areas.
Te slum environment is not conducive to physical
wellbeing. According to the Mumbai Human
Development Report, 2009, prevalence of TB is
much higher in slums - as much as 600 per
1,00,000 compared to 458 per 1,00,000 in non-
slum areas.






Challenges to Child Nutrition in Slums
43
Insecurity of tenure for unauthorised, recognised but not
notifed, illegal, squatters, pavement dwellings, resettlement
colonies occupying private or otherwise non-residential land.
NFHS 3, 2005-2006, found that about one quarter of these
residents did not feel safe from eviction.
Rising income disparity
As per NSSO 68th Round (2011-
2012), average spend or income of
the richest in urban areas was 15
times that of the poorest.
Poor diversity in diet and nutrition: Low spending on fruits,
milk and vegetables by the poor in urban areas, leads to extremely
micro-nutrients defcient diet. As per NSSO 68th Round (2011-
2012), per person monthly rupee spend on milk for the richest
was Rs. 422 and for the poorest, Rs. 111. Te richest spent Rs.
200 on egg, fsh and meat, while the poorest, Rs. 66. Spend on
fresh fruits was Rs. 244 and Rs. 30 respectively.
Te cut-of date for notifcation of
slums which was 1995 has only recently
been extended up to 2000, not to other
slums.
Housing tenure determines access to basic
services like piped water, sanitation and
even Anganwadi Centres. As a matter
of policy BMC supplies water to slums
in the tolerated category, i.e., slums
constructed prior to 2000.
Housing tenure determines coverage
of BMCs ward-wise health services of
immunisation tracking, de-worming;
family planning etc. It also determines
structural quality of houses. Tere is
limited coverage of preventive services
by health posts and dispensaries.
Larger economic and social policies
impacted by electoral politics, political
will, business and market forces
Lack of supportive agricultural
policies
Large number of very small and
marginal farmers sufering losses in
agriculture
Poor cold storage facilities
for vegetables during and afer
transport to the city afects prices
in retail markets. An estimated
9,60,000 kg of vegetables are
wasted everyday due to transport
and other losses at Navi Mumbais
APMC Market.
Migrants, who may not possess required skills and education end up
gaining employment in the huge informal sector. According to Mumbai
Human Development Report 2009, migrants are engaging in production-
related occupations at least half are becoming indispensable to the
citys economy by flling in cheap, labour-oriented and unskilled jobs.
Rural to urban migration is a signifcant determinant of undernutrition among children
and their mothers. From both exploratory and multivariate analyses, it was evident
that migrants of rural origin form the most vulnerable category in Mumbai. Study:
Choudhary & Parthasarthy*
CHALLENGES TO CHILD NUTRITION
IN SLUMS
Legal status of residence in the city/security of
housing tenure
As per Census 2011, 65. 7 % slums fall into recognized
(not notifed) and identifed (not notifed) category








44
CHALLENGES TO CHILD NUTRITION IN SLUMS
Integrated Child Development
Service (ICDS) Anganwadi Centers:
Tere are limited services in Mumbai
against demand and very limited
coverage across unauthorised slums.
Te Inadequacy of Social Safety
Nets + Health Programmes
A large number of extremely needy
persons are lef out on account
of administrative and operational
difculties in running these
programmes.
Public Distribution System
(PDS): Benefciaries face
issues of quality, lack of timely
availability and limited quantity
of food supplies.
Mid Day Meals
Four in every fve SHGs and NGOs supplying Mid Day Meals to 3.8 lakh students in 1,174 BMC
primary schools in the city ofered poor quality meals in 2012-13. (Mumbai Newsline, Te Indian
Express July 24, 2013)



Special interventions to meet the health and nutrition needs of
adolescents (10-19 years) are needed

Te Inadequacy of social safety nets and health programmes
45
References:
*Is Migration Status a determinant of urban nutrition insecurity? Empirical evidence from Mumbai city, India, Neetu Chaoudhary and D.
Parthasarthy
Mumbai Belly, Mumbai Mirror June 23, 2013
**Srivastava, R. & Sasikumar, S. K. (2003), An overview of migration in India, its impacts and key issues. Paper presented at the Regional Conference
on Migration, Development and Pro-Poor Policy Choices in Asia, June 22-24, Dhaka, Bangladesh.
ILO Asia-Pacifc Working Paper Series, Decent Work in Ahmedabad: An Integrated Approach: Te vicious circle of insecurity of tenure and
poverty, Mahadevia and Shah 2009
Mumbai Human Development Report 2009
Census of India 2011
Child Health and Immunization Status in an Unregistered Slum of Mumbai, Joya Banerjee, May 14, 2010, Partners for Urban Knowledge & Action
Research (PUKAR) & Harvard School of Public Health (HSPH)
ICDS Mumbai Visit Report, National Commission for Protection of Child Rights by Dr Dinesh Laroia, Dr Yogesh Dube & Shaifali Avasthi, March
2011
Chapter 4.
PROFILE OF CLUSTERS SELECTED
FOR THE STUDY
48
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Profle of Structured Slum (Mata Ramabai Ambedkar Nagar, Ghatkopar East, Mumbai)
According to the local BMC health post, the current
population of Ramabai Ambedkar Nagar is estimated
to be about 95,000. Te stretch of three settlements
comprising Ramabai Ambedkar Nagar, Kamraj Nagar
and Nalanda are roughly estimated to have a population
of more than 5 lakhs. Te area has chawl structures that
are permanent. As one goes closer to mangroves the
homes have increasingly poorer structural quality.
49
Access to clean environment:
Overcrowding increase in population over the years has placed a tremendous strain on the existing civic infrastructure especially sanitation and
housing infrastructure, rendering it grossly insufcient.
Top view of a part of Ramabai Ambedkar Nagar.
50
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Homes bordering the mangrove/nalla stand next to a garbage dump close
to the colony.
Gutters at every corner are breeding grounds for mosquitoes and parasites.
51
Residents hardly have the choice of avoiding the unclean surroundings.
Dustbins in the whole area are
grossly insufcient and every
corner has piles of solid wastes,
wet as well as dry, dumped
around the dustbins.
Tis water body near the mangroves is abused by the residents for dumping of solid
wastes in large quantities.
Solid waste disposal practices are varied across the slum. Of the surveyed residents, 50% disposed garbage at common public dustbins in the area. Others reported that they disposed
garbage in the nalla, or in front of, or behind, their homes.
52
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Access to clean drinking water
Access to potable water is an issue of concern afecting every resident of Ramabai Nagar, irrespective of income, location or type of house. Te unplanned
pattern of settlements, sporadic rise of new settlements almost daily, has resulted in complete failure of the sanitation system. Te water situation in the
area has put the community at a high risk of diseases such as gastro-enteritis, jaundice, enteric fever and malaria and is the single most important factor
afecting the nutrition security of the community.
Potable water pipes are close to open sewage drains, soak pits and overfowing gutters. Tis ofen results in gutter water seeping into the drinking water pipes. Broken or damaged
water pipes are only temporarily sealed.
53
Potable water pipes are at ground
level, cracked in places and
soaked in open fowing kitchen
and toilet sewage. Tey are prone
to extreme contamination.
Residents face the problem of receiving yellowish sediment water, stinking water and in some cases water having worm infestation, throughout the year. Te situation is much worse
during the monsoon, especially for residents close to the nalla.
Given the slow pace at which water
fows through the pipes, people have
to rely on electricity run motors to
draw water into their homes.
Tis was highlighted in an earlier
study by ORF Mumbai on water
supply in the city (Dhaval Desai,
Time is Running Out Does Mumbai
Have Enough Water?; March 2013)
Most residents do not purify water beyond straining with a cloth at the collection source.
Tis further aggravates the impact of unclean water. In the sample that was studied, 51% of
the families purifed water through a cloth strainer, 21% used the boiling or fltering process
and 28% did not practice any method of water purifcation.
54
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Te water pipelines of the municipal corporation are not well-protected. Insufcient
and poor quality water fowing through pipes results in residents breaking existing
connections and making newer connections. Pipes are also broken to create water
access and to accommodate the needs of newer migrants in temporary dwellings. In
some unstructured slums, this is done by the water mafa that sells water to nearby
residents.
Substantial number of residents do not have piped water source from civic authorities.
Tey draw water from man-made shallow wells where water pipes pass underground.
Tose who draw water from shallow man-made wells, ofen have to deal with insects
breeding in the water.
Access to sanitation:
Inadequate toilets and lack of sanitation i.e. safe disposal of human excreta, has further enhanced the risk of nutrition insecurity for the residents. ORF
Mumbai Report, SanitationNow (July 2013) featured a review of the sanitation situation of Ramabai Ambedkar Nagar and found that the entire slum
population has access to only 45 toilet blocks and about 1,082 toilet seats in all, not counting the 36 that are closed. Considering the BMCs own accepted
norm of providing one toilet seat per 50 people, Ramabai Ambedkar Nagar, with a population of 95,000 should have at least 1900 toilet seats nearly
double the number currently available!
55
Using the toilet is an un-diginifying experience that requires the user to benumb his senses during use. Tis is on
account of the terrible stench and flth that is not only due to poor maintenance, but also due to the burden of a
large number of persons having to use the limited resources.
Overfowing septic tank in front of the home of this elderly
resident.
Local activists from Ramabai Ambedkar Nagar mentioned that, Pay and Use toilets constructed by SPARC, an NGO, are not connected to the BMC
sewerage mains. Te sewerage outlets from these toilets are lef out in the open. Some of them haphazardly drain into an open nalla that runs through
the slum.
56
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Residents said that none of the BMC-built toilets have water connections, even through water is indispensable for sanitation. Ostensibly, this is
meant to prevent water thef and misuse of water in the toilets, since the toilets are not manned. Only a few toilets built by local NGOs have water
connections, while people using other toilets have to carry water from their homes. Tese toilets are washed twice-a-week as per ofcial claims. In
reality, though, the clean-up happens far less regularly. If nearby residents are willing and co-operative they manage the clean-up at least once in three
days, by hiring local help. Children below fve years of age defecate outside their homes as it is more convenient, safer and a time-saving option for their
caretakers. Te faeces are not disposed properly and fow through the drains between the homes.
Access to healthcare
Healthcare services in Ramabai Ambedkar Nagar are a patchwork of the government set-up, quacks, inexperienced doctors, AYUSH doctors who practice
allopathic medicine, private practioners and charity-based providers. A large number of private doctors working longer hours than the municipal health
posts ensure easy access to immediate treatment of minor sicknesses and referral services.
Staf at the health posts feel that their work falls short of the needs of the large population. Government
health posts play an important role in preventive healthcare, particularly immunisation for BCG,
DPT, polio, measles and mumps, etc., through the systematic child tracking that is carried out by
all health posts catering to more than one lakh population. Community Health Volunteers (CHVs)
are engaged all throughout the year to carry out disease tracking surveys to spread awareness on
prevention of diseases.
Family planning advice and services is another important part of the preventive services. Te CHVs
are trained to ensure that antenatal care patients and pregnant women get themselves immunised,
get registered at proper hospitals, take iron supplements, and follow proper child feeding practices if
the children are found to be sickly or underweight.
Te Muthumariyama Trust OPD clinic in Ramabai
Ambedkar Nagar is the largest allopathic OPD clinic
that operates in the area with minimal service charges
for patients. Tis clinic sees an average of 500-1000
patients on a daily basis at its two centers.
57
Government health post dispensary in Ramabai Ambedkar Nagar.
Curative treatment for tuberculosis, malaria, and leprosy is
also provided at the health posts. Provision of DOTS, free of
cost sputum examination, leprosy screening and treatment
in association with Alert India, besides malaria investigation
and treatment is provided as well. Checks are kept on whether
TB patients are taking their medicines regularly.
Two renowned NGOs Alert India and SNEHA, have also been
serving the community with campaigns against TB, leprosy
and maternal and child nutrition respectively.
Spandan homeopathic clinic in Ramabai Ambedkar Nagar provides treatment for disability afected
children in the slum and for other chronic diseases.
Mental health needs for the large population are almost completely unmet. MBBF's
Spandan Holistic Institute of Applied Homeopathy has been working in the Ghatkopar
area since 1997, providing free of cost holistic healing for all ailments including mental
health disorders. Tey screen and test children for mental disorders, counsel parents
and children and provide holistic mental health solutions. Te foundation also runs
a school for children with learning disorders. (Sourced from ORF Mumbai Publication
titled An Urgent Call to Improve Mental Healthcare in India: A case study of M.B. Barvalia Foundation's
Commendable Work by Sriya Srikrishnan, 2012)
58
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Ayurvedic mobile vans in Ramabai Ambedkar Nagar
Symptoms of common ailments that is widespread among the population:
Conversation with medical ofcers in the area indicated the following about the general health of the population:
Some felt there is progression of diseases due to treatment by quacks.
Tere are also certain behaviours like lack of personal hygiene, consuming poor diets, consuming water without proper treatment, unsanitary
practices which repeatedly lead to scabies, enteric fevers, diarrhoea and undernutrition among the community.
As regards pregnant women, there is prevalence of pica, a behavioural problem with craving to eat items that are not food, such as, calcifed stones.
Possible causes of pica include vitamin, mineral or other dietary defciencies.
59
Other problems that impact, and are impacted by, undernutrition:
Early marriages and poor maternal health are also common which is one of the reasons for undernutrition in children.
Alcoholism is a menace in the area that has destroyed peace within families and eats into the money set aside for food.
Some doctors are also of the opinion that knowledge about including all nutrients in the food is neither part of tradition nor known to the residents
through education. Te staple diet, which consists mainly of rice and dal and one vegetable, is far from an ideal diet, that is diverse and rich in fruits
and milk. Tey eat rice and dal habitually not due to poverty, but as an eating habit.
Frequent worm infestations are seen in children. Loop worm, which is a water borne parasite, is also seen in the children.
Tuberculosis is a common air-borne disease that is exacerbated by undernutrition and congested living conditions.
60
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Profle of unstructured slums (Indian Oil Nagar and
neighbouring squatter settlements)
Mumbai City Development Plan Report 2005 to 2025 states that pavement dwellers,
residents of un-notifed slums and squatter settlements arisen afer 1995 are most
vulnerable in terms of access to basic necessities of life including housing, sanitation,
healthcare and food. Te two main pockets chosen for this study were Indian Oil
Nagar and neighbouring slums.
Te settlements are located near the Indian Oil bus stop, of the Ghatkopar Mankhurd
Link Road. Indian Oil Nagar is a settlement housing mostly those people who migrated
to the city around the year 2000. Te population comprises largely the Pardhi and
Wadari tribal communities who are small and marginal farmers and landless labourers
from rural Maharashtra and Karnataka. Te neighbouring squatters were a colony of
mainly sweepers and rag pickers. Indian Oil Nagar is a large settlement of 230 families
with a population of 900-1000. Te residents of the other neighbouring squatters
settlements are a mix of rural and urban migrants from diferent states. Residents live
in temporary shelter and have sufered demolition drives by the BMC in the past.
Indian Oil Complex marked on the map is a housing society. Te
unstructured slum is located on the other side of the Ghatkopar-
Mankhurd Link road exactly opposite the complex. Hence the cluster
is called Indian Oil Nagar. Te clusters have not been located on the
Google map.
61
Reusable items collected from sorting the garbage from the nearby dumping
ground by rag-pickers living in the slum cluster.
Debris from previous demolitions of the cluster carried out by BMC.
All residents live in temporary shelters like these.
62
PROFILE OF CLUSTERS SELECTED FOR THE STUDY
Access to sanitation
In the absence of toilets, residents defecate near these mangroves close to their dwelling. Some use
public toilets available in the nearby slums. Tere is absence of any regular system of gathering
solid waste for disposal. Solid waste is dumped into the nalla bordering the settlement.
Access to health & education
Most children are registered at the nearby municipal school, some at the boarding schools in
villages. A sizeable number of children have dropped out of school, or are not enrolled in any
school. Some of them, though, attend informal schools. Tere is absence of coverage of preventive
health services and immunisation. Tis area has not been reached by ICDS projects. Treatment
of minor ailments is provided by local NGOs through mobile medical vans on a regular basis. In
case of emergencies, they visit government or private doctors.
Access to food
Most residents are employed as sanitation workers, in masonry jobs and a small number are
employed in shopping malls. Most of them have very low and irregular incomes and hence, face
extreme food insecurity. Added to this, their homes are in the middle of a highway which is very
far from any market.
Children line up for food from an NGOs mobile van in Indian
Oil Nagar
Solid waste is dumped into the nalla
63
Access to Water Supply
Many residents do not have access to piped water supply on account of their unapproved slum status. Water is purchased at the rate of Rs 5 per 20 litre
can from the nearby chawls. A single household uses 4 to 5 such cans per day. Water from the drain fowing nearby is used for other chores.
Daily chores of bathing and washing by residents of Indian Oil Nagar using water from the drain. Photos by Rachel DSilva, Janki Pandya and Anuradha Raut
Chapter 5.
FINDINGS
For now I ask
no more
than the justice
of eating.
67
T
he profles of children presented here bring into focus very sharply the problem of child undernutrition, food insecurity and the abject lack of
state support for people living in unstructured slums. Apart from the appalling living conditions, certain social factors, such as early conception,
lack of adequate spacing between child-births, etc., are seen to exacerbate the prevalence of undernutrition among the children.
Profles of undernourished children
Aakash is aged three years. He is sufering from undernutrition. His weight is six kilos. Te normal weight of children his age is 14 kilos. He is potbellied,
bow-legged and is unable to stand straight. He also has difculty in urination. Son of a casual labourer, he is the second among three siblings. He was
enrolled at a balwadi run by an NGO in the community, which has stopped functioning lately. He sufers from recurrent cold, cough and diarrhoea. Like
most women from this cluster, his mother had not taken iron and folic acid tablets before the birth of this child. Besides, she was anaemic and had poor
diet during pregnancy. Aakash was born prematurely, at home. He has had a history of poor feeding during infancy. It is no wonder that Aakash has
had delayed milestones of development. Within the frst three years of life, he has been a victim of bronchial infections and measles. He ofen has bouts
of diarrhoea and has a low appetite for food. To add to his woes, his home is a temporary shelter adjoining a dusty highway, directly contributing to his
overall poor health and nutrition.
Devdas, aged seven years, is underweight. He was sufering from boils during the examination by the ORF-MBBF team. He has a history of poor feeding
during infancy. Born to his mother who was 18 years old at the time of delivery, he was abandoned when he was nine months old and was looked afer
by other close relatives. He is an extremely angry and irritable child, according to family members. He performs fairly at the local municipal school. His
brother Satish aged fve years also sufers from undernutrition. Examination revealed that Satish had a recent bout of malaria, has a poor appetite and
complains of general weakness.
Kuberu is four years old. He sufers from undernutrition. Te child has extremely poor physical hygiene. He was also sufering from rashes and water
discharge from ears at the time of examination. His poor nutrition has resulted from a number of factors like poor feeding during infancy and lack of
iron supplements taken by his mother. Like many other children in this cluster, he has not been immunised since birth. He sufers from hyperactivity,
which according to his parents, is the cause for his poor appetite and ill health.
68
FINDINGS
Vishal, aged three and a half years, sufers from severe undernutrition. He weighs eight kilos instead of the norm of 14 kilos. He experiences severe
abdominal pain due to worm infestation and complains of pain in the limbs too. He is potbellied and shows signs of anaemia. His mother sufered from
anaemia and weakness during pregnancy. She also recalls having had insufcient and poor diet during her pregnancy. Te child sufers from recurrent
respiratory infections.
Vishnu, aged eleven years, has poor height and weight as per the norm for his age. He is 10 kilos less than the normal weight. He was sufering from
scabies, boils and body rash at the time of examination. He was said to have a bout of pneumonia immediately afer birth. His mother has a record of
poor breast feeding and he was born to his mother when she was only 16 years of age. He attends the nearby municipal school and fares adequately in
studies. He also enjoys the mid day meals provided at school.
Tree year old Meera, sufers from undernutrition. She weighs 6.5 kilos instead of the norm of 13 kilos for her age. She has overt physical signs of
undernutrition like pot belly and brittle hair. She has very low appetite, sufers from recurrent bouts of cold and cough. She constantly eats indigestible
things like mud. She also experiences pain in her limbs. Her mother had weakness during pregnancy. Her oldest sibling was born when her mother was
just 15. Her high birth order i.e. fourth among siblings may be responsible for her poor nutrition. Her mother has also had multiple pregnancies with
intervals of one year. Meera has not been immunised since birth. Her overall appearance is shabby and her personal hygiene is poor.
Sunil, aged six years, sufers from headache, cold, poor attention span and fares poorly in studies. He has to face seasonal starvation especially during the
monsoon months. Even otherwise, he has a poor appetite.
Suhani, fve years, is anaemic and has a distended belly. She sufers from pain in the abdomen, has difculty in breathing and displays signs of
hypothyroidism. She has a history of eating indigestible things. Te oldest among four siblings, she was born when her mother was 19 years; her mothers
present age is 24.
69
Ganesh is a pavement resident aged seven years. He experiences pain in his limbs. He displays signs of anaemia. He studies in Class 1 and demonstrates
average academic performance. He has to face starvation at times on account of the unstable nature of his fathers employment.
...And their mothers.
Laxmi is a mother of six and lives in a temporary shelter in Indian Oil Nagar. She says poor people have to face many problems. Sometimes we have
food and sometimes we have to sleep hungry. I do not know whether we will have food tomorrow. We face extreme insecurity of water and food. Lack of
water is our greatest problem. We survive on monthly ration from the ration shop for two weeks, afer this we have to buy from the market. We have to
beg on some days we cannot help it, as it helps us survive. Her family including herself eats vegetables and meat once in ffeen days. Te rest of the
days they manage with rice, chapattis, bhakri, and sometimes enjoy the luxury of dal. Tey face extreme food insecurity during rains when for about four
months, they have no work. An NGO comes to provide meals for the children in their basti. Te NGO also sends a van equipped with medical facilities.
Food received from begging is ofen stale, but we sort out the portions that are ft to eat. We are going to stop begging, if we are assured of food, she says.
Shubhangi is a mother of two. Her husband earns about Rs. 3000 a month. He gives me
Rs. 70 everyday with which I have to run the house and provide food. He is an alcoholic.
Because of the tension I have to face, I always feel sick. I also experience pain in the chest
and difculty in breathing lately. I also sufer from body ache and do not feel like eating
anything. I want to put the children in a boarding school so that they can at least have
a better life, but my husband has warned me against doing so. My children are weak all
the time. We visit the doctor only when they fall very sick. Lack of water is our biggest
problem, some days we have to spend as much as Rs 40 to buy one or two small cans of
water. Food? We manage it somehow from here and there. We try to keep our utensils and
house as clean as possible, but our children always look shabby and dirty because they play
Residents of Indian Oil Nagar are constantly exposed to dust from
the highway.
70
FINDINGS
in the open here. So much of dust comes from the highway. We cannot stop children from playing outside.
Rekha, a mother of one child, lives with her sisters family in Indian Oil Nagar. Te ORF-MBBF team of researchers caught up with her on the festival
of Eid. She uses water from the drain outside her house for bathing. We buy drinking water. Te water from the gutter is okay to use for other chores
because it gets fltered by the time it reaches this place, she says. "Some of the children from here", she says, "have gone begging because today is Eid.
Tey will use the food and money for the entire month. Our food depends entirely on our work. For us women, who have to stay home for the children,
we have to manage with whatever our husbands give us. We eat vegetables only when we can aford to buy them.
Residents of Indian Oil Nagar and neighbouring squatters use water
from the nearby drain for bathing.
Home of residents bordering the highway.
71
Nutrition Status of Children
In the structured slum, a higher percentage of children showed normal nutrition status.
Out of the 150 children, 89(59.33%) had normal
nutrition status, while 61(40.67%) children were
underweight.
Out of 150 children, 99(66%) were having normal height
for age, while 51(34%) were falling below the 3rd percentile
in other words were stunted, as per Marwaha et al. growth
scale.
72
FINDINGS
Out of the 150 children from the unstructured slum,
only 45(30%) were having normal nutrition status, while
105(70%) were underweight.
Out of 150 children,
73(48.67%) were having normal height, while
77(51.33%) were stunted for age.
A higher number of children from unstructured population reported respiratory infections, headache, pain in abdomen, watering of eyes
and pain in limbs. Distended abdomen was found only among the unstructured slum population, especially between ages of 3 to 6 years.
Mouth ulcers and bleeding of gums, eye problems were reported more among the structured slum children.
Poor appetite, tooth caries and worms in stool were reported by both structured and unstructured slum children.
In the unstructured slum, a higher percentage of children were underweight and stunted.
73
Tere is a higher percentage of underweight and stunted children in the unstructured slum as compared to the structured slum.
74
FINDINGS
As per the IAP system of classifcation
36
, higher percentage of children from the structured slum showed mild undernutrition and small percentage
showed severe undernutrition. On the contrary, in the unstructured slum higher percentage of children showed severe undernutrition.
36 IAP system of classifcation:-Te Indian Academy of Pediatrics classifcation (IAP) system distinguishes well-nourished and malnourished children using a statistical approach,
namely, percentiles, percentage of the median. Tree grades of malnutrition are identifed on the basis of their weight-for-age in comparison with the standard Harvard reference
population. Mild malnutrition is between 80% and 70% of the median, moderate malnutrition is between 70% and 60% of the median and severe malnutrition is below 60% of
the median.
75
Nutrition status of children based on age
Findings showed higher rate of underweight and poor nutrition status during the growth spurts i.e. before 6 years and above 10 years of age, with a dip
in levels of underweight for the ages 7 to 10 years.

Food and deprivation faced by the children, has led to poor growth and undernutrition during the two growth spurts, when the requirement for food is
the greatest i.e. before the age of 6 years and above the age of 10 years
37
.
Children between 7 to 10 years had better nutrition status in comparison to the other two age groups. Children between 3 to 6 years of age were seen to
have extremely low nutrition status.

37 Growth Spurts, Krauses Food & Nutrition Terapy (12th edition). Pages 200, 222 & 246
76
FINDINGS
Percentage of underweight females was higher (63.93%) than underweight
males (36.06%) in the structured slum.
Stunting was also higher among females (47.54%) than among males
(43.13%).
In the unstructured slum, percentage of underweight and stunted males
was higher at (52.38%) and (51.94%) respectively than the girls, who were
underweight at (47.61%) and stunted at (48.05%).
Nutrition status of children based on gender
77
Clinical signs of nutrition defciencies and associated co-morbidities were also seen in the children (See Annexure C for detailed table)
Clinical Signs of nutritional defciencies and
associated co- morbidities
Average Percentage recorded in
Structured Slum
Percentage recorded in Unstructured
Slum
Frequent Headache 33% 25% 41%
Frequent Diarrhoea 12% 18% 7%
Upper Respiratory Infection 47% 35% 60%
Frequent Fever 40% 47% 33%
Mental health and overall behaviour; prevalence in children from structured and unstructured slum
Mental Health & Overall Behaviour Percentage recorded in Structured
Slum
Percentage recorded in Unstructured Slum
Delayed Development Milestones 7 %
Poor Memory 38%
Poor Scholastic Performance 40%
Abnormal Behaviour (Irritability, Hyper activity) 2% 13%
Abnormal Behaviour(Mental Retardation) 3%
As mental health is the efect of number of environmental factors, poor nutrition may be one of the causes of poor scholastic performance and
poor memory among the cases from the structured slum that were reported during investigations. Memory and Scholastic Performance could not
be gauged for the unstructured slum population as a sizeable number of children were not enrolled in school, had dropped out of school, or were
attending non-formal schools.
A large number of children had extremely poor overall hygiene, particularly among unstructured slum population.
78
FINDINGS
Impact of Environmental Factors on Nutrition Status
Te following environment and social variables of the study population showed statiscally signifcant association with their nutrition status.
Table 1: Signifcant Associations
38
of Undernutrition with Environment/Social Factors Across Structured and Unstructured slums
38 Signifcant Association: Signifcance is a statistical term that tells how sure you are that a correlation exists. In statistics signifcant means
probably true (not due to chance). When statisticians say a result is highly signifcant they mean it is very probably true.
79
Te vast diferences in nutrition status across structured and unstructured slums are explained further by environmental factors which afect
nutrition status.
Higher percentage of children from tent structures were
underweight and stunted in comparison to those living in
permanent concrete structures.
Further, the relation between type of shelter and nutrition status
was found to be highly signifcant; two tailed p value < 0.05, for
underweight and < 0.01 for stunting using Chi-square test
39
.

All children from the unstructured slum had tent houses with or
without cemented foor. Only about nine children living in the
structured slum had to reside in such temporary shelters. All the
other children from the structured slum had concrete houses.
In several other studies too, temporary shelter is found to have
an efect on nutrition status and health as a result of constant
exposure to dust and dirt. Concrete housing is an indication of
slightly better income, second or third generation of migrants to slums and also of location of the home in a slightly better area within the structured
slum. Unstructured slum populations have temporary shelter, little or no security of their land and physical structure and, the precarious status of
housing makes them more prone to ill health.
39 Chi-square test: A common statistical analysis in epidemiology that involves dichotomous variables. In order to determine whether those persons who were exposed have more
illness than those not exposed a test of the association between exposure and disease in the two groups is performed.
80
FINDINGS

Higher percentage of children having to defecate in
the open were found to be underweight and stunted
in comparison to those who had access to closed
sanitary facility.
Further, the relation between type of sanitary facility
and nutrition status was signifcant with two tailed p
value<0.01, for underweight and two tailed p value of
< 0.05 in relation to stunting using Chi-square test.
Open defecation is common for nearly all children
below 5 years of age across structured and
unstructured slums, but availability of sanitary
facility in structured slums reduces practice of open
defecation as children grow older. A number of
studies have suggested that poor sanitation may be
associated with adverse nutritional outcomes via diferent pathways, including diarrhoea and other FTIs and gastro-intestinal disorders such as tropical
sprue or tropical enteropathy( disease of small intestine causing mal-absorption of food).
40
40 Recent studies that have assessed efect of open defecation on nutrition outcomes are: Dean Spears, Arabinda Gosh, Oliver Cumming, 2013, Open Defecation and Childhood
Stunting in India: An Ecological Analysis of New Data from 112 Districts, in website of PLOS medicine, <http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.
pone.0073784> and experimental study titled: Village Sanitation and Childrens Human Capital: Evidence from a randomized experiment by the Maharashtra government. World
Bank Policy Research Working Paper number 6580, (2013) in e-library worldbank.org, <documents.worldbank.org/curated/en/2013/08/18125015/>
81
Higher percentage of children without access
to piped water supply were underweight and
stunted in comparison to those who had access
to piped water supply.
Further, signifcant association was seen
between nutrition status and piped water
supply, across structured and unstructured
slum, the two tailed p value being <0.01, for
both underweight and stunting using Chi-
square test.
All children from the structured slum had
access to piped water close to their homes.
Children from the unstructured slum had
no access to piped water supply close to their
homes. Access to piped water reduces the burden of spending to buy water for daily use. In the reference population here, those having no access to
piped water purchased drinking water cans for Rs. 20 per can. Tey used the water fowing in the nearby drain for other non-potable purposes including
bathing and washing.
82
FINDINGS
Higher percentage of children from households
who faced food shortages were underweight
and stunted in comparison to those who had
household food security.
Further, a signifcant association was found
between nutrition status and household food
security for underweight, the two tailed p value
being <0.01 using Chi-square test.
Income status based on occupation of parents
showed signifcant association with nutrition
status in the unstructured slum, two tailed p
value <0.05 using Chi-square test.
In urban areas access to food depends largely
on afordability as per the market rates. About
61.36% children across both the structured and
unstructured slums facing household food insecurity on certain months, days or seasons were underweight.
Chapter 6.
24-Hour Dietary Intake Findings and
Recommendations on Diet
(Children from structured slum)
Children in Ramabai Ambedkar Nagar buying savouries from
a vendor afer school.
A food care in Ramabai Ambedkar Nagar selling fried savouries Children in Ramabai Ambedkar Nagar returning home with food received from
an Anganwadi centre
86
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Majority of the children in the structured slum fell short of meeting the expected
energy levels required for their age. Only 31 out of 150, i.e. just 20.66%, met the
daily requirement of calorie consumption of 90% and above.
Most children in the structured slum met the protein requirements as they had
consumed dal, the biggest source of protein for vegetarians. Te consistency of
the dal is not known. Studies in the past have mentioned that people from slums
ofen consume dal with thin consistency. Children from families who ate non-
vegetarian food also met the daily protein requirements.
87
A sizeable percentage of children in the structured slum were consuming less amount of milk, vegetables and
fruit due to unavailability, unafordability or personal dislike for it
About 41% children in the structured slum
consume half or less than half of the entire
serving of the mid day meal
About 24% children in the structured slum had
skipped one of the meals
88
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Mid Day Meal Scheme
Te Mid Day Meal Scheme was introduced in India in 2001 to provide a minimum content of 300 calories of energy and 8-12 gram protein per day for
a minimum of 200 days. Te primary objective of the scheme was boosting school enrolments, improving retention and reducing school drop-out rates
and providing nourishing food for school children.
In September 2004 the scheme was revised to provide for central government assistance for cooking cost, cooking assistance, construction of kitchen-
cum-stores, procurement of kitchen devices and transport subsidy.
In Maharashtra , the scheme has covered 81119 primary level schools (including government and government-aided schools, madarsas, maqtabs) and
39233 upper primary schools reaching out to over 1.8 crore children of the school going age.
Te scheme has been hugely successful in meeting its primary objectives. By and large the scheme is managed by Self Help Groups (SHGs) but due to
lack of proper oversight on the part of ofcials, this arrangement is ofen found to founder on quality issues and of late there has been talk of replacing
SHGs with centralised kitchens. Annamrita, a scheme run by ISCKON in many cities across India, has established a reputation for being professionally
run, using modern equipments and providing high quality food.
However, this is only one side of the story. SHGs complain that the government does not pay their dues in time and even when they do, the margins are
wafer thin in nature. Clearly, there is a need to review the management of the scheme. A deeper look at the issue is outside the scope of this report. Te
following diagrammatic chart presents an overview of the problem.
89
Mid Day Meal Scheme in Mumbai
328 Self Help Groups and ISKCON provide Mid Day Meals to 2,548 schools
Government spend per child Rs 3000 per year
Cooking cost currently paid to SHG: Rs 3.20- 3.50 per child per day
(Source: Interviews with SHG)
Revised cooking cost with efect from 1st July 2014
Rs 3.59 per child per day primary and
Rs 5.38 per child per day secondary.
(Source: Mid-day Meal website)
Issues
Issue 1: Quality of Raw material
Issue 2: Nutrition standards & Hygiene
Issue 3: Variety of Menu
Self Help Groups (SHGs)
Problems faced by SHGs
Budget is not infation proof; rising price of LPG and vegetables have not been taken
into consideration
Late payment by the government renders scheme unproftable
Difcult to break-even
Faults and failures of SHGs
Monotonous menu makes meals unpalatable, boring
Most of the compliance standards established by the government have not been met
Does not meet hygiene standards
Mixed opinion of taste and quality by benefciaries
STATE NORMS and the DEGREE OF COMPLIANCE
Green leafy vegetable in khichdi:

