Urban Nutrition Program: May 2012 Update

Improving Urban Nutrition

with Deep Griha Society

Tracing the project’s arc

Date: June 15, 2012

Anisha Shankar, DI Fellow

Since 1975, Deep Griha Society has served Pune’s impoverished communities and neighboring

villages through childcare services, women’s empowerment programs, education, and awareness

raising.

Children in these communities begin suffering from the effects of poverty and lack of knowledge

early, often in the womb - malnourishment is rampant.

Deep Griha and Design Impact believe that the solution – better nutrition for children – can have

also a positive impact on local women. What if a nutritious snack program implemented over a 6-

month period shows higher weights, heights, and hemoglobin counts for the 270 children at Deep

Griha’s daycare centers? These positive health impacts could catalyze a new livelihood option –

manufacture and sale of these snacks - for local women’s self-help groups while children in the

community would have increased access to nutritious foods.

The organization, the project.

The time-and-activity line.

December January February March April May

IMMERSION

December spent in full

learning mode. Observe-

talk-shadow-repeat. Do

children in crèches eat

enough? Aadhar Kendra

children seem to eat well.

Mind boggled by array of

programs on offer. Several

ideas to approach outcome

goals.

RESEARCH

Extremely productive

contact with pediatric

nutrition research

group at Jehangir

Hospital. Read-read-

read and refine

outcomes and

measures of progress.

DGS signs off on

project plan.

DESIGN-IN-ACTION

Alternate between

kitchen and sampling

table. Experiment with

(1) cheap, (2) tasty, (3)

healthy, and (4) easy-

to-make (5) finger

foods. Then ask DGS

staff which ones they

liked best.

PRE-IMPLEMENTATION

MEASUREMENT

Height, weight and

hemoglobin counts

demonstrated

measures of nutritional

impact. Weigh,

measure, then repeat,

and again, but get it

right! Botched blood

draws heart breaking.

DESIGN-IN-ACTION &

LOOKING AHEAD

Food testing is hard!

Soliciting feedback in

culturally relevant way

harder still! What if

program successful?

Need funding plan in

place, if so.

Brainstorm with DGS

staff to get best ideas!

REACHING OUT AND

REFLECTIONS

Can’t do it alone, can’t

do it alone, can’t do it

alone! Reach out to

DGS staff and ask for

help. Other times, just

do it and get it done,

and “jugaad” isn't a bad

word.

THE IMMERSION

In my first two weeks at DGS, I was startled to

find myself mostly dismayed. How could I

possibly be useful or effective in this

programmatically-sprawling and hierarchy -

ordered organization? And then helped with

intake for a volunteer-led health camp for the

crèches.

With the sharpness and clarity that only

belongs to a few moments in life, I knew that

everything else was mostly irrelevant.

Grinning, skinny, crying, scared, naughty, and

snotty, these children were the reason I was

here and dang it I was going to do this job to

the best of my ability.

What motivates you?

Observe-Shadow-Talk-Repeat.

So I spent the next few weeks

learning about current nutrition-

related practices, menus, and

donations. I found out that

Venkateshwara Hatcheries donates

daily vats of rice and dal to DGS that

makes it possible to feed the

approximately 270 children that come

to DGS’ crèches.

But I couldn’t help notice that the rice

is white and the dal could be thicker. I

found DGS was supplementing these

as best it can within its limited

budget. But plainly there were

opportunities to make any new

nutritional efforts count for these

children.


Talks with Dr. Prakash and with medical volunteers revealed that the children in the crèches

tend to be underweight and anemic, a daily DGS meal and snack notwithstanding. So

children in these impoverished communities without access to this food likely have a much

tougher go of it. Research papers indicated the same thing.


I also wanted to see if children in other programs fared better. I found that some did. The

Aadhar Kendra program, which connects a donor to each child identified as coming from a

difficult home life, is better resourced. Children eat one meal that seems power-packed. They

get some combination of dark leafy green vegetables, eggs, sprouted lentils, whole grains, and

dal.

The Sit Down with the Director

THE DIRECTOR

Then I sat down with the Director, Dr.

Neela Onawale, to truly understand

what DGS wanted.

In collaboration with DI, DGS’ is

gazing out at the community – let’s

make available a substitute locally-

made healthy snack for the many

packaged ones that community

children are known to consume.

Local women’s self-help groups could

produce these snacks and sell it in the

community.

Maybe we could do this and

simultaneously add value to the

crèche meal program. The project plan

was coming together…

The Plan

Test snacks. Sample for

DGS staff. Select

favorites. Have nutritional

analysis performed.

Feed to crèche

children for at

least 6 months.

Train

community-

based SHGs in

snack–making,

quality control.

Identify markets.

Help with

marketing.

Children in

the community

Measure children’s heights,

weights, and hemoglobin counts

Regular nutrition education for care-

givers? Can trainee nurses deliver?

THE RESEARCH

DGS’ long life and consistent service to

its target population makes it a natural

partner for many organizations.

The Hirabai Cowasji Jehangir Medical

Research Institute has based many of its

pediatric nutrition research studies at

DGS. It was a relationship that I got on

board with and quick. Research head Dr.

