There is a pressing need to empower practicing pediatricians all over India with knowledge, capabilities and services that enable them to enhance the nutritional status of the children under their care. IAP is planning to pilot an initiative for this and on success of the pilot, extend it to all our members.

This document outlines the need and proposed solution that will be piloted.

We request the Nutrition Committee to kindly evaluate the evidence and the science supporting the proposed solution. Based on the evidence and science provided, we request you to give us an approval for the pilot program, along with your recommendations and modifications (if any).    

India is home to almost one-fifth of the world’s population and has undergone a nutrition transition from an underweight to an overweight population during recent decades (Agrawal, 2002; Dandona, 2017). This has come at significant cost to population health and well-being and to already overburdened health systems. (CNNS 2018).

With respect to the Minimum dietary diversity, meal frequency and acceptable diet the following observations were seen:

• 42% of children aged 6 to 23 months were fed the minimum number of times per day for their age
• 21% were fed an adequately diverse diet
• 6% received a minimum acceptable diet Food consumption among school-age children and adolescents
• More than 85% consumed dark green leafy vegetables and pulses or beans at least once per week One-third consumed eggs, fish or chicken or meat at least once per week ν  60% consumed milk or curd at least once per week

The nutrition imbalance exists not only in low socio-economic strata but nutritional deficiencies and imbalances are rampant in middle class and urban populations as well. In the modern era, physical activity has decreased, cooking methods have changed, processed foods have become common and coupled with nuclear families/ working parents- children often end up bearing substantial health insults stemming from nutritional imbalances.

Parents generally do not understand (or do) a diet consultation for their child. They feel that they know what they are doing. While awareness is growing slowing, as a nation we are far behind. 

Pediatricians hold the parent’s confidence and hence education and recommendation via the Paediatric Clinic is one of the most effective ways to make the parents understand the need for a balanced diet and provide professional guidance. 

For a stronger next generation, we believe, that all pediatric clinics across India must be empowered with the ability to conduct nutrition assessments and recommend sustainable and balanced dietary plans for children. Healthy nutrition prevents the risk of malnutrition, obesity and related metabolic diseases in childhood and adulthood, improves quality of life during childhood. Adequacy of micronutrients like Iron, Zinc, Calcium, Vitamin-C, Vitamin- B and Omega-3 fats in diet bolsters immunity, promotes child wellbeing and prevents long term health issues. A balanced diet is necessary for optimal growth (physical, mental, emotional).  To accomplish this right guidance is important and the fact remains that food habits developed early in life last for a lifetime.

(Ref: https://www.indianpediatrics.net/suppl2009/S12.pdf)

Registered dietitians are the natural choice to assist doctors in the care of patients with nutrition-related disorders. They are skilled in providing nutrition assessment, lifestyle advisory with a focus on disease prevention information. 

Over the last few years there has been a vast increase in dieticians. However, we still see a dearth of good Paediatric Nutritionists. Child is not a small adult, hence what works for adults may not be suitable for children. A child’s nutritional requirements keep changing with age. Given that today’s parents are very aware, it is important that a Nutrition Consulting Service follows scientific methods and data driven approaches. With rapid jumps in technology, it is now possible to analyse a child’s diet pattern and recommend a suitable diet. We no longer need to follow the One Size Fits All approach.

We recommend that IAP enables a scientific and data driven approach of providing Nutrition Guidance to Parents. 

The next section of this document describes the Process of identification of children who need Nutrition consultation and the method of doing the consultation.

1. Identification of children needing nutrition consulting: – To know whether a Nutrition assessment is advised, the Paediatricians will be given a set of these guidelines to ensure that Nutritional advocacy and follow up actions are advised. These guidelines will enable identification of
   1. Common symptoms of nutritional deficiencies – Any Nutritional deficiency identified with clinical signs by the Paediatrician 
   2. Blood tests showing deficiencies of macro or micronutrients – Hemoglobin, Vitamin A, Zinc, Vitamin B12, Folate
   3. Growth chart deviations – Easily picked up by the Paediatrician indicating the need of immediate nutritional intervention to correct the faltering growth trajectory.

             (Ref: https://www.indianpediatrics.net/suppl2009/S12.pdf)

2. Assessment methodology and supporting science – This is based on the proven ABCD of Nutritional Assessment methodology.   

1. Step 1: Child profiling- The session would start by understanding the child’s environment, his key statistics including Age, Weight, Height and Gender. Household consumption of Oil, sugar, salt, fruits, vegetables, millets and pulses. 
2. Step 2: Dietary recall for 2/3 days – Analysis of food diary can help Nutritionist in understanding the child’s daily food and nutrient consumption. This will be compared with his/her nutrient requirement (Please see annexure 2 which details the variables considered). 
3. Step 3: Nutrition report: Based on the dietary recall an array of important macro and micro nutrients essential for various important functions in the body are calculated and compared against close to 80 percent of RDA (Recommended Dietary analysis) dependent on age/ gender set by ICMR (Indian Council of Medical Research). This will be done using an advanced software algorithm designed for IAP’s NAAP program. 
4. Step 4: Meal plan recommendation: A meal plan is then generated for the Child and shared with the doctor. The Parent is given tips and is asked to visit the doctor for consultation.

The process is based on the 80% RDA

5. The calculations for Nutrition will be based on standardised cooked weight of food items entered into the food diary. Some key relevant data points for dietary assessments include: –

• Identify timing and locations (school/ home) of meals – ask about snacking patterns in between meals, during the evening and night. 
• Ask about where the meals are eaten, such as in the kitchen/dining room, living room, or bedroom, and if they are eaten in front of the television or computer. 
• Quantify sweetened beverage consumption – including all soft drinks, fruit juices, as well as chocolate milk. 
• Assess positive components of the diet, such as fruit and vegetables, fish, and grains. 
• Assess portion sizes – although the quality of food is critical, quantity can sometimes be an issue as well. Compare portion sizes with parents and other family members. 
• Ask what the child eats during school time. 
• Ask what the adolescent eats when is out of home.

6. Supporting science- The Nutrition Software shall use validated benchmarks such as the food database as per IFCT 2017, WHO/IAP growth charts and ICMR recommended RDA’s  since Estimated Average Requirement is not available in Indian Standards. We will used 80% of nutrient RDA as set by ICMR/ NIN for checking adequacy of dietary intake.
7. Dietary recommendation and supporting arguments – Once the data is analysed, the Nutritionist is able to understand the deficiencies in the diet. The nutritionist then creates a diet plan. The dietary interventions are suggested based on culture, cuisine, lifestyle, likes and dislikes of the child.
8. Recipes profiling – The recipe bank must consist of recipes from across the country which are standardised by a team of dietitians. Considering the complexity and diversity of cuisines across the nation, our initial studies indicate that the recipe bank requires at least 7500 recipes and variants thereof. Each recipe must also be validated in a laboratory for nutrient composition and variations in a scientific manner and documented. We must not look at popular assumptions and information from sources who have not followed such a standardisation methodology. Profiling must include adequate representation of both cooked and packaged foods. They are kept zone specific to maintain the authentic cultural cooking methodology usually followed.
9. The diet plans suggested emphasizes cuisine specific foods to overcome nutrient deficiency with optimum choices ensuring portion control for every child to combat overeating practices
10. Guiding principles – Highlight the importance of home cooked whole foods, healthy cooking practices, giving healthy twists to exotic recipes at correct meal timings making it easier for the child to be compliant to the suggestions offered.

3. Compliance enhancement methodology and supporting arguments

1. Easy to follow diet plans – The Nutritionist recommends a diet plan, keeping in mind the child’s schedule and timings of tiffin snacks versus various textures of food consumed at different meal timings.
2. Diet advice to be delivered via the paediatrician – The guidelines shared with the parent’s will be adhered with national protocols, and nutrient specificities set by IAP nutrition experts and available literature to support the same.
3. Specially prepared and specific maternal education given to pediatrician for distribution to mothers– This ensures that the mother understands the near term and lifelong consequences of the deficiency and associates with it as a “serious illness” and not as a “generally ignored wellness issue”
4. To enhance the compliance – Follow-up call will be given for patients in the program to ensure the child is monitored closely.
5. The Pediatrician will be equipped with a questionnaire to measure the compliance.

Therefor Compliance Assessment will include Pediatrician involvement and will not  be based on biased opinion.

4. Service delivery methodology and supporting arguments
   1. Easy quick enrolment into the Nutrition program will be enabled for optimum service delivery. This will be done on phone calls for NAAP- IVR enrolment of the child. The patient would be enrolled through the NAAP or given an IVR number to call.

2. This is best done by recommending enrolment into a 1 month NAAP program. The program will be delivered on phone calls and a customised software. The chat functionality on the software shall ensure maintaining connection building motivation, and overall compliance of the child and parents to the program. The Health Coach will be in touch with the family and ensure best outcomes and adherence towards the goal set by the Clinician.

5. Outcome Mapping 

The outcome mapping will be based on the following objective and measurable parameters. The matrix will be finalised after an approval from the committee members.

• Growth Chart Interpretations
• Food Diversity Score
• Compliance Assessment by the Pediatrician

Annexure 1:

A. Conditions For which a Child MUST undergo Nutrition Consult based on clinical or biochemical diagnosis

• Obesity / Overweight- On WHO/IAP growth charts
• Anaemia
• Cow’s milk protein allergy
• Lactose Intolerance
• Food Allergies
• Micronutrient Deficiency – Diagnosed on biochemical test or clinical signs
• PEM / Stunting – Diagnosed on Growth charts
• Diabetes / DKA
• Inborn errors of Metabolism 
• Celiac Disease
• Wilsons Disease
• Actively involved in Competitive Sports

Annexure 2: Planned Methodology of Analysis and Meal Plan Recommendation

1. Analyse Child Growth 

Purpose

The purpose of the growth tracker is to help the Caregiver understand if their child is growing as expected. Growth indicators include height, weight and BMI. Growth charts in India are published by Growth chart committee of Indian Academy of Pediatrics (IAP). 

Growth is often a function of what one eats, lifestyle and genes. If a child’s growth is not within the statistical range as seen for children in India then it’s an indicator that a child is not taking proper nutrition or not having enough physical activity or both.  

Methodology

The Nutritionist inputs the child’s age, weight, height and gender of the child. The application then calculates the BMI of the child using the formula (Weight (KG)/Height(m)²) (Formula published by Centre for Disease Control Government of US and used widely). 

The Inputted Weight, height and BMI is charted on the IAP- WHO combined Growth Chart to locate where the child lies in the growth chart. 

Result Interpretation

The IAP charts simply slots children in a Percentile graph which tells us what percentile of children fall in the same growth percentile as the child being compared. 

The interpretation of the Growth charts will be as follows – 

• Low weight-for-height Standard Deviation of more than 2 Z score / < 3^rd Percentile BMI from the applicable Growth Charts: Wasting or thinness indicates in most cases a recent and severe process of weight loss, which is often associated with acute starvation and/or severe disease. 
• High weight-for-height Standard Deviation of Z score / >75^th Percentile BMI from the applicable Growth Charts: “Overweight” is the preferred term for describing high weight-for-height.
• Low height-for-age Standard Deviation of Z score / < 3^rd Percentile BMI from the applicable Growth Charts: Stunted growth reflects a process of failure to reach linear growth potential as a result of suboptimal health and/or nutritional conditions.
• Low weight-for-age Standard Deviation of Z score / >75^th Percentile BMI  from the applicable Growth Charts: Weight-for-age reflects body mass relative to chronological age. It is influenced by both the height of the child (height-for-age) and his or her weight (weight-for-height), and its composite nature makes interpretation complex.

Ref: https://www.who.int/nutgrowthdb/about/introduction/en/index2.html

References

1. BMI Calculation Formulas https://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/childrens_bmi_formula.html 
2. Combined WHO and IAP growth Charts: https://www.iapindia.org/iap-growth-charts/ 

Annexure 3: Meal Plan Recommendation 

Purpose

The purpose of the providing meal plans is to provide a balanced diet to a child considering their Recommended Daily Allowance (RDA) as per the growth tracker output. These meal plans are carefully curated by the Nutritionist and then recommended to the child. 

