Findings of a collaborative study in Uttar Pradesh, India, by the International Food Policy Research Institute (IFPRI), Family Health International (FHI) and John Hopkins (JH), funded by the Bill and Melinda Gates Foundation (BMGF) have been tweeted out from the IFPRI Twitter handle on the 4^th of June 2020 along with a graph, stating

 ‘Vegetarian women more likely to have probability of nutrient adequacy and diet diversity during pregnancy than non-vegetarian women”   

Source: IFPRI twitter handle

A next tweet claims that this study ‘is a finalist for the Emerging Leaders in Nutrition Science Award”

On enquiry, another tweet was put out 24 hours later, with the addition of the text in bold.

“Vegetarian women were more likely to have probability of nutrient adequacy and diet diversity during pregnancy than non-vegetarian women, but these differences are likely confounded by socio-economic and caste status”.

We are shocked by this study as well as the way it has been projected in the public domain, for the reasons stated below

Vegetarian and non-vegetarian are not scientific categories. In the current politically and ideologically charged environment of India, specifically in State of Uttar Pradesh, even somewhat sensitive researchers would have been conscious of the ethical pitfalls and dangers of this kind of a nutritionally irrelevant discourse. Predictably, the projected ‘results’ show up the confusions and contradictions.

This study shows that only 8% of self-reported non-vegetarian women consumed flesh foods and only 4.2% consumed eggs. Although, this is not representative of meat eating statistics of the rural population in India, the authors make no attempt to explain this glaring inconsistency. The finding that ‘non-vegetarians are not eating enough animal foods’ should disturb anyone concerned about nutrition. Instead of being concerned about this important finding which highlights that only 8% of non-vegetarians actually get to eat some meat, the authors turn the findings on its head and try to appear on the right side of the political dispensation by projecting that vegetarians have more food diversity

Animal proteins are important for iron absorption and animal foods are a good source of Vitamin B12, Vitamin A and Riboflavin, in addition fish is a rich source of N3 fatty acids. These nutrients are especially vital during pregnancy because over 60-80 of pregnant women are known to be anaemic with multiple nutrient deficiencies.

As Natarajan and Jacob (2015)[1], point out, ‘self-identification’ into the categories of vegetarian/non-vegetarian is not reliable because even meat eating people may self identify as ‘vegetarian’ out of social pressure. For instance, if children in government schools where Akshaya Patra provides food were asked about what they eat at home, they are likely to say that they eat ‘sattvik[2] food without onion and garlic’. This could be attributed entirely to the current social and political pressures on eating choices, irrespective of what children eat or enjoy eating in reality.

As any well trained nutritionist would know, dietary diversity is one aspect of nutrition, but it cannot be taken in isolation while ignoring portion size, adequacy and nutrient density of food, especially in pregnancy. Several studies use a cut-off of ≥15 g for a food to be considered for dietary analysis. No effort has been made in the tweets put out by IFPRI to indicate what the cut-off quantity is and whether this led to exclusion of certain foods in the analysis. To give an example of nutrient density, 15 gm of meat or egg is not equivalent to 15 gm of cereal, so not representing these differences shows poor methodology and even poorer understanding of nutrition.

Since this is a study about pregnancy it should also be known that pregnant women in India have dismally low pre-pregnancy weights and heights, poor weight gains and anemia during pregnancy, resulting in low birth weights and post-partum complications, all closely related to consumption of a monotonous cereal pulse diet bereft of good quality protein, iron, and calcium. To repeat, focusing only on diversity while ignoring adequacy and nutrient density defeats the purpose of studying nutrition intakes in pregnancy.

Women from better socio-economic background, are likely to have more food diversity with more access to animal foods like dairy. Women from dominant caste are also likely to be from better socio-economic background, which in turn can contribute to better pregnancy outcomes. Martin-Prével et al (2015)[3], observed that women of reproductive age who consume five or more food items are also highly likely to consume at least one animal-source food. Having being co-authors with Martin-Prével on other studies, it is inexplicable how the researchers from IFPRI have overlooked this point and reach the conclusion that vegetarians have more diversity.