Anuradha Khadilkar and nutritionist

Veena Ekbote were a fount of

perspectives, tips, research papers, and

good advice and I am deeply grateful to

them.

They’ll show up later in this story as well,

so stay tuned…

Know what’s known

Doing the research

DGS identified protein and iron as the two nutrients of greatest need for the children in the

community. The research supported this and I planned in pre- and post-program measurements

after six months of snack supplementation.

Doing the research

The Nutritive Value of Indian Foods was my bible during this period. I identified foods that were

high is protein and iron and then searched online for recipes that combined such foods or

where substitutions allowed the content of these two nutrients to be boosted.

Doing the research

Both recent Master’s graduates in nutrition, their help and enthusiasm

made this work so much easier. I know – I did much recipe testing after

they left and doing it alone was hard! We researched ingredients,

calculated the nutritional content of recipes, and made careful notes

during testing.

Claire Malseed and Jennifer Isautier arrived to volunteer at DGS just

as I was starting to research recipes. Such luck!

DESIGN IN ACTION

They might have been nutritious

but not all the snacks I made went

down easily! My goal was to select

two sweet and two savory snacks

and I was surprised by how much

work, at every stage, that was. So,

it wasn’t just the toil in the kitchen,

finding a way for DGS staff to

provide honest feedback was also

a real challenge. It took three

rounds and the simplest, most

obvious methodology to get it right

(I think).

Cook-Sample-Survey-Repeat

Weigh, soak, wash, grind, mix, shape, cook...whew

Did you like it?

It is hard to cook up a bunch of cheap, nutritious, tasty, and easy-to-make finger foods, but it

was nothing compared to the difficulty of designing a good survey. My first attempt was naïve!

I used a range of sad to happy faces and found myself explaining what the faces represented to

every person who sampled the snacks. No, I wasn’t going to use this format again.

Did you like it?

In my second attempt, I replaced the faces with nine short “yes/no” statement s such as “It

looks very good to eat” (appearance), and “It tastes very bad” (taste). I think it was still

confusing. Staff turnout was low at the tasting table and all that effort was worth it only

because a group of women from the community were at the Tadiwala Road office attending a

meeting.

Did you like it?

In my last attempt, I either was exhausted

or had finally wised up. I just put two

questions to each sampler – “which snack

did you like best?”, and “which one was

your second choice?”. There was no

confusion now – everyone easily compared

between the three and picked their

favorites. I also got very good turnout. Many

wanted the recipes, which I took to be a

very good sign.

Ok, now it’s your turn.

I now had two sweets (ladoos) – wheat and peanut, and millet, flax, and coconut, and two

savories – chickpea burgers, and soy burgers. It was time for recipe sharing. Ranjana Bhosale,

the team lead for the crèches assigned four staff members to this training.



At the end of the day’s training, I also had 400 gram

samples for each snack ready to take to the laboratory

for a protein and iron analysis.

LOOKING AHEAD

Although the snack supplementation

program was technically supposed to run for

six months, I wanted to make sure DGS had

a plan to make it permanent if they liked the

results. I turned to staff at all levels of the

organization to brainstorm responses to this

question.

Three sessions and 45 participants later, we

had three possible routes to take. I left this

plan with the team leaders, encouraging

them to select the best one (or variations

thereof).

Realistically, I don’t expect this plan to

progress past six months in its current form.

But, I believe that this exercise is in an

opportunity for staff to learn about

brainstorming.

Let’s brainstorm.

raw

materials

funds

labor

Professional

cooks

Women’s self

help groups

DGS staff

& friends

Snack Program

Track nutritional

standing, height, weight,

and hemoglobin count,

then compare to the

World Health

Organization standards.

The brainstorming output: three solutions.

3 potential models

outcome

THE PRE-IMPLEMENTATION

MEASUREMENTS

I wanted to share a powerful story with

the self-help groups so they would be

excited about the production of ladoos. I

wanted them to know that these snacks

are tasty and (we expect) have a

measureable positive impact if

consumed everyday.

Researcher Veena is confident that the

six month snack implementation program

will show results. So I scheduled height

and weight measurements sessions. It

took three tries to get it right—but we’ve

been able to establish base-line

measurements for the children.

We are also doing basic blood tests on

the children. We had a minor set back

with a less than expert phlebotomist, but

these measurements are now underway,

with the direct oversight of Dr. Prakash.

Taking baseline measurements for the study

Measuring heights and weights is trickier than you think.

In the first round of height weight measures, we used a simple analog weighing scale and a

tape measure. This was the equipment at hand, but I worried that the measurements were not

fine enough to note small changes that might be attributable to the snack program. The

equipment definitely had to change.

Measuring heights and weights is trickier than you think.

In the next round, we upgraded our equipment – a digital bathroom scale and a wall-mounted

stadiometer, partly funded by DGS volunteers and friends. But although we didn’t know it, we

weren’t quite there yet. We measured over 200 children in this second round as well.

You never know what you’ll get if you ask.

It sometimes pays to be that pesky question-asker. I sent so many emails to Veena over the last

six months that when they announced the workshop on measurements to assess pediatric

nutritional status, I naturally got invited. It was a Sunday excellently spent. I learned good

measurement protocols.

Measuring heights and weights…the right way.

The first order of business: purchase 1, 2, and, 5 Kg weights to calibrate the digital scale before

every weighing session to ensure that the reading it provided matched the known weight of the

object. The second order of business was to (a) position the child correctly on the scale, and (b)

take two successive readings (three if the first two weren't exactly the same).


It helped that we had secured the crèche team lead’s presence because it would have been

difficult to explain to the crèche teachers why we were back to disrupt normal proceedings! We

were in the summer by this time, so measured only 156 of the 270 children enrolled.

Nonetheless, we got a good baseline sample of weights that I have confidence in.


This little stadiometer presented a few frustrating moments which I’ll cover in the “reflections”

section but I was glad we had it. We quickly got the hang of mounting it, correctly positioning

the children gently but firmly, and taking two (if the first two were exactly the same) or three (if

the first two didn’t match) successive measurements. If we took three, we recorded the median

height for the child. All measurements were also entered in the children’s health cards.

The weight-for-age measure provides an indication of nutritional status. Low weight-for-age indicates moderate to severe malnutrition. We plotted the final round of measurements using WHO’s AnthroPlus program which compares the population to the median. This plot appears on the following page.

The red line curve shows that about 1/8th of the 156 children (19) are severely malnourished, that is, more than three negative standard deviations from the median (http://www.who.int/nutrition/topics/severe_malnutrition/en/index.html).

Almost 1/4th (43 of 156) are moderately malnourished, i.e., between 2 and 3 negative standard deviations from the median (http://www.who.int/nutrition/topics/moderate_malnutrition/en/index.html ).

Comparing DGS children to the WHO standard.

http://www.who.int/nutrition/topics/severe_malnutrition/en/index.html

http://www.who.int/nutrition/topics/moderate_malnutrition/en/index.html

Comparing DGS children to the WHO standard (weight-for-age).

Many of the severely malnourished

children are likely already part of

DGS’s special nutrition program, but

this effort acts as a prompt to re-

examine and refer these children as

needed. Changes to the nutrition

status, post-supplementation, of

these children will be of particular

note.


I also visited a few of the local Tadiwala Road women’s self-help groups to gauge their

reaction to the project idea…with a bowl of ladoos. One group already supplies meals to the

local school under government contract. They’re interested but savvy enough to ask what

support DGS will provide in getting them started. This work will occur in the second phase of

this project (starting August 2012).

REACHING OUT AND REFLECTIONS

Despite all that got done, by the end of April, I was quite

disheartened. Some of it due to the debacle of the blood

draws, some of it because the project didn’t seem to have

an in-house champion, but a lot from the realization that I

just couldn’t drive all the tasks myself.

Then I followed some very sage advice–ask for help. What

an idea! And I did – I went to a weekly team lead meeting,

refreshed their understanding of my role at DGS as DI

Fellow, elaborated on the project plan, and laid out the

specific asks to keep the work going. Suddenly, a lot got

done in a relatively short amount of time.

On the other hand, I also learned that sometimes, it is a lot

easier to just do the work. I also did some “jugaad” or work

arounds to keep on going.

Sometimes, you just have to do it yourself.

The stalwarts of DGS

Bismilla (lefy), Poonam (right), and Amrapali (not pictured) answered my biggest request. Team

leads identified them for the day-to-day oversight of the snack supplementation program and to

support the upcoming collaboration with select SHGs. They are committed, efficient, and smart,

and I believe represent the next line of middle managers at DGS. This progression is not the

norm at DGS but with a combination of mentorship and the independence to act, they could be

the start of a very successful policy for DGS.

Asking for leadership

My second request was to have team leads take responsibility for specific aspects of the

project. I handed off the hemoglobin measurement task to Dr. Prakash, and Ranjana stepped

up to offer reassuring leadership in both completing the height-weight measurements, and in

overseeing the recipe training session.

These later conversations with team leaders gave me good insight into how to get work done. In the

absence of better structure, many DGS volunteers simply take the initiative to start projects designed

to meet perceived needs. Often, staff treat these as temporary projects that aren’t officially

sanctioned.

The nutrition project was likely viewed in the same light and so it was very hard to get lower level staff

to provide help. As far as they were concerned my requests were for yet another non-significant or

short term project. This meant I often spent much time planning, managing, and implementing tasks

(largest to the slightest).

This is where, however, team leads come into their own. They are perfectly accustomed to issuing

task orders to lower level staff and lower level staff is equally accustomed to getting it done. When I

finally realized this, I began to funnel requests for help through the appropriate team leader. Life got

much less stressful after that!

Getting someone else to issue orders

Design Impact

Thank you for your time! If you have questions, please don’t hesitate to contact me.

Anisha Shankar, Fellow

anisha.shankar@d-

impact.org

www.d-impact.org

Documents

Urban Nutrition Program: May 2012 Update