Mothers, parents should be involved in supervision of cooked meal:

Proper maintenance of records at school level, including time, weight, quality of food:

Routine health checks of students:

Routine health checks of suppliers and those serving the meal:

State education department has suggested that varied items like khichdi, dal rice, idli sambar, rice kheer, tomato rice, vegetable rice be served:

State education department has suggested that once in a week, biscuits, bananas or eggs be given to students:

Regular meetings on Mid Day Meal to be taken by senior ofcials at the school level:

Stock register and expenditure register should be maintained by schools for inspection:

Not followed
Partially followed
90
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)

On Te Plate
Day 1 Peas Usal Bhat
Day 2 Moong Usal Bhat
Day 3 Dal Khichdi+ biscuit
Day 4 Chana Usal Bhat
Day 5 Moong bhat
Day 6 Biryani
Composition of the menu mandated by the state government:
For example, for primary students:
Moong dal khichdi
100 gm of rice+20 gm of moong dal/tur dal etc
+ 5 gm soyabean or Agmark oil
+2-5 gm of spices/condiments
+ 50 gm palak/methi/tomato/potato/green peas/carrot/
caulifower
Total cooked meal : 250-275 gm
Minimum calories per plate : 450
Protein per plate : 12 gm
Problems faced by BMC
Difculty in getting approval for centralised kitchen by ISKCON
and other NGOs approval for all the schools from the state
government.
High cost of providing the meal.
Difculty in ensuring timely monitoring.
Losses due to corrupt practices of SHGs.
Political pressure is being brought by SHGs to continue SHG
contracts.
Proposed Solution:
Upgrading SHGs in terms of cooking cost, kitchen infrastructure
and devices
ISKCON Centralised Kitchen and similar efcient models:
Has previously met compliance standards in the country and in
the city.
Cost is divided between government and donations each
providing half the required amount.
Saved cost for the Municipal Corporation.
Need to gauge the opinions of benefciaries towards ISKCON meals
in the city.
Need to establish a strategy for partnership between corporate
sponsors and ISKCON in school adoption for providing Mid Day
Meals.
References: Unpalatable truth, Te Indian Express, Mumbai Newsline- July
24, 2013
A Day in the life of Akshay Patra Foundations kitchen in Jaipur, Te Sunday
Express, 4th August 2013
91
Te following observations were recorded afer detailed analysis of the data obtained from the survey. Te observations are compared with ideal
requirements for every meal. Te fndings show substantial divergence between the actual and the ideal.
Meal Ideal Actual
Breakfast Should provide 1/6th of ideal daily energy requirement;
Heavy and healthy;
Helps in building strong immunity;
It should include wholesome food like poha, upma, roti, paratha,
milk, fruits, egg, cereal-pulse combinations like dosa and idli etc.
Most of the children consume bakery products like
khari, butter toast, puf, bread etc.
Tea was a common beverage instead of milk.
Evening Snack Should provide 1/6th of ideal daily energy requirement;
Helps in replenishing energy lost during school, and physical
activities;
It should include light but healthy items like rice fakes chivda,
kurmura bhel , sprouts, vegetable sandwich, etc.
Most of the kids consume bakery products like
khari, butter toast, puf, bread etc.
Outside foods, especially from neighbourhood
vendors are also preferred.
Skipping evening snack is common.
Lunch/ Dinner Should provide 1/3rd of ideal daily energy requirement;
Roti, sabzi, dal, rice combination is preferred;
Dal: protein based product;
Roti/rice: carbohydrate rich products;
Vegetables: provide vitamins, minerals.
Mainly cereal rich diet, roti and rice form major
portion of the meal.
Dal is generally watery reducing its protein content.
Very few children consume green leafy vegetables.
Potato is most commonly consumed as a vegetable.
19% kids skipped lunch.
92
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Meal Ideal Actual
Mid Day Meal Should satisfy 1/3rd of daily energy and protein
requirement of the child;
Primary: Calories 450 Kcal,
Protein12 gms;
Upper Primary:
Calories 700 Kcal, Proteins 20 gms;
Khichdi is served to children in lunch boxes
provided by school.
Monotonous: Khichdi is the only food item served
repeatedly on most days of the week.
Vegetables are put in the khichdi only on two days of
the week.
More than half of the children throw away almost half of
khichdi every day, leading to avoidable wastage.
About 41% children had consumed half or less than half
of the entire serving.
Fruits, Vegetables and Milk Important source of vitamins and minerals;
Fruits: 2-4 servings/ day;
Vegetables: 2-5 servings/ day;
Milk and milk products: 2-3 servings/ day.
Even afer considering the low economic background
and special grading system, very few kids consumed
fruits and vegetables in their diet. 78% had no fruits,
33% had no vegetables.
Tea is the commonest beverage in which milk is included
in the childrens diet, 38% had no milk at all.
93
Mid day meal being served in lunch boxes; and sometimes dumped by children.
94
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Recommendations on nutrition and diet:
Nutritional awareness programme for children and parents: Awareness regarding optimum nutrition and nutritious food choices should be given
not only to the school children, but also to parents, as they are the decision makers and bread earners. Tey can plan the monthly budget on food
and decide which food items to buy.
Te community specially must be instructed about the importance of a healthy breakfast and the benefts of building immunity, helping them to choose
between junk food and nutritious food and the importance of having milk daily. Parents must be instructed to try and prepare home cooked food like
roti, poha, upma, paratha, roasted chivda, murmura bhel etc. for breakfast and at snack time to replace currently consumed processed foods and items
purchased from local vendors who are located amid unhygienic conditions.
Additions to daily diet:
Cheap/healthy foods: Tere are a few food items which are high in nutrition and yet cheap. Tese must be added to the daily diet. Cereals like ragi which
are rich in calcium, jowar and bajra which are high on fbre and iron and are also cheaper than wheat and rice should be added to the daily diet. Seasonal
vegetables and green leafy vegetables are cheaper as compared to other vegetables and should be added to the daily diet to increase the cost efectiveness.
Soya food can be a rich source of protein. Fruits such as banana, guava, papaya, etc., which are cheap and high in nutritional values must be consumed.
Fresh seasonal fruits are cheap and should be added to the daily diet. For example, apples are cheaper in the monsoons; berries are cheaper in winter,
etc. Jaggery which is cheaper as compared to sugar and high in iron content, can be added to increase the calorifc value of food items or can be served
in small helpings with lunch and dinner.
Dairy products: Milk and milk products are very important sources of protein, calcium, and the Vitamin B group, particularly for vegetarians. Addition
of these products to the daily diet is very important for the growth of children. Our study shows that 38% of the children do not consume milk. Instead
of milk being consumed in the form of tea, children can be served milk with chocolate, honey or sugar. Milk products like paneer, cheese, curd, butter
milk can be given especially to those children who dislike plain milk.
95
Vegetables and fruits: Vegetables and fruits play a very important role in providing minerals and vitamins. Tey help to add taste, colour and appearance
to the food. Yellow and orange coloured vegetables and fruits like pumpkin, carrot, mango, and papaya are good sources of vitamin A. Green leafy
vegetables like palak, shepu, methi, cabbage, caulifower leaves, raddish leaves, beet root leaves are good source of iron, calcium, vitamins A and C. Citrus
fruits like oranges, sweet lime, all types of berries are high in vitamin C. Banana, which is the cheapest and best source of calories and potassium, can be
served as snack instead of bakery products. Te above mentioned vegetables can be cooked as sabzi, salad, added to and used as stufng in parathas or
added to khichdi or pulao, soups, raita etc. Fruits can be served as part of breakfast or as a snack, can be given as milk shakes, with curd or cottage cheese
in the form of fruit raita, in salads, fresh juice, desserts such as gajar halwa etc.
Non-vegetarian foods: Poultry products, red meat and sea food are excellent sources of protein, vitamins and minerals. Due to religious beliefs and
non-afordability, many do not and cannot have a non-vegetarian diet. An egg a day or chicken, fsh or red meat 2-3 times a week is a good way to meet
macro as well as micro nutritional requirements. Children who have a non-vegetarian diet can be provided boiled eggs in the Mid Day Meal programme.
Improving quality and adding variety to the Mid Day Meal: Te Mid Day Meal is an excellent initiative by the government to provide 1/3rd of their
daily energy and protein requirement for children. Despite huge amount of resources being spent, the Mid Day Meal programme is unable to achieve its
full potential. Its major shortcomings are as follows:
Monotonous food: Most schools daily only serve khichdi as part of its Mid Day Meal programme. Vegetables are rarely mixed with the khichdi. Lack of
variety makes the food uninteresting for children of all age groups. Young children who generally are picky eaters, soon tend to develop an aversion to
such food.
Wastage of food: About 41% of the children were found to consume half or less than half of the entire serving. Te rest is discarded in the bins inside the
school premises. Tis is gross wastage of food and money.
Scope for improvement in Mid Day Meal6 Day Cyclic Menu
41
: Te best way to achieve the maximum beneft out of the Mid Day Meal scheme is
to provide food which is nutritious, afordable, tasty and varied. Serving diferent food items everyday will help break the monotony of food served to
children, and draw more children to beneft from the scheme.
41 Te section Improving the Six-Day cyclic menu under the Mid Day Meal Scheme has a detailed plan with recipes prepared by Dr Mihir Maher
96
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Improving the appearance: Te appearance of food plays a major role in its being accepted by young children. Terefore, it is important to make the
food look attractive. For example, adding colourful vegetables helps to provide good appearance and at the same time, improves the nutritional value of
the food served.
Commonly seen problems in this age group and among children from low economic background are low weight, frequent infections, anaemia, vitamin
A defciency, scurvy, low bone mineral density. A multi-disciplinary approach is urgently needed to tackle these problems. A balanced diet which can
supply the required macro and micro nutrients will play an important role in overcoming these problems. Te provision of good hygiene and sanitation
in and around homes, societies and schools will help reduce the chances of infections and lead to an overall improvement in the health standards of the
children.
97
Improving the Six-Day cyclic menu under the Mid Day Meal Scheme:
Te budget of Mid Day Meal/ child/ day should be raised to maintain the quality
of food served, keeping in mind infation and soaring prices of food items.
Rice and wheat are provided for free by the government to the Mid Day Meal
contractors. Hence, the 6 Day Cyclic menu contains either wheat or rice as one
ingredient with other ingredients planned to provide ideal calories and proteins
to the children.
Like rice and wheat, the government should also provide jowar or ragi for free.
Tese cereals are cheaper than wheat or rice. Tis will help add variety to the
menu without raising the budget.
As per the norms prescribed by the Ministry of Human Resource Developments
MDM division on November 24, 2009, each primary class child is daily entitled to food accounting for 450 calories and 12 grams of protein and each
child in the upper primary is daily entitled to 700 calories and 20 grams of protein.
As per the Directorate of Education (DOE), raw quantity of rice or wheat is kept at 100 grams/primary class child and 150 grams/upper primary class
child. Raw quantity of pulse is kept at 30 grams/primary class child and 40 grams/upper primary class child.
Cost of salt and spices is accounted at 5% of total food cost. Cost of fuel used for the preparation of meals is 10% of the total food cost. Cost of labour
and transportation is 10% of the total food cost.
Day 1 Vegetable khichdi
Day 2 Stufed paratha
Day 3 Palak khichdi with soya chunks
Day 4 Roti, sabzi and dal
Day 5 Pitla with rice
Day 6 Roti with moong sabzi
98
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Day 1: Vegetable khichdi
Tis khichdi can be made innovative by changing vegetables each day. For example, carrot, peas, french beans, palak, dudhi, etc. can be
varyingly used.
Te dal can be changed to change the taste. for example, tur dal, moong dal, etc. can be used.
Day 1 : Vegetable khichdi (Per Day/Per Child)
Primary Upper Primary
Quantity Energy (Kcal) Protein (gm) Costing Quantity Energy (Kcal) Protein (gm) Costing
Ingredients
Rice 100 333 6 free 150 500 9 free
Moong dal 30 100 7 2 40 133 9.4 2.7
Carrot 50 12 0.5 0.3 70 17 0.7 0.4
Onion 50 12 0.5 1 70 17 0.7 1.4
Potato 50 50 1 0.7 70 70 1.4 0.7
Oil 5 45 0.35 10 90 0.7
Salt and Spices
(5%)
1 tsp 0.22 1 tsp 0.28
Other Components
Fuel (10%) 0.45 0.57
Labour and
Tr ans por t at i on
(10%)
0.45 0.57
Total 552 15 5.47 807 21.2 7.32
99
Day 2: Stufed paratha
Te stufng can be changed by adding diferent vegetables.
Each child can be served 2 to 3 parathas, which adds up to the component of raw grain provided per child.
Soyabean fakes can also be used instead of dal in the stufng in combination with potatoes or vegetables.
Day 2 : Stufed paratha (Per Day/Per Child)
Primary Upper Primary
Quantity Energy (Kcal) Protein (gm) Costing Quantity Energy (Kcal) Protein (gm) Costing
Ingredients
Wheat 100 333 11 free 150 500 16.5 free
Potato 100 100 2 1.4 150 150 3 2.1
Moong dal 30 100 7 2 40 133 9.4 2.7
Oil 10 90 0.7 15 90 0.7
Salt and Spices
(5%)
1 tsp 0.2 1 tsp 0.27
O t h e r
Components

Fuel (10%) 0.4 0.55
Labour and
Transportation
(10%)
0.4 0.55
Total 623 20 5.1 873 28.9 6.87
100
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Day 3: Palak khichdi with soya chunks
Dill leaves (Shepu) can be mixed with palak to increase the iron and calcium content of the khichdi.
Other seasonal vegetables can also be added to provide variety.
Day 3: Palak khichdi with soya chunks (Per Day/Per Child)
Primary Upper Primary
Quantity Energy (Kcal) Protein (gm) Costing Quantity Energy (Kcal) Protein (gm) Costing
Ingredients
Rice 100 333 6 free 150 500 9 free
Palak 100 25 1 1.2 150 37.5 1.5 1.8
Soya chunks 25 100 10 1.4 30 120 12 1.7
Oil 5 45 0.35 10 90 0.7
Salt and Spices
(5%)
1 tsp 0.15 0.21
O t h e r
Components

Fuel (10%) 0.3 0.42
Labour and
Transportation
(10%)
0.3 0.42
Total 503 17 3.7 748 22.5 5.25
101
Day 4: Roti, Sabzi and Dal
Palak is mentioned here as one example, other green leafy vegetables can be used along with potatoes, seasonal vegetables. Tese green leafy vegetables
are rich in calcium and iron.
If ragi is provided by the government, rotis can be made from a mix of wheat and ragi. Ragi is a very good source of calcium.
Day 4: Roti, sabzi and dal (Per Day/Per Child)
Primary Upper Primary
Ingredients Quantity E n e r g y
(Kcal)
P r o t e i n
(gm)
Costing Quantity E n e r g y
(Kcal)
P r o t e i n
(gm)
Costing
Roti Wheat 100 333 11 free 150 500 16.5 free
Oil 2.5 22.5 0.17 5 45 0.35
Sabzi (Green
leafy vegetables )
Palak 100 25 1 1.2 150 37.5 1.5 1.7
Oil 2.5 22.5 0.17 5 45 0.35
Dal Tur dal 30 100 7 1.65 40 133 9.4 2.2
Oil 5 45 0.35 10 90 0.7
Salt and Spices
(5%)
1 tsp 0.17 1 tsp 0.26
Fuel (10%) 0.35 0.53
Labour and
Transportation
(10%)
0.35 0.53
Total 548 19 4.41 850 27.4 6.62
102
24-HOUR DIETARY INTAKE FINDINGS AND RECOMMENDATIONS ON DIET (CHILDREN FROM STRUCTURED SLUM)
Day 5: Pitla with Roti or Rice
Pitla is an authentic Maharashtrian dish which is prepared from besan or gram four. It is high in protein and very tasty. It can complement roti as
well as rice.
When pitla is served with roti, the only diference is in the consistency, the preparation is slightly thicker and it is called jhunka.
Jhunka goes well with jowar bhakri. If government can provide jowar, like rice and wheat, jowar bhakri can be provided to the children.
Spring onion is always slightly costlier as compared to other green leafy vegetables. Terefore, it can be replaced with coriander, spinach, methi. Tese
changes in pitla vegetables will provide the much needed variety in the diet.
Day 5: Pitla with Rice (Per Day/Per Child)
Primary Upper Primary
Ingredients Quantity E n e r g y
(Kcal)
P r o t e i n
(gm)
Costing Quantity E n e r g y
(Kcal)
P r o t e i n
(gm)
Costing
Rice Rice 100 333 6 free 150 500 9 free
Pitla Besan or
gram four
30 100 7 1.5 40 133 9.4 2
Spring onion 50 12 1 2 75 18 1.5 3
Oil 5 45 0.35 10 90 0.7
Salt and
Spices (5%)
0.16 0.28
Fuel (10%) 0.38 0.57
Labour and
Transportation
(10%)
0.38 0.57
Total 490 14 4.77 741 19.64 7.12
103
Day 6: Roti with Moong sabzi
Moong sabzi can be made with a little gravy and roti can also be served with rice.
Moong can be replaced by moth beans, chole, black chana, etc. to add variety.
Seasonal vegetables can be added to enhance the taste.
Day 6: Roti with Moong sabzi (Per Day/Per Child)
Primary Upper Primary
Ingredients Quantity E n e r g y
(Kcal)
P r o t e i n
(gm)
Costing Quantity E n e r g y
(Kcal)
P r o t e i n
(gm)
Costing
Roti Wheat 100 333 11 free 150 500 16.5 free
Oil 2.5 22.5 0.17 5 45 0.35
Moong sabzi Moong 30 100 7 3.25 40 133 9.4 4.33
Oil 5 45 0.35 7.5 67.5 0.52
Salt and
Spices (5%)
0.16 0.26
Fuel (10%) 0.38 0.52
Labour and
Transportation
(10%)
0.38 0.52
Total 500 18 4.69 745 26 6.5
Chapter 7.
Recommendations
105
106
CONCLUSION & RECOMMENDED PLAN FOR ACTION
F
indings from the detailed surveys in the two clusters studied in the ORF-MBBF study have proved the need for a multi-pronged, broad-based
approach to solving the problem of undernutrition. Experience of social welfare programmes from other parts of the world have shown that
schemes that are explicitly multi-sectoral in nature, seeking to simultaneously improve childrens diets, their access to education and health
services and the fnancial status of poor families have a better chance of success
42
.
Vast improvements are necessary in the areas of sanitation, drinking water, health and education facilities for children from slums. Similarly, improvement
in diet, health education, child care practices, and poverty reduction eforts are also needed urgently for the families living in the slums. And most
importantly, when it comes to providing these basic amenities the government cannot discriminate between structured and unstructured slums. Once
people have been allowed to set up their dwelling however informal it may be, it is obligatory upon every government to provide these amenities.
Malnutrition deaths in unauthorised slums are high as stated by Rajmata Jijau Mother-Child Health and Nutrition Mission, Government of Maharashtra.
Pavement dwellers are the most vulnerable, so are the residents of all un-notifed slums and squatters colonies arisen afer 1995 in Mumbai.
43
Hence
there is the immediate need to focus on nutrition interventions for unstructured slums in the city.
Health services in the slums must be revamped to tackle malnutrition:
Management of malnutrition has been limited to the confnes of the ICDS project and that too for children in the 0-5 years age group in the structured
slums.
Tere is a need for extending the responsibility of primary health services to tackle malnutrition among children of all ages both in the
structured and unstructured slums. Immediate steps need to be taken by PHCs and private clinics in the vicinity to deal with SAM and MAM in an
integrated manner.
Special Centres to treat MAM and SAM should be started in the PHCs on the lines of Nutrition Rehabilitation Centres (NRCs) in rural areas
run by the central government. Medical as well as special nutritional supplements like Ready-to-use Terapeutic Food (RUTF) must be provided
for those children who are severely malnourished.
42 http://generation-nutrition.org/sites/default/fles/editorial/acute_malnutrition_an_everyday_emergency_low_res.pdf (p.25)
43 Mumbai City Development Plan 2005-2025, Urban Basic Services in Slums
107
Nutrition Counselling Clinics must be opened in all government hospitals and public and private maternity homes in slums.
Provision of primary health services, de-worming for children, child care and infant feeding education through mobile clinics must be taken
up as many of the slum residences are situated on highways, far away from the slums clinics and health posts. Tese are important steps to removing
barriers to inclusion and social security.
Private clinics, with their long working hours and proximity to their clientele, have been efective in providing curative healthcare services to people
living in the slums. Tese private healthcare providers can also be efective links in strengthening the fght against malnutrition in the slums.
Tere must be training of health workers and counsellors under various health programs like HIV, Adolescent and Reproductive Sexual Health
(ARSH), Sickle-cell, in providing nutrition-counselling.
Te Mid Day Meal Scheme in the city must be redesigned into a more comprehensive programme:
Te importance of the MDM programme in keeping children from starvation during school hours cannot be ignored. Te programme must not be seen
merely as just another government scheme as it is currently looked at, but must become the bulwark of the mission to eradicate child undernutrition
from the entire city of Mumbai. Currently, the Mid Day Meal scheme is only focussed on providing protein and caloric intake required by children.
In addition, there is a need to provided essential micro-nutrients in the diet. Te potential for school meal programme to tackle hunger as well as
address micronutrient defciencies in children which impact growth, general health and cognitive development through fortifcation and supplements
is immense.
Various food items, such as milk, biscuits, fresh fruits and soup can be provided as part of school meals. For such an ambitious scheme to work,
the Mid Day Meal programme, the school health programme, community based organisations and corporate philanthropists need to pool their
resources and work in a coordinated manner.
Te management of Mid Day Meals is a top down approach and much needs to change with respect to this approach. It needs to become more
community-based, with the involvement of local philanthropy, community kitchens, CBOs, religious food charities.
Te much-needed improvements in the design of the Mid Day Meal scheme, in terms of variety, making the meal attractive and appealing and,
including local menus in the diet can be made with inputs from all or any of the above mentioned organisations.
108
CONCLUSION & RECOMMENDED PLAN FOR ACTION
Integrated Child Development Scheme (Anganwadi services) must be extended to all people living in unauthorised slums;
Anganwadi services such as supplementary nutrition and pre-school education must be extended to all unauthorised, illegal slums. Health
education, health services such as immunisation, health check-up and referral services must be provided in convergence with public health systems.
Such interventions can be taken up in collaboration with NGOs.
All unauthorised slums must be urgently surveyed and given the basic services of health posts, Anganwadis to begin with.
About 80% of Anganwadis are run in the houses of slum dwellers with no independent water or toilet facility. Tere have to be innovative solutions in
dealing with the issue of lack of space in order to intensify the Anganwadi services to people living in slums. Tere is need to identify and provide
space for Anganwadis in municipal schools and community halls in slums.
Tere must be convergence between Municipal Health Department and Women and Child Development Department in the running of the
Anganwadis.
Te Municipal School Health Programme must be enhanced through partnerships:
Existing School Health programme
44
(SHP) in Municipal Schools for children in 1st, 3rd, 5th, 7th and 9th standards must be enhanced
through partnerships with NGOs having expertise in the treatment of nutrient defciencies, refractive problems and mental disabilities. NGOS
can also help in facilitating more number of one-to-one interventions for children in need.
Weekly iron and folic acid supplementation, nutrient supplementation and de-worming must be carried out systematically on a regular basis
in all municipal schools as part of the School Health Programme.
Tere exists scope for enhancement of the SHP through its integration with the Rashtriya Bal Swasthya Karyakram (RBSK) for Child Health
Screening and Early Intervention Services under NUHM, as and when it is rolled out in urban areas.
Parent-teacher awareness programmes must be implemented on the lines of the highly successful 'Meena Raju' mass communication initiative
44 School Health Programme (SHP) provides a mix of health assessments, curative services, rehabilitation, follow-up, healthy child and school competitions, child to Child/
family/community programming, immunisation, frst aid and emergency care, statistics, training and other activities. Tese programmes reach approximately 5 lakh children
per year through Std. 1, 3, 5, 7, 9. Te school health programme is run jointly under the BMC health department (which is responsible for administration) and the education
department (which is responsible for logistics).
109
launched by the UNICEF in 1998 for countries across South Asia, focussing on themes such as gender, child rights, education, protection and
development
45
. New themes can focus on personal hygiene, cultivating healthy food habits and choices.
Acceptable standards of food safety and hygiene need to be ensured especially among eateries that surround schools in order to ensure the
health of all children.
Tere should be training of all adolescent girls and boys in hygiene, child care, reproductive and sexual health and family planning as part of
life-skills education.

Tere must be better coverage of Maternal Health and Nutrition Interventions
46
in both structured and unstructured slums:
Our interviews with young mothers have shown that the coverage of maternal health and nutrition interventions in unstructured slums have been far
from efective.
A number of interventions
47
and their efectiveness for maternal health and child survival have been established by several studies in India and
around the world. Tese must be employed in both structured and unstructured slums to improve nutrition of expectant mothers and young
adolescent girls.
As shown through the study, early pregnancies among mothers in the unstructured slum was a contributing factor to the malnutrition of child.
Attention must be given to early pregnancies and multiple pregnancies among mothers to prevent and treat possible malnutrition in their
children.
Appropriate diet, iron and folic acid consumption for expectant mothers, early initiation of breast feeding with timely weaning along with
weaning foods are important nutrition-specifc indicators that must be widely publicised in the media.
Tere must be improvement in sanitation and civic facilities for all slum dwellers:
Government policy must take a neighbourhood and person-centred approach. Efective interventions involve not only treating the disease but also
45 http://www.unicef.org/rosa/media_2479.htm
46 From the Presentation, Call to Action for Child Survival in Maharashtra: An Initiative of Government of Maharashtra, supported by development partners, July 25, 2013,
UNICEF and Government of Maharashtra
47 UNICEF (2013):Interventions to Address Stunting and Other Forms of Under Nutrition, Improving Child Nutrition: Te achievable imperative for global progress, pg
17,(www.unicef.org/media/fles/nutrition_report_2013.pdf)
110
CONCLUSION & RECOMMENDED PLAN FOR ACTION
48 Unger A, L W Riley (2007): Slum Health: From Understanding to Action PLOS Medicine, Vol 4 Issue 10 e295. Viewed on 19 September 2013(www.plosmedicine.org/.../
info%3Adoi%2F10.1371%2Fjournal.pmed.00...)
addressing the underlying social and living conditions of slums. Improving health status may require the simple acts of closing open sewers to limit
diarrhoeal disease.
48
Te two main factors that have a signifcant impact on nutrition and public health are sanitation and housing. Te Swach Mumbai
Prabhodhan Abhiyan a community centred initiative introduced by the BMC in 2013, is aimed at solid waste management in garbage clearance and
gradually tackling other slum environment related issues. It is a promising campaign aimed at improving slum life and aims to cover both the authorised
as well as unauthorised slums in the city.
Provision of more toilets which are maintained in hygienic conditions and clean piped water supply to residents of unorganised slums will
make a big diference to the nutrition outcomes of children living here. Where space is a constraint, mobile toilets can be provided for unstructured
slums to serve the un-met need of sanitation facilities.
Tere is need for more community maintained toilets, timely garbage segregation, composting and sewage clearing, in all slums. Tis must be
done through the cooperation of reliable community based organisations.
Te BMC has to work urgently towards developing a whole new system that will deliver clean potable water in slums. A movement akin to the
Nirmal Bharat Abhiyan needs to be undertaken for bringing drinking water to the poor in urban India.
Eforts must be made to reach out to children of recently migrated families

Tere must be tracking of migratory families through baseline surveys.
Mobile Anganwadi services and day care creches, health clinics, mobile toilets and clean drinking water must be provided to these families.
Migrated families should be ensured of ration from the PDS regularly.
Eforts must be made to reach out to children of seasonal migrants through mobile anganwadi services and mobile crches.
Role of Community Based Organisations and NGOs
Generally, NGOs have a deep commitment and positive approach accompanied by work driven by good intentions. Hence, they must be given all
necessary resources and capacity to be able to play a positive role in health and nutrition in urban slums at various levels. Notable eforts in reducing
111
child undernutrition in slums by NGOs like SNEHA and by Mumbai Mobile Crches for children of migrant construction workers in the city should
be scaled up and replicated. Similarly, there exist models for feeding programmes for the hungry like Vision Rescue, Reliance Foundations India Food
Banking Network and Share My Dabba, Indonesia's Kedai Balitaku programme led by Mercy Corps
49
and community kitchens like the Hamal Panchayat
Kashtachi Bhakar kitchen initiative (HPKB)
50
.
Role of citizens
Te slum population is hidden behind barriers of class, flth, apathy, negative preconceived notions and are alienated from the citys large urban middle
classes. Te better-of citizens, who employ most of these slum residents as drivers, maids, security guards, sweepers, etc., must try to build closer and
amicable relationships with them instead of distancing them from their lives. Colleges must adopt slum exposure and outreach as part of building moral
and social conscientiousness in young students. Tis must also include citizens from the middle class willing to devote some of their resources within their
limited capacities for the betterment of the under-privileged in urban areas. Lastly, government and civil society must work at various levels through
media, dialogue and advocacy to create sanitation for all, equal access to sufcient nutritious food, water and healthcare for all. College students can play
an important role. Experts must guide internship programmes for Home Science/Nutrition students, and provide opportunities for medical students
to develop easy and context specifc solutions to malnutrition. Colleges providing training in social work can also be involved in nutrition counselling,
advocacy and conducting surveys under able mentorship.
Role of the private sector
Te Lancet Series 2013 on maternal and child nutrition points out that undernutrition contributes to the deaths of three million children each year. It
thwarts the physical growth and life chances and leads to national economic productivity loss as well. Only collective action will end undernutrition.
Te private sector has substantial potential to contribute to acceleration of improvements in nutrition. Te Executive Summary Te Lancet Maternal and
Child Nutrition Series 2013 states that, in view of the needs and substantial resources, and given the infuence and convening power of the private sector,
several opportunities exist for the private sector to contribute towards improved nutrition outcomes, targeting both nutrition-specifc and nutrition-
sensitive interventions. Measures such as collaboration around advocacy, monitoring, value chains, technical and scientifc collaboration and staple food
49 Mercy Corps launched Kedai Balitaku (KeBAL) programme which translates as My Child's Cafe in the Indonesian language in 2009 to address the failing health of children
in some of Jakarta's most impoverished neighbourhoods through afordable healthy food carts for children while providing job opportunities for area cooks and food cart
vendors.
50 Te HPKB kitchen initiative is a community kitchen that provides low cost nutritious meals to more than 15,000 people per day. Run as a social enterprise it operates as a cen-
tralised kitchen in Pune with eleven distribution centers across the city.
112
CONCLUSION & RECOMMENDED PLAN FOR ACTION
51 Te Bhavishya Alliance (2006-2011), served as a rare opportunity for those in corporate, government and civil society sectors who are committed to reducing undernutrition
to plan and implement a series of innovative pilot projects in target areas of Maharashtra. Some of the founding partners were Unilever, HDFC, UNICEF, Taj Group of Hotels,
ICICI, Synergos and others. http://www.synergos.org/partnerships/pcnindia.htm
52 India Food Banking Network: Food banking is a system that moves food from donors to the people who need it and engages all sectors of society in the efort. Tis initiative is
spearheaded by Reliance Foundation and others. http://www.indiafoodbanking.org/
fortifcation are required.
From among numerous examples, two notable examples of the private sector contribution towards nutrition are Te Bhavishya Alliance
51
and India
Food Banking Network
52
. Corporate sector can adopt anganwadis, schools, PHCs to make them malnutrition-free. Corporate sector can also collaborate
in capacity building of ASHAs, ANMs, anganwadi teachers, cooks and other staf. Tey can help implement tele-medicine and other innovations.
Role of efective governance for improved nutrition outcomes
Economic growth does not necessarily lead to good nutrition and improved nutrition outcomes. Te following are some entry points for strengthening
governance to improve nutrition.
Establishment of Nutrition Missions in all states
Joint work plans and budgets for interventions that target
nutrition through the work of various ministries
A greater portion of the budget needs to target
undernutrition (as opposed to food provision or
infrastructure development).
Baseline surveys to improve nutrition status across all
structured and unstructured slums. Baseline surveys
throw light on the exact nature of the problem and help
to shortlist interventions that can have a maximum
impact in the area studied.
Nutrition sensitive programmes and
approaches
Agriculture and food security
Social safety nets
Early child development
Maternal mental health
Womens empowerment
Child protection
Classroom education
Water and sanitation
Health and family planning
services
Nutrition specifc interventions and
programmes
Adolescent health and preconception
nutrition
Maternal dietary supplementation
Micronutrient supplementation or
fortifcation
Breastfeeding and complementary feeding
Dietary supplementation for children
Dietary diversifcation
Feeding behaviours and stimulation
Treatment of severe acute malnutrition
Disease prevention and management
Nutrition interventions in emergencies
Nearly 15% deaths of children younger than fve years can be reduced if these
interventions are scaled up
ANNEXURES
114
ANNEXURES

ANNEXURE: A
A Comparison of Growth Scales
115
116
ANNEXURES

ANNEXURE: B
Marwaha et al Nationwide reference data for height, weight and body mass index of Indian schoolchildren
117
118
ANNEXURES
119
120
ANNEXURES
List of Findings on Clinical Signs of Nutritional Defciences and Associated Co-morbidities

Clinical signs of nutritional
defciencies and associated co-
morbidities
Percentage in
children from
S t r u c t u r e d
Slum
Percentage in
children from
Unstructured Slum
Clinical signs of nutritional
defciencies and associated co-
morbidities
Percentage in
children from
Structured Slum
Percentage in
children from
Unst r uctured
Slum
Low Appetite 19% 39% Ridged Nails 10% 5%
Eating Indigestible things 6% Brittle Nails 2% 5%
Worms in Stool 24% 53% Distended Abdomen 32%
Easy Tiredness 12% 3% Swelling/ Oedema 1% 3%
Poor Hair Density 28% 11% Tetany, Muscle Spasms 4% 3%
Poor Hair Lustre 38% 75% Bowing of Legs 2%
Frequent Skin Eruptions 12% 9% Joints Pain 2% 3%
Boils/Acne 5% 6% Limbs pain 26%
Hyper Pigmentation 21% 7% Tooth Development Disorder 7% 14%
Dry Skin 22% 3% Tooth Carries 16% 23%
Bleeding Gums 5% 2% Frequent Headache 25% 41%
Swollen retracted Bleeding Gums 14% 3% Frequent Diarrhoea 18% 7%
Mouth Ulcers 18% 2% Upper Respiratory Infection 35% 60%
Angular Stomatitis 0.76% 1% Frequent Fever 47% 33%
Poor Wound Healing 16% 12% Abdomen Pain 29%
Poor Vision at Night 16% Watering of Eyes 8%

ANNEXURE: C
121

ANNEXURE: D
Focus on Nutrition-Sensitive interventions to improve Nutrition outcomes, Perspective of Te Lancet
Maternal and Child Nutrition 2013 series
53
Te Lancet Maternal and Child Nutrition 2013 series throws light on nutrition-specifc and nutrition-sensitive interventions as approaches to tackle the
problem of child malnutrition. Our study shows the impact of environmental and social factors like type of shelter-structured or unstructured, access to
proper sanitation, safe water and household food security on childrens nutrition status. Te fndings of our study demonstrate the need to urgently focus
on nutrition-sensitive interventions which deal with environmental and social factors in the lives of children. Nutrition-sensitive interventions such as
agriculture and food security, social safety nets, early child development, maternal mental health, womens empowerment, water and sanitation, child
protection, classroom education, health and family planning services must be taken up at once alongside nutrition-specifc interventions.
53 Te Lancet (2013): Maternal and Child Nutrition - Executive Summary of the Lancet Maternal and Child Nutrition Series. Viewed on 19 September 2013(www.thelancet.com/
series/maternal-and-child-nutrition)
122
ANNEXURES
Key messages on nutrition-specifc interventions
A clear need exists to introduce promising evidence
based interventions in the preconception period and in adolescents
in countries with a high burden of undernutrition and young age
at frst pregnancies; however, targeting and reaching a sufcient
number of those in need will be challenging.
Promising interventions exist to improve maternal nutrition and
reduce intrauterine growth restriction and small-for-gestational-
age (SGA) births in appropriate settings in developing countries, if
scaled up before and during pregnancy. Tese interventions include
balanced energy protein, calcium, and multiple micronutrient
supplementation and preventive strategies for malaria in pregnancy.
Replacement of iron-folate with multiple micronutrient supplements
in pregnancy might have additional benefts for reduction of SGA
in at-risk populations, although further evidence from efectiveness
assessments might be needed to guide a universal policy change.
Strategies to promote breastfeeding in community and facility settings
have shown promising benefts on enhancing exclusive breastfeeding
rates; however, evidence for long-term benefts on nutritional and
developmental outcomes is scarce.
Evidence for the efectiveness of complementary feeding strategies
is insufcient, with much the same benefts noted from dietary
diversifcation and education and food supplementation in food secure
populations and slightly greater efects in food insecure populations.
Further efectiveness trials are needed in food insecure populations
with standardised foods (pre-fortifed or non-fortifed) to assess
duration of intervention, outcome defnition, and cost efectiveness.
Treatment strategies for severe acute malnutrition with
recommended packages of care and ready-to-use therapeutic foods
are well established, but further evidence is needed for prevention and
management strategies for moderate acute malnutrition in population
settings, especially in infants younger than 6 months.
123
Nearly 15% of deaths of children younger than 5 years can be reduced
(ie, 1 million lives saved), if the ten core nutrition interventions we
identifed are scaled up.
Te maximum efect on lives saved is noted with management of
acute malnutrition (435 000 [range 285 000482 000] lives saved);
221 000
(135 000293 000) lives would be saved with delivery of an infant
and young child nutrition package, including breastfeeding
promotion and promotion of complementary feeding; micronutrient
supplementation could save 145 000 (30 000216 000) lives.
Tese interventions, if scaled up to 90% coverage, could reduce
stunting by 203% (33.5 million fewer stunted children) and can
reduce prevalence of severe wasting by 614%.
Te additional cost of achieving 90% coverage of these proposed
interventions would be US$96 billion per year.
Data for the efect of various nutritional interventions on
neurodevelopmental outcomes is scarce; future studies should focus
on these aspects with consistency in measurement and and reporting
of outcomes.
Conditional cash transfers and related safety nets can address the
removal of fnancial barriers and promotion of access of families to
health care and appropriate foods and nutritional commodities
Assessments of the feasibility and efects of such approaches are
urgently needed to address maternal and child nutrition in well
supported health systems.
Innovative delivery strategies, especially community-based delivery
platforms, are promising for scaling up coverage of nutrition
interventions and have the potential to reach poor populations
through demand creation and household service delivery.
124
ANNEXURES
Key messages on nutrition-sensitive interventions and programmes
Nutrition-sensitive interventions and programmes in agriculture, social safety nets, early child development, and education have enormous
potential to enhance the scale and efectiveness of nutrition-specifc interventions; improving nutrition can also help nutrition-sensitive
programmes achieve their own goals.
Targeted agricultural programmes and social safety nets can have a large role in mitigation of potentially negative efects of global changes and
man-made and environmental shocks, in supporting livelihoods, food security, diet quality, and womens empowerment, and in achieving scale
and high coverage of nutritionally at-risk households and individuals.
Evidence of the efectiveness of targeted agricultural programmes on maternal and child nutrition, with the exception of vitamin A, is limited;
strengthening of nutrition goals and actions and rigorous efectiveness assessments are needed.
Te feasibility and efectiveness of biofortifed vitamin A-rich orange sweet potato for increasing maternal and child vitamin A intake and status
has been shown; evidence of the efectiveness of biofortifcation continues to grow for other micronutrient and crop combinations.
Social safety nets are a powerful poverty reduction instrument, but their potential to beneft maternal and child nutrition and development is yet
to be unleashed; to do so, programme nutrition goals and interventions, and quality of services need to be strengthened.
Combinations of nutrition and early child development interventions can have additive or synergistic efects on child development, and in some
cases, nutrition outcomes.
Integration of stimulation and nutrition interventions makes sense programmatically and could save cost and enhance benefts for both nutrition
and development outcomes.
Parental schooling is consistently associated with improved nutrition outcomes and schools provide an opportunity, so far untapped, to include
125
nutrition in school curricula for prevention and treatment of undernutrition or obesity.
Maternal depression is an important determinant of suboptimum caregiving and health-seeking behaviours and is associated with poor nutrition
and child development outcomes; interventions to address this problem should be integrated in nutrition-sensitive programmes.
Nutrition-sensitive programmes ofer unique opportunity to reach girls during preconception and possibly to achieve scale, either through
school-linked conditions and interventions or home-based programmes.
Te nutrition-sensitiviy of programmes can be enhanced by improving targeting; using conditions; integrating strong nutrition goals and actions;
and focusing on improving womens physical and mental health, nutrition, time allocation, and empowerment.
126
ANNEXURES

ANNEXURE: E
Questionnaires
127
128
ANNEXURES
129
130
ANNEXURES
131
132
ANNEXURES
133
134
ANNEXURES

ANNEXURE: F
Recommended Dietary Allowances for Indians
135
Maternal Health and Nutrition Interventions in Maharashtra
Tese interventions span rural and urban populations. A number of nutrition interventions
54
and their efectiveness have been established by several
studies in India and around the world. Tese must be employed with proper planning afer conducting slum wise baseline surveys to improve nutrition
status.
Te presentation titled, Call to Action for Child Survival in Maharashtra: An Initiative of Government of Maharashtra, supported by development
partners, made on July 25, 2013, UNICEF and Government of Maharashtra highlights the focus areas:
Antenatal care and birth preparedness:
Identifcation of high risk mothers
Tracking of severely anaemic mothers
Skilled birth attendance and emergency obstetric care
Janani Shishu Suraksha Karyakram (JSSK)
55
, Janani Suraksha Yojana implementation
Maternal Death Review MDR
54 UNICEF (2013):Interventions to Address Stunting and Other forms of Undernutrition, Improving Child Nutrition: Te achievable imperative for global progress, pg
17,(www.unicef.org/media/fles/nutrition_report_2013.pdf)
55 Janani Shishu Suraksha Karyakram(JSSK) is an initiative to assure free services to all pregnant women and sick neonates accessing public health institutions.

ANNEXURE: G
136
CONCLUSION & RECOMMENDED PLAN FOR ACTION
Strengthening delivery points and monitoring quality of services
Child Health and Nutrition Interventions:
Special New-born Care Units/ New-born Care Corners at all delivery points
Home-based new-born care by Accredited Social Health Activist (ASHAs)
Listing of low birth weight children
Routine immunisation
Availability of Oral Rehydration Terapy (ORS) and zinc for diarrhoea at sub-centres and with ASHAs
Availability of antibiotics for pneumonia , vaccines, Iron folic acid (IFA) syrups and tablets
Infant & Young Child Feeding (IYCF), Supplementary Nutrition Programme at Anganwadi Centre (AWC), identifcation and management of
Severe Acute Malnutrition (SAM) children
Family Planning:
Promotion of Postpartum Intrauterine Contraceptive Device (PPIUCD) by Auxiliary Nurse Midwife (ANMs)/facilities
Delaying frst pregnancy and promoting spacing of births
Permanent methods of birth control
Implementation of Pre-Conception and Pre-Natal Diagnostic Techniques Act
56
, PC-PNDT (1994):
Monitoring sex ratio at birth and during 0-4 years in the district and facility-wise sex ratio (in frst and consecutive births)
Search and seizures, prosecution and convictions
56 Pre-Conception and Pre-Natal Diagnostic Techniques Act,1994, is a federal legislation implemented by the Parliament of India to stop female foeticide.
137
Other Important Programme Interventions
Adolescent health clinics & their utilisation
Anaemia control and management across life cycle (for children, pregnant women, adolescent girls and boys, women in reproductive age group):
availability of appropriate drug formulation, platform for distribution to benefciaries
Weekly Iron and Folic Acid Supplementation (WIFS)
Rashtriya Bal Swasthya Karyakram(RBSK)
Convergence with Nutrition and Water Sanitation & Hygiene (WASH)
Convergence between National Rural Health Mission (NRHM), Nirmal Bharat Abhiyan (NBA)
57
, National Rural Drinking Water Programme,
Integrated Child Development Services (ICDS)
In addition, convergence with other departments likes Tribal Development, Panchayat
Political will, good governance and leadership are key determinants
Upgrading of sub-centres: more staf, infrastructure.
Medical Mobile Units (MMUs): Additional MMUs
Performance-based incentives: Special incentives to medical and para-medical staf for performing duties in highly congested and inaccessible areas
(e.g.; identifed health facilities)
Role of Medical Colleges
In providing technical assistance on all interventions related to Reproductive, Maternal, Neonatal, Child Health + Adolescents (RMNCH + A)
58
Supportive supervision and mentoring of the RMNCH + A interventions
It is envisaged that each medical college will be given the responsibility for one or two districts for capacity enhancement and for supportive
supervision.
57 Te Nirmal Bharat Abhiyan (NBA) is a comprehensive programme to ensure sanitation facilities in rural areas with the broader goal to eradicate the practice of open defeca-
tion.
58 Reproductive, Maternal, Neonatal, Child Health + Adolescents (RMNCH + A) interventions have been adopted by the Government of India to address the major causes of
mortality among women and children
138
ANNEXURES
LIST OF ABBREVIATIONS:
APMC: Agricultural Produce Market Committee
ASHA: Accredited Social Health Activist
ANM: Auxilliary Nurse Midwife
BMC: Brihanmumbai Municipal Corporation
CBO: Community Based Organisation
CNSM: Comprehensive Nutrition Survey Maharashtra
DOTS: Directly Observed Treatment Short-Course
FTI: Faecally Transmitted Infection
IAP: Indian Academy of Pediatrics
ICDS: Integrated Child Development Scheme
IYCF: Infant and Young Child Feeding
MAM: Moderate Acute Malnutrition
MBBF: MB Barvalia Foundation
NCPCR: National Commission for Protection of Child Rights

ANNEXURE: H
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NFHS: National Family Health Survey
NGO: Non Governmental Organisation
NSSO: National Sample Survey Organisation
ORF: Observer Research Foundation
PDS: Public Distribution System
SAM: Severe Acute Malnutrition
SHP: School Health Programme
SNEHA: Society for Nutrition, Education & Health Action
UNICEF: United Nations International Children's Fund
WHO: World Health Organisation
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ANNEXURES
About the Authors
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ABOUT THE AUTHORS
Rachel DSilva is an Associate fellow at ORF Mumbai. She is a post graduate in Political Science from Mumbai University. At ORF,
she contributes to research and advocacy in the areas of public health, sanitation, urban governance for inclusive development
and school education. Email: racheldsilva@orfonline.org.
Dr. Nitin Kothawade serves as full-time medical ofcer with M. B. Barvalia Foundation. He has several years of experience
in the holistic treatment of disability afected children. He is an integral part of the MBBFs slum outreach work. He can be
reached at drnitin2610@gmail.com.
Dr. Mihir Maher is a dietitian and physiotherapist. He has done his physiotherapy from Seth G. S. Medical College and K. E. M.
Hospital in 2006 and, since then, is practicing physiotherapy. He fnished his Masters in Dietitian (M. Sc DFSM) in 2013. He is a
lecturer and consultant on nutrition for various corporate groups like TATA Motors Ltd. He can be reached at bepositiveclinic@
gmail.com.
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About MBBF
M.B.Barvalia Foundation is a public charitable trust established in February 1997 with objectives of promotion of
holistic health & value-based education.
Under the leadership of Dr Praful Barvalia, the Foundation's chairman and one of Mumbai's leading homeopaths,
Spandan Holistic Institute of Applied Homeopathy has changed hundreds of lives. Dr Barvalia is also a member
of the Board of Studies of Maharshtra University of Health Sciences and visiting faculty Homeopathic Medical
College, Bharti Vidypeeth University. He is also the editor of the Indian Journal of Homeopathic Medicine for over
10 years and written over 500 articles and presented papers at various national and international fora.
MBBFs Holistic Child Care Centre works in the area of developmental disability, catering to the entire spectrum
of childhood disabilities and mental health disorders. Its other units are Spandan Holistic Institute of Applied
Homeopathy, Medical Centre and Indian Journal of Homeopathic Medicine.
Spandan Holistic Institute is based on the philosophical foundation of HolisticPsycho Educational Approach: Symphony. Tis innovative method
is based on integration of the holistic concept propounded by Dr. Samuel Hahnemann, founder of Homeopathy and Jean Piagets concept of child
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ABOUT MBBF
development. Te foundation strongly believes in Swami Vivekanandas ideas about the divine potential manifest in every individual. It thus strives to
translate these concepts to various demanding situations in health and education.
A large number of patients have been treated through MBBF's OPD clinics and slum-based clinics in the suburbs of Mumbai. Every year, 1,000 special
children and their parents receive multidisciplinary evaluation and counselling through Free Child Care Camps organised by Spandan Holistic Institute.
Over the years, the institute has successfully integrated autistic children to mainstream/slow learner schools, provided treatment, therapy and educational
inputs to a number of special children.
MBBF works closely with AYUSHMinistry of Health, Government of India, on research in Autism. Teir AYUSH-Public Health Initiative project with
schools is dedicated to the needs of children from slums and under privileged areas with disabilities and mental health dysfunctions. Teir upcoming
project is a comprehensive Mother-Child Complex and Institute of Holistic Health Sciences in Mumbai comprising of an Advanced Paediatric Hospital,
a Maternity Home and a Homeopathic Institute. Tey can be reached at www.holisticfoundation.org
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About ORF Mumbai
Observer Research Foundation is a multidisciplinary public policy think tank started in Delhi in 1990 by the
late Shri R K Mishra, a widely respected public fgure, who envisaged it to be a broad-based intellectual platform
pulsating with ideas for nation-building. In its journey of over twenty years, ORF has brought together leading
Indian policymakers, academics, public fgures, social activists and business leaders to discuss many issues
of national importance. ORF scholars have made signifcant contributions towards improving government
policies, and have produced a large body of critically acclaimed publications.
Beginning 2010, ORF Mumbai has been re-activated to pursue the foundations vision in Indias fnancial and
business capital. It has started research and advocacy in six broad areas: Education, Public Health, Urban
Renewal, Inclusive and Sustainable Development, Youth Development and Promotion of Indias Priceless
Artistic and Cultural Heritage. It is headed by Shri Sudheendra Kulkarni, a social activist and public intellectual
who worked as an aide to former Prime Minister Shri Atal Bihari Vajpayee in the PMO. ORF Mumbais mission statement is: Ideas and Action for a
Better India.
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ABOUT ORF MUMBAI
ORF Mumbais ongoing initiatives:
ORF Mumbai has facilitated the creation of the Mumbai Transport Forum, a broad-based platform of transport experts, academics and advocacy
groups working towards improving the public transport systems of Mumbai.
ORF Mumbai has collaborated with Ratan J. Batliboi Consultants Private Limited (RJBCPL), one of Indias top architects and town planners, to
initiate projects for the revitalisation of Mumbais freedom movement heritage. Te project is based on the tenets of Placemaking a term for
creative redevelopment of multi-use public places.
In the area of public health, ORF Mumbai is working for a sustained campaign for TB control in Mumbai through public-private-people partnership
that will rigorously debate, advocate and act on the core solutions which can realistically and signifcantly reduce TB burden in Mumbai over the
next decade.
A key endeavour of ORF Mumbai is in the sphere of womens safety, for which, it has forged healthy partnerships with the MCGMs Savitribai Phule
Gender Resource Centre and the Mumbai Police.
ORF Mumbai has launched a neutral, broad-based platform called Change Agents for School Education and Research (CASER) for working
towards connecting excellence, research and advocacy to strengthen the school education system, making it more holistic and positively afect
millions of school children, irrespective of their background or constraints.
Change Agents for Higher Education and Research is ORF Mumbais new and novel initiative in the space of higher education in India. As the
Government prepares to work towards improvement in the quality of higher education delivery, as part of the new National Higher Education
Mission (RUSA), we suggest how this can be achieved in a structured and scalable way through engaging Change Agents for Higher Education
and Research (CAHER). CAHER will be a platform, anchored at ORF Mumbai, which will enable change agents to come together to create a
multiplicative efect in the impact of their work. Te focus of CAHER will be on quality academics, on capacity building among all stakeholders, and
on creating an inclusive and participative movement.
ORF Mumbais Publications
Forthcoming