Methodology

The following were the guidelines considered while designing the Curated Meal Plan

1. 80% RDA requirement was considered based on growth tracker results. 
   1. The RDA recommendations from ICMR was used as the base. This has been followed for children who fall in the normal growth trajectory. 
   2. For children who do not fall in the normal growth trajectory, ICMR does not have additional norms. To cater to the differential nutrition requirements of such children we have taken the best practices followed by practicing Nutritionist.  The Macro & Micro Nutrition benchmarks used are mentioned in table 3.
   3. Beyond 2years of age the custom meal plans aimed at 100 percent delivery of the selected nutrients.
2. The curated meals plans are thus designed considering validated Macro and Micronutrients (ICMR 2012). The list comprised of Energy, Carbohydrate, Protein, Fats, Calcium, Vitamin B12, Iron, Vitamin A and Vitamin C. These micronutrients are essential for growth and development.
   1. Calcium – Essential for Bone growth and development
   2. Vitamin B12 – Essential for brain and cognitive development in children
   3. Vitamin A – Promotes rapid growth, combat infections, vision development.
   4. Iron – Prevent from Anaemia, stamina, growth and formation of haemoglobin in the body.
   5. Vitamin C – Disease fighting antioxidant, enhance immune functions
   6. Zinc – Enhances sense of smell and taste, regulates the immune system
   7. Omega 3 fats – Good fat, essential for brain health
   8. Folic acid – Important nutrient to make RBCs and WBCs in the bone marrow
   9. Fibre – Helps in altering bowel movements, aids in healthy weight gain.

3. The custom meal plans provided considers – Common Food allergy, timing of meals – weekdays, weekends, age of child – Toddlers, play groups, school going. These conditions enabled time and consumer friendly choices to meet the nutrient goals.
4. Finer details like types of food and various textures with respect to toddler and school going children are also considered in the Custom Meal Plan.

E.g. – Dry snacks for short tiffin, One meal dish for Lunch Breaks etc.

5. Estimation of portion size – The Nutrition team based on feeding practice shall create a template and standardised across age groups and food items based on energy delivery, serving sizes and type of food item. E.g. – Paratha – in Number, while Dal – Small Bowl, Medium Bowl, Large Bowl. Refer table 5.
6. Nutrition Delivery: While curating a meal, based on age, meal preference and allergies it is very difficult if not impossible to get all macro and micronutrient to match 80% of  RDA.
7. Absorption of the nutrient from Food groups – eg – Calcium from Milk and Milk products is better absorbed than Calcium from Leafy vegetables due to presence of Phytates. Absorption values considered are as per table below

References

Table 2: RDA Table from ICMR for children showing normal growth

Reference: Recommended Dietary Allowance for Indians (ICMR, 2010) – Ca (Calcium), Vit B12 (Vitamin B12), Fe (Iron), Vit C (Vitamin C) and Vit A (Vitamin A – Retinol).

http://cbseacademic.nic.in/web_material/Curriculum/Vocational/2018/Food%20Nutrition%20&%20Dietetics_XI.pdf

Table 4: RDA Zoning scale 

The Recommended Dietary Allowance for the nutrients tracked will aim at delivering 80 percent of the values to be met. Once the final Estimated Average Recommendations are released by recognised authorities (ICMR / NIN), they will be considered accordingly. 

Along with Nutritional assessment and guidance, Physical activity schedule will be shared on the following logic:

• Age appropriate exercises
• Minimum equipment’s to be used
• A structured plan with number of repetitions and counts to be given
• You tube links for exercise recommendation will be shared with the children as demo videos.

Figure – Sample Day wise Exercise Plan

PORTION SIZE CHART

While it is important to meet the Nutrition needs of the child, it is also important to suggest relevant portion size of food so that the child does not feel hungry or does not end up eating a lot of food (quantity). The portion size table recommend the quantity of food to be given to a child based on his age and based on the food being consumed. These portion size chart aids in the development of the meal plan. 

Table 5: Recommended Portion Size