|Therapeutic Milk : specifications|
|nutriset -Reply||Rita Bhatia||12.05.97|
|Re: Judith McGuire, Nutrition||David Alnwick||03.06.97|
|Nutriset, Therapeutic milk, F100||Michael H.N. Golden||03.06.97|
Date: Mon, 12 May 97 09:01:00 EST
I am looking for some input on the "theraputic milk" product by Nuriset.
I am unfamiliar with this product, but have been told that MSF and ACF are currently using it...
Does anyone have experience using this product? What are the advantages/disadvantages?
How was it developed (ie in conjunction with NGOs)?
Any comments on the micronutrient composition? Are there other similar/better products?
Date: Mon, 12 May 1997 19:45:01 +0200
From: Rita Bhatia <BHATIAatunhcr.ch>
Subject: nutriset -Reply
A lot has been done and a lot has been known about this product. ACF had done the field testing in Refugee and other settings. UNHCR UNICEF and most of the NGO have adopted this as policy to use this in Therapeutic Feeding programmes.
We don't call it Nutriset but Therapeutic Milk.
Andre Briend and Mike Golden are the Brains behind this.
It seems you are based in Nairobi. Please contact Veronique Genaille at the UNHCR office who will give you all the details.
It is an excellent product from Nutritional and Management point of view.
Rita Bhatia UNHCR Geneva
Date: Tue, 3 Jun 1997 19:37:16 -0400
From: dalnwickathqfaus01.unicef.org (David Alnwick)
Subject: Re: Judith McGuire, Nutrition
I had a frantic call from our person who does purchasing of food and related items in Copenhagen regarding specifications for F-100.
She had asked Nutriset to quote on a large order for F-100 using the WHO 1996 draft report, Nutriset had responded to say their product met criteria of the UNDP/IAPSO Emergency Catalogue.
I calmed her down, and said that the WHO report had not in fact been published, and that I thought that NUTRISET had it right - however:- when I looked at the WHO document, your EJCN paper, the UNDP/IAPSO piece and the packet labels of Nutriset and Compact products, I found small but important differences.
First of all, comparison is very difficult, because each publication uses different units of measurement and comparison - per 100kcal, per 100 grams, per liter of rec-constituted feed, or per liter of stock solution. Secondly, in your EJCN article you specified minimum desirable levels of ions for minerals, and then gave some 'examples' of how these could be met. This is fine for a scientific paper, but in the business of issuing competitive bids, maybe we need to be a bit more precise. What is your view on this? should we just tell the manufacturers, make sure you have xx mg of Zn 2+ per 100 grams, or shouled be be telling them that we want between xx and yy mg of Zinc sulphate hepatahydrate per 100 grams of final product. What about 'overages' of vitamins, I have learnt that with retinol, many manufacturers routinely add up to 150% of 'label specification' in order to ensure that the final product will have at least specified quantity - should we address this in a tender document, or leave to the whims of individual manufacturers.
The WHO document (albeit the proverbial draft) does not unfortunatly help much, it does not give a final specification for a pre-mixed F-100. The table which specifies mineral concentrations calls for a stock solution, which can then be added to a home made milk/oil/sugar mix, but this stock solution omits calcium for example (presumably because it is not very soluble).
Small things can become big issues when we are judging competing tenders from companies for orders worth millions of dollars.
Subject: Nutriset, Therapeutic milk, F100
Date: Tue, 3 Jun 1997 17:27:06 +0100 (BST)
From : Michael H.N. Golden
In view of Janet-Marie's request for information on "Nutriset" it might be worth briefly setting out the history of this product.
1) The background work for this product and the constituents was all done by various researchers at the Tropical Metabolism Research Unit in Jamaica over about 30 years.
2) In 1989 I developed a prototype which was used in Jamaica on a series of children in the Metabolic ward, with measurements of body composition and biochemistry of the major nutrient markers being made longitudinally during recovery. This prototype was then changed to reduce its calorie density to 100kcal/100ml but was otherwise very similar.
3) In 1991 IDECG sponsored a meeting on the management of severe malnutrition, which I attended. The second major draft of the resulting manual, which included the fromula, was accepted by WHO as its new guidelines on the management of severe malnutrition in 1992.
4) The formula was later presented by myself to a meeting of GERM in France and subsequently at a meeting of NGOs in Paris at Epicentre that was organised by Andre Briend. The proceedings of this latter meeting were then published by Briend (the meeting organiser) and myself in the Lancet and EJCN.
5) Nutriset, took the formula and started to produce it in pre-packaged sachets which they called "therapeutic milk", this was because the official name "F100" used in the (now) WHO/IDECG manual was not yet published.
6) Action Contra la Faim started to use the product immediatly and reported that it was a great success. Then ICRC, CONCERN and MSF started to use the product and similarly reported its success. So far over 300,000 children have been successfully rehabilitated with pre-packaged F100, and many more with the product made locally from DSM, Sugar, Oil and the vitamin-mineral mixture.
7) The formula has also been published in the Medical literature in English (Golden, M.H. Severe Malnutrition. In: Oxford Textbook of Medicine, edited by Weatherall, D.J., Ledington, J.G.G., and Warrell, D.A.Oxford:Oxford University Press, 1996,p. 1278-1296) and more recently in Andre Briend has translated this chapter into French for the Francophone countries. This chapter, as well as the unpublished WHO manal gives the rational for the ingredients in the formulae.
8) We have produced "specifications" for this formula for UNDP. the formula and specifications are in the public domain so that any manufacturer with the ability and qualioty control can produce it (the manufactured product contains the fat in a micro-encapsulated form - like coffee creamer - which gives a more satisfactory and easily mixed product).
9) The company Compact, in Denmark, has also started to manufacture the same formula so that it is now available commercially from at least two sources. Hopefully, manufactures in Canada and the USA will start to produce the formula for those NGOs etc that can only get funds "tied" to domestic producers can start to used these products.
10) the WHO manual is still not published (mid 1997) - however, Schofield and Ashworth have taken the main manual and used it to produce training modules (with minor modifications to one of the formulae) and popular articles.
So many years of research in Jamaica have gone into producing this formula which has been extensively field tested by Action Contre la Faim and laterly other NGOs. At last the research is being put into practice instead of simply filling journal pages.
F100 (the preferred name for the complete formula), "therapeutic milk" and the Nutriset and Compact products are all the same basic formula.
Incidentally, it has come to my attention recently that some facilities are mixing DSM, oil and sugar together (without the correct mineral/vitamin mix) and calling this F100 - this is NOT correct and the children will not recover adequately without the full formulation. Equally, we have seen that attempts to produce the formula "on site" in the kitchens usually leads to lower rates of weight gain because of the problems with quality control of the final mixture.
F100 is designed for the rapid growth phase of treatment.
There is a second formula - F75 - in the manual which is designed for the acutely sick child which has a lower osmolality, sodium, fat and protein content and a higher carbohydrate content than F100. It is marketed by nutriset under the name "Phase 1 milk".
Action Contre la Faim is routenly using this formula in its TFCs during phase 1 of treatment, and the data to demonstrate the advantages of this approach are being analysed at the moment.
Most other NGOs have not used the F75 formula because their advisors think that using more than one product is logistically complicated. However, all the nurses at field level where it is being used report that they see far fewer complications when the two-formula approach is used.
Prof. Michael H.N.Golden