The dietary data for this study comes from pregnant women enrolled at baseline from an Alive and Thrive maternal nutrition program in Uttar Pradesh, India – a project funded by the Bill and Melinda Gates foundation. Incidentally, BMGF has also funded this study. Considering the results of the study, it is surprising that these women have not benefitted from the BMGF project. Is it possible that the project itself has become a hostage to promoting vegetarianism in UP? In addition, being a population under a specific project, this group of women cannot be taken to represent the general population and especially not to make sweeping conclusions about “vegetarian and non-vegetarian” women.

The researchers claim that median intake of micronutrients was below the estimated average requirement (EAR) for 9 out of 11 micronutrients with only zinc and thiamine having a median intake slightly above EAR. Not surprisingly the results show that intake is low in both categories. This is a classic example of the pitfalls of relying on oral questionnaires for nutrition data collection in an atmosphere of fear and marginalization of meat eaters. Even a rigorously conducted 24 hour oral recall method can show variations of upto 25%. Biochemical estimations may have given us some insights into the actual intakes in the two groups

We are shocked by the fact that results of studies with potential large impact on women, especially pregnant women, are put out on Twitter like slogans or sensational headlines.  Sharing teasers on social media while withholding the full study wouldn’t fall into the category of serious or ethical research.

This valorising of vegetarianism and dismissal of meat eating is not isolated, but rides on the back of several years of false assertions that India is ‘vegetarian’. There has been criminalisation of meat (particularly beef) eating communities, vehement denial of eggs to children (who are often some of the poorest, most vulnerable and malnourished) in spite of the Right to food being a legal mandate.

Blatant promotion of religious, sattvik, casteist, vegetarian institutions like Akshaya patra irrespective of serious objections by public health people, food rights activists, doctors, researchers, are symptoms of imposition of a majoritarian view in India. This is made worse by the growing global push towards predominantly plant based diets through multilateral agencies like the Eat Lancet Commission and promoted by Indian counterparts, inspite of global criticism. This ‘study’ is therefore not innocent.

It is alarming that IFPRI, John Hopkins, FHI and BMGF are coming together to put out the message on social media that vegetarian food is superior – a pre-existing casteist and anti-minority myth in India. That this study is a finalist for the Emerging Leaders in Nutrition Science award, is probably the icing on this vegetarian cake.

We do hope that the authors will rethink about publishing this study in the present form.

Dr. Sylvia Karpagam (Public health doctor) and Dr. Veena Shatrugna (Retired deputy director, National Institute of Nutrition)

References

[1] Natarajan and Jacob “Provincialising’ vegetarianism putting Indian food habits in their place, Economic and Political Weekly, March 2018.

[2] A sattvic diet is a brahmanical vegetarian diet

[3] Martin-Prével, Y., Allemand, P., Wiesmann, D., Arimond, M., Ballard, T., Deitchler, M., Dop, M.C., Kennedy, G., Lee, W.T. & Mousi, M. 2015. Moving forward on choosing a standard operational indicator of women’s dietary diversity. Rome: FAO.

Endorsed by

1. Dr. Amar Jesani, Independent researcher
2. NAMHHR (National Alliance for Maternal Health and Human Rights), India Secretariat
3. National Federation of Indian Women, New Delhi.
4. Chaand Ohri, Campaign against racism
5. Aarti Bhatt, MD, Campaign Against Racism
6. Ayesha Khan, Right to Food campaign
7. Anita Rego, Independent consultant
8. S Chakraborty, IIT Bombay
9. Latha, Homemaker
10. Devassy Kadaparambil, Child rehabilitation Don Bosco
11. Anisha Rimal, Campaign Against Racism
12. Dr.Mohan Rao, Independent researcher in Bangalore
13. Balu, Bangalore Dalit Forum
14. Malleshwari, Bangalore Dalit Forum
15. Sharmila, IIT Bombay
16. Ramesh, IIT Bombay
17. Siddharth K J , Independent Researcher, Bengaluru
18. Prabhir Vishnu Poruthiyil, IIT Bombay
19. Ramdas Rao, Human rights worker
20. Patience Binali Ndovi, One community
21. Latifa, Health for all
22. Jerald D Souza, Ashirvad_ Centre for social concern.
23. Smitha Nair, Tata institute of social sciences
24. Swathi Seshadri, Researcher
25. Sneha Visakha, Legal Researcher
26. Ms.Firdose, Activist
27. Ashwani Raj Volunteer, All India SC/ST Fisherman Council
28. P R S Mani, All India People’s Forum
29. Arul Anthony, Health for All
30. S. Krishnaswamy Retired Professor, Madurai Kamaraj University
31. John J R, IT
32. Dr Sushrut Jadhav, Division of Psychiatry, University College London
33. Samia Braxton, High School
34. Sona Mitra, Researcher, New Delhi
35. Nawasha Mishra, Right to Food Campaign
36. Arundhati Dhuru, Suhas Kolhekar, Meera Sanghamitra, Madhuresh, Amulya Nidhi and others, National Alliance of People’s Movements (NAPM)
37. S Sen Gupta, IIT Bombay
38. Dr Sharfaroz Satani, Alt News science
39. Sejal Dand, Anna suraksha Adhikar Abhiyan Gujarat
40. Soma KP, Makaam
41. Sameet, Right to food campaign
42. Anupama K. French Institute of Pondicherry, Department of Ecology
43. Jharkhand Women’s Health Network 
44. Prerna Bharti, Jharkhand
45. Moshe, Citizen
46. Nidhin Sasi, IT Employee
47. Shiva Shankar, Visiting Professor, IIT Bombay
48. Sonal Kellogg, None
49. Shazin Siddiqui, Human Collective
50. Pushpa Achanta, Women Against Sexual Violence & State Repression (WSS)
51. Chetana Kumari P, Freelance writer
52. Dr Monica Thomas, Consultant Neurologist
53. Teena Xavier, Public health activist
54. Swathi Shivanand, Independent researcher
55. Sreekanth, None
56. Neeta Hardikar, Anna Suraksha Adhikar Abhiyan, Gujarat
57. Samar Khan, Health Activist
58. Ashalatha S, Makaam
59. G THIRAVIYAM, FWF
60. Vinay KS, Advocate
61. Yogini, NGO
62. Sangita Atram, NGO
63. Brinda Adige , Global Concerns India
64. Anita Cheria, OpenSpace
65. Prasanna Babu Krishnappa, Activist
66. Amrith Shenoy, Sahabalve, Udupi
67. George M K, Loyola College of Social Sciences
68. K. Sajaya, Independent Journalist and Social Activist
69. Abrar Rashid, Student
70. Vidya Iyengar, Citizen
71. Varsha Bhargavi, Where Are The Women?
72. Lissy, CFTUI
73. Uma Bhrugubanda EFLU, Hyderabad
74. Seethalakshmi. MAKAAM
75. Ashalatha, Seema , Sejal MAKAAM
76. Ravali – Concerned citizen
77. Tannu, Student
78. Prashanti Ganesh, Total Strength System LLP
79. Umesh, Research editor
80. P Sunthar, IIT Bombay
81. Shiba Minai, Journalist/Activist
82. Aaron Abraham, N Concerned Citizen
83. Rosamma Thomas, Journalist
84. Khizer e alam, Covid frontline worker
85. Ojas Shetty, Urban & Transport Practitioner
86. Nusay Bah, Peace activist
87. Sunil Kumar None
88. Ashish Kajla, Researcher
89. Paul Schaafsma, Political theorist and climate justice activist
90. Avani Chokshi, CPI(ML)
91. Dolly Arjun, PA-C Campaign Against Racism-Boston
92. Zareen, Homemaker
93. Kaneez Fathima, Activist
94. Raees Muhammed, Dalit Camera
95. Baijayanta Mukhopadhyay, PHM Canada
96. Latha LR, Sanman society
97. Ila Ananya, Azim Premji University
98. Wan Manan, Alma Ata University
99. Vaibhav, Researcher
100. Sumithra, Researcher
101. Manzar Jameel, Social activist
102. Vidya, Assistant Professor, TISS Mumbai
103. Alwyn, Health for all
104. Vijay Dhama, None
105. Sathyan, HIT
106. Manavi, Student
107. Pratap Bhai, Citizen
108. Omar Farook, Human Collective
109. Yousuf S., None
110. Jayasree Subramanian, Academician
111. Evita Das, National Alliance of People’s Movements
112. Burnad Fatima, Makaam
113. Soundarya Iyer, French Institute of Pondicherry
114. Akash Bhattacharya, Azim Premji University
115. Jayendra Kovur, Medical officer at Botalama community health center, Khorda, Odisha
116. Swati Narayan, Institute for Human Development
117. Ishrath Nisar, Social activist
118. Abi Vanak, ATREE
119. Nargis Ismail, Non vegetarian
120. Reva Y, Signing as concerned individual
121. Swaliha Asiya, Content Strategist & Consultant
122. Sanjay Kumar Bharti, Social Development Sector
123. Sumi Krishna, Independent researcher, Bengaluru
124. Mayank Member
125. Anjan Katna ATREE
126. Lakshmi Kutty PhD scholar, Centre of Social Medicine and Community Health, JNU
127. Anil Sadgopal, All India Forum for Right to Education (AIFRTE)
128. Kirana, Baduku community college Bengaluru
129. Shashi Mourya, All India Forum for Right to Education
130. Veena Srinivasan, ATREE
131. Shewli Kumar, Tata Institute of Social Sciences
132. Susie Tharu, Retd Prof
133. Radhika Desai, Independent Researcher
134. Vasudev Charupa, Human Rights activist
135. Vanisha N MSU, Baroda
136. Samira Nadkarni, Journalist
137. Sulakshana Nandi, Public Health Researcher, Chhattisgarh
138. Sagari R Ramdas, Food Sovereignty Alliance, India
139. Qais Khan, Engineering professional, self employed
140. Sudeshna Sengupta, Independent Researcher and Consultant
141. Jashodhara Dasgupta, Independent Researcher, New Delhi
142. Rifath Ali, Health for all
143. Sunayana Sajith, PhD student at Western Sydney University
144. Chirashree Mobile Creches
145. Srilata Sircar University College London
146. JC Anthony, Retd. Senior Scientific Officer, Indian Air Force
147. Dr. Imrana Qadeer, Distinguished Professor, Council for Social Development, New Delhi
148. Prabir Chatterjee, Kolkata

Response from IFPRI researcher, Purnima Menon

From: Menon, Purnima (IFPRI-New Delhi) <P.Menon@cgiar.org>
Date: Fri, Jun 19, 2020 at 11:16 AM
Subject: RE: A critical response to a study in India by IFPRI, John Hopkins, and FHI
To: Veena Shatrugna <veenashatrugna@yahoo.com>, Sylvia Karpagam <sakie339@gmail.com>
Cc: alexandra.bellows@jhu.edu <alexandra.bellows@jhu.edu>, Kachwaha, Shivani (IFPRI-New Delhi <S.Kachwaha@cgiar.org>, sghosh@fhi360.org <sghosh@fhi360.org>, KKappos@fhi360.org <kkappos@fhi360.org>, JEscobar-alegria@fhi360.org <jescobar-alegria@fhi360.org>, Nguyen, Phuong Hong (IFPRI) <P.H.Nguyen@cgiar.org>, Sarswat, Esha (IFPRI-New Delhi) <E.Sarswat@cgiar.org>, Avula, Rasmi (IFPRI-New Delhi) <R.Avula@cgiar.org>

Dear Dr.  Shatrugna and Dr. Sylvia,

 Thank you for your letter.  I am responding to your note as the lead of the IFPRI research team on this paper, which is a sub-study of a much larger body of work to study the impact of maternal nutrition interventions– including the promotion of all foods, including animal-source foods – on diet quality.

 As we noted on the social media channels, the conference abstract and poster were the only materials available for review.  The full research paper, which addresses many of your concerns and those of your co-signees, is currently under peer review in an academic journal.   In addition to the peer review comments, we will also consider your feedback via this letter in our revisions.  We will let you know when that paper is available – we anticipate this will take a few weeks, if not more. 

 We are happy to jointly plan communications with you and others once the full paper is available to ensure that the findings are not misinterpreted.   Please be assured that we are aligned with your perspective that diverse diets that include animal source foods, for those who choose to consume them, are important for nutrition.

 Best regards,

Purnima.    

Response from Dr. Veeena Shatrugna

Dear Purnima, and Researchers from IFPRI, John Hopkins, and FHI,
 
 Greetings! I am writing this mail on my behalf and on behalf of Sylvia, and the 148 signatories to the above letter. (of course many more signed it later)

Thank you for your mail responding to our critique of your study on Pregnancy Nutrition in UP, India. Let me first apologise for the delay in responding…these are Covid times remember, and hope you will understand
 
You suggest that we wait for the publication of the paper which is under peer review which will also take into consideration our inputs provided in the critique. You further state that “We are happy to jointly plan communications with you and others once the full paper is available to ensure that the findings are not misinterpreted.etc.” and inform us that it “is a sub-study of a much larger body of work to study the impact of maternal nutrition interventions– including the promotion of all foods, including animal-source foods – on diet quality.”
 
I am not sure what you expect to achieve from your final paper when it is published. The damage to Nutrition science has already been done with your tweets. Our concern is not whether your final paper when published will redeems itself but rather the trend that your paper has set in areas of Nutrition research in India.
 
For lack of a better word I can only say that your paper is dangerously close to explaining the “Exotic Oriental” in the field of Nutrition. One of the reasons for this might very well be that there are very few areas of undernutrition left for serious study…Dr. Gopalan and the NIN have successfully laid bare and teased open the terrain of malnutrition, in terms of epidemiology of Malnutrition, RDAs, Clinical manifestations, Biochemical changes in undernutrition, Treatment and prevention of Malnutrition, Nutritive value of Indian foods to name a few areas. What is required at this time is food and more food for the large masses of people both urban and rural through a serious implementation of food programs and not calculations of the p value between 2 groups which are in any case not comparable in terms of caste and class (your observation).

  At a time when the country under the new dispensation is floundering on questions of food entitlements and right to food for the poor and specially children and pregnant women, your research serves to divert the attention to questions of vegetarians and non vegetarians.It is almost a surreal celebration of the food habits (vegetarianism)  of the people of a distant land.
 
The Right to food activists with an army of barefoot nutritionists are monitoring the Government’s non serious attempt at providing some bare cereals during the lockdown phase. We would have appreciated a well thought through statement from your team urging the Govt. to at least provide food/cash or both to rural and urban poor families. This has been advocated by all economists of the left or right. As scientists from prestigious institutes like IFPRI, John Hopkins and FHI it was imperative that you rise to the occasion, show concern and help prevent severe malnutrition in terms of underweights, anaemia, children with SAM and other manifestations of prolonged hunger. We would have liked to collectively persuade the Indian Government to take food seriously.
 
Even earlier we would have appreciated your intervention in the cultural onslaught on the school kids when egg was being denied to them by the Government funded central suppliers, a self proclaimed vegetarian sattvic outfit called the Akshaya Patra.

Some of you are maybe aware of the political minefields you are treading in the area of Nutrition. Is it a result of a total disregard for the serious questions of hunger and even starvation haunting our land? or is it just the novelty of the variables thrown up by the majoritarian and dominant ruling dispensation?

In future we do hope you will take India and its people seriously in terms of understanding our issues of health and Nutrition.
 
Regards

Veena Shatrugna


Former Deputy Director,
National Institute of Nutrition,
Hyderabad.