Yoghurt and severely malnourished - Diarrhoea management    
Yoghurt&severely malnourished Michael Golden 27.08.98
Yoghurt&severely malnourished adults Janak Upadhyay 31.08.98
Re: Diarrhoea Management in for adults Heema Shukla 28.08.98
Re: Re: Diarrhoea Management in for adults D Stevenson 30.08.98
Diarrhoea Barbara E. Golden 01.09.98
Re: Yoghurt&severely malnourished adults Steve Collins 02.09.98
lactose and yogurt Andre Briend 04.09.98
Re: lactose and yogurt George Fuchs 20.09.98
Re: lactose and yogurt Nevin Scrimshaw 21.09.98

Date: Thu, 27 Aug 1998 10:47:52 +0100
From: Michael Golden <m.goldenatabdn.ac.uk>
Subject: Ngonut: Yoghurt&severely malnourished adults

To answer Steve Collin's last point about yoghurt in severe malnutrition.

YES - it does work well, and yes F100 can be made into a yoghurt as well as traditional HEM. It was used very successfully by Jean-Pierre Beau in Abijan, Cote d'Ivoire (a sophisticated city). He also reported that it worked well in HIV+ as well as patients malnourished without HIV.

In ACF it has also been used with some success but we have now abandoned the manufacture of yoghurt on site - the problem is the maintenance of the cultures (contaminated starter cultures requires a new culture to be brought in from outside, during which time there is a change in the protocol which is very disruptive), the maintenance of microbiological quality control when milks are being fermented under unhygienic conditions, the need to anticipate 24h in advance the volume required, the need for a "safe place" to make the yoghurt (most TFC kitchens are free-for-alls at some time -especially at night), the planning and degree & quality of supervision required, and the sheer extra work that it imposes upon the staff. In some situations it was not possible because of the environmental conditions.

In the Scientific Committee of ACF we have tried to get freeze-dried lactobacilli that could be added to the F100 powder so that it only needs to be incubated to make yoghurt - so far we have not succeeded because of the storage conditions of the F100 before it used (needs to be viable for up to a year, to withstand being stored in a closed metal container in tropical temperatures for weeks or months where temperatures can be very high, and then to be able to "outcompete" the local bugs when it is made up - most of the Lactobacilli people deal with temperate or factory strains that make cheese or yoghurt etc) - and we would still have the problems of quality control etc that we had with home-made yoghurt. Unfortunately, the bacteria used by the pastoralists in Africa to make their traditional yoghurt in gourds all seem to be mixed cultures of several organisms that have been viewed with scepticism from a safety point of view. I think that there is a lot of help that the milk microbiologists could give - but we are not at that stage yet.

We have also explored the possibility of making the F100 into yoghurt under industrial conditions and then spray-drying it - that would be the ideal solution. The advice that we have had from the manufacturers of F100 is that it would increase the price to an unacceptable level. I have asked one manufacturer if they would be prepared to produce a test-batch, nevertheless, so that we can field test the product against conventional F100 to see if indeed it does reduce the prevalence of diarrhoea etc, decrease time to minimum weight, be less damaging if inhaled etc. - the problem here is one of scale - for the spray-drying tower to be switched to a new product (instead of DSM/DWM etc) there needs to be an absolute minimum of 10,000 kg to make it viable (even then the losses are considerable at the beginning and end of a run and the tower is out of commission between products for quite some time - so that 50,000 kg is much more viable) - this then leads us to a catch22, we need a test batch of say 2 ton to properly evaluate whether it is a clinically better product - but cannot afford to pay for 50 tons at an increased price to do the experiment! (it would be better with F75, but the quantities purchased and used are simply to small at the moment - but we could do the experiment with a few hundred kilo)

I, like you, am convinced that it would make a far superior product and we would bring the management of severe malnutrition and persistent diarrhoea very much closer together - the patients are almost the same when they present and get totally different treatment depending upon the training and interests of the staff they happen to meet. Perhaps with donor and manufacturers support ACF will be able to get a "test-batch" of spray-dried yoghurtised-F100/ F75 for proper field testing.

On another point - in malnutrition it is the absorptive "capacity" that is reduced - there is even a lower rate of absorption of 5%glucose!
I am against endless dilution of the diet because of the problems of deliberately underfeeding the starving at a theoretical level and at a practical level the staff learn that this is the way to manage the patients.

When you dilute to isotonicity (or slightly below - say 260 mOsm/l - see Olivier Fontain's paper on hypo-osmolar ORS), there is an impeccable rationale for this, which we have addressed with the new F75 and F100 formulations, further dilution however is not necessary. If the feeds provoke diarrhoea then I suggest that the QUANTITY at each feed is reduced (say to half or one quarter) rather than the concentration reduced to half or one quarter - in terms of the gut transport systems this is equivalent - however there are great advantages in this approach. It make it visibly clear to everyone that less is being given and the staff are not lulled into a sense of false security that "enough" is being given because of the "normal volume"; it allows you to use one product for all instead of having several different diets which are easily confused at both the kitchen and phase level one-with-another in the setting of an emergency TFC, and it makes organisation and staff-training much less difficult; and, most important, it then leaves you with the option of increasing the frequency of feeds to get the required amount in - an option which you deny yourself with the dilution tactic.
Now, I understand that in a severe emergency with few staff and 300 patients increasing the frequency may not be an easy option either - but it is not more difficult than having a series of different feed dilutions that have to be correctly given to the correct patients. We have, in the past, given 12, 18 or 24 feeds per day (so that the amount presented to the gut at any one time is reduced) successfully (this is organised by giving 2 or 3 separate feeds simultaneously at each "feed-time" and the caretakers keep the second/third mug for two/one hour and give them between the regular feed times - this saves a lot of work and is easily organised) .
When this does not work we have put down an ng-tube and dripped the F75 into the intestine continuously which really does take the stress of having to absorb a whole bolus from the gut at one time (works much better if the ng-tube is through the pylorus). The main problem we found with this technique was bacterial contamination of the gi-infusion equipment so I do not recommend it in TFC type situations unless there is absolutely no alternative.

There was an interesting technique describes some time ago of putting the feed into a balloon and allowing the elastic tension on the balloon to "infuse" the feed slowly - I have no experience with this technique and so cannot comment further - perhaps those who have used it could comment.

Sorry the comment is so long!

Peace and love.

Prof. Michael H.N.Golden
INTERNET m.goldenatabdn.ac.uk Dept of Medicine and Therapeutics
Univ of Aberdeen, Foresterhill
AB9 2ZD. Scotland, (UK)
Tel(direct) +44 (1224) 663 123 527 93
Tel +44 (1224) 681 818 ext 52793/53014
Fax +44 (1224) 699 884

Date: Mon, 31 Aug 1998 14:19:48 +0200
From: Janak Upadhyay <UPADHYAYatunhcr.ch>
Subject: Ngonut: Yoghurt&severely malnourished adults

Dear all,
I wonder why are we advocating milk based product for diarrhoea management for adult when a substantial percentage of the non-Caucasians adult could be lactose intolerant. As Dr. Golden has pointed the difficulty of providing yoghurt in the field situation, perhaps some short of porridge (which is low in protein and of right texture) could be the solution, of course not excluding ORS and other medical treatment. Pardon my naive comment. We will be grateful to receive reaction from the experienced colleagues in the field.
Janak Upadhyay
Food Unit
UNHCR, Geneva

Date: Fri, 28 Aug 1998 15:14:12 +0100

From: shuklahcatsbu.ac.uk (Heema Shukla)

Subject: Ngonut: Re: Diarrhoea Management in for adults

Dear Janak

You have rightly raised an important issue about milk-based product for management of diarrhoea in a population where majority of the healthy adults have primary lactose intolerance. The situation may be further aggravated by secondary lactose intolerance due to malnutrition and infection.

Mike has discussed the use yoghurt, but has anybody used lactose hydrolysed milk-based product?

Dr Heema Shukla

Food and Nutrition Research Centre

School Of Applied Science

South Bank University

London SE1 OAA

email: shuklahcatsbu.ac.uk

Tel: +44 171 815 7954

Fax: +44 171 815 7999

Date: Sun, 30 Aug 1998 11:54:10 +0100

From: D Stevenson <dsatholyrood.ed.ac.uk>

Subject: Re: Re: Diarrhoea Management in for adults


Yoghurt and similar fermented milk foods are widely used in countries where lactose intolerance is believed to be prevalent. Does conversion of milk to yoghurt remove enough lactose (or convert it to organic acids - which may still appear in analyses as "carbohydrate") to remove the problem ? Or is another factor in yoghurt protective ? (Or have I got it wrong ?).


David Stevenson, Public Health Sciences, University of Edinburgh

From: "Barbara E. Golden"

Subject: Ngonut: diarrhoea

Date: Tue, 1 Sep 1998 11:11:52 +0100 (BST)

Steve did not use F75 in Somalia: he used a 'simpler, home-made' formula that appeared to induce temporary but vicious diarrhoea in many severely malnourshed adults. In those circumstances, with frequent watery diarrhoea, he did the only thing possible, he gave ORS and as much of the feed as they could tolerate - but he gave them together ie as diluted feed. He could have given the same thing as separate ORS & feed. What you're suggesting, Mike, comes earlier BEFORE the patients develop feed induced diarrhoea & dehydration. But, I think you say, your patients don't develop feed induced diarrhoea!

My question is, Was this because the home-made formula was imbalanced/lacking in some way, and if so, how? - over to you, Steve!; or, given their poor gut function, was it because the initial feed wasn't given in sufficiently small, frequent aliquots?

Best wishes,



Barbara E Golden BSc MD FRCPI MRCPCH DCH Dept Child Health, University of Aberdeen Medical School, Foresterhill, Aberdeen AB25 2ZD Phone: 01224 681818 ext 53894 Fax: 01224 663658 b.e.goldenatabdn.ac.uk

Date: Wed, 2 Sep 1998 18:17:35 -0400
From: Steve_Collins_at_po330a01atsmtplink.unicef.org (Steve Collins)
Subject: Re: Ngonut: Yoghurt&severely malnourished adults

Thanks for the info on the yoghurt. Here in the DPRK as I understand it there is a dired milk factory which is at present lying idle..I wonder whether, given the very high incidence of diarrhoea and the cultural acceptability of yoghurt, it might not be a bad place to pursue the idea further...I'll look into it.

On your other ponts re diarrhoea and dilutions. I fully accept your rational about not dluting milk below isotonicity in order to prevent osmotic diarrhoea, togehter with the importance of increasing the frequency of feeding to reduce the load on the intestine.... now with the low osmolarity F100 or the F75 I can see that multi dilutions are even less desirable. So for the purposes of protocols and teaching the message should be loud and clear that maintaning food intake is essential. However in Somalia we had no access to patients between 5pm and 8.00am and maintaining hydration was a real problem as the motivation of the night staff wasn't all that it could have been. The appearance of severe life threatening diarrhoea in a most of the patients started on this milk (whilst at the same time they all reported feeling much better and having increased appetites) necessitated radical action. During the first few days I tried to treat the patients with only minimal dilution and plenty of ORS but after a death from dehydration in a young man with good appetite, apparently well and who was drinking as much ORS and milk as he was offered, another oedematous patients who lost fifteen Kgs in a few days!!! (rather faster than the 1/2 Kg / day I was aiming for) and a couple of near misses that required abrupt IV hydration when we arrived in the morning, I realised that something else was needed.
The dilution technique didn't necessitate the preparing of different milks as the dilution was performed by the attendant as they gave the milk out. They quickly understood that they were to dilute according to the severity of diarrhoea and this message appeared to be often reinforced by the patients who would push for dilution when they had diarrhoea and were thirsty.
In Somalia where more than 6 - 8 feeds / day were not feasible and there was only home made HEM I think that the dilution technique was a valuable tool which should not be ruled out in other cases where the situation is unusual. In simple diarrhoea in malnourished adults (I'm not talking about children), in an enviroment where diarrhoea is common, death from dehydration is a real risk, whereas as re-feeding more slowly during the initial phase of treatment has not in my experience obviously caused many problems. Usually I have found that once adult started on the milk and regain appetite there are few hitches save for diarrhoea and dehydration. Note this is not true in situation where oedematous malnutriton is very common in the abscence of diarrhoea where heart failure can be a real problem.

I think that the important point here is that protocols and teaching according to them are essential but they cannot be tailored for every eventuality and there is a great need for common sense if the situation demands it.



Date: Fri, 4 Sep 1998 11:11:17 +0200
From: briendatext.jussieu.fr (Andre' BRIEND)
Subject: Ngonut: lactose and yogurt

Dear NGOnuts,

Some comments re: lactose and yogurt; It happens I have colleeagues here working on that topic which I often discussed with them.

Lactose content is only slightly decreased in yogurt compared to unfermented milk. This decrease of the lactose content is not enough to explain the observed better tolerance of yogurt. Several explanations have been suggested.

a) persistence of lactase activity in vivo.

There are several studies suggesting that bacterial lactase activity remains active in the gut after absorption. In a way, it might replace the lactase produced by the gut in lactase deficient subject.

b) mechanical property of yogurt

An other important factor is the change in physical properties of milk after fermentation. Cow's milk contains mainly casein as source of protein which precipitates in the stomach as a result of the low pH. The liquid phase, containing high concentrations of lactose is fisrt quickly emptied from the stomach, surpassing the gut capacity for lactose digestion in lactase deficient subject. Fat + casein are then slowly relased. Yogurt apparently behaves differently, and is emptied from the stomach in one phase, casein, lactoserum and fat together. The result is that lactose comes much more slowly into the gut, resulting in a better digestion. By the way, the better tolerance of breast milk compared to cow's milk might also be related to a different casein lactoserum ratio presumably avoiding this rapid initial gastric emptying of lactose rich liquid phase.

In collaboration with Nutriset, we have attempted to improve the digestion of F100 by changing its mechanical properties in order to mimic the physical properties of yogurt. This was tested in adult volunteers here in Paris; In fact, the idea was dropped, in particular because we found that gastric emptying of F100 is very slow, presumably because of its high energy content, and well tolerated by lactase - subject. When F100 was given to adult lactase deficient subjects, they reported no sign of intolerance.
Altering F100 physical properties to improve lactose digestion seems to have little practical advantages. These conclusion might not apply to lower energy density milk products; The effect of very high viscosity of expermiental F100 like solid diets (Plumpy nut, I don't know if there is lactose in BP100) has not been tested, but it is not impossible that they improve lactose digestion. To be further explored.

As mentioned by Mike, the prospect of using yogurt in food aid programmes always retained attention. So far, however, there is little evidence of its effects on diarrhoea, recovery and so on. JP Beau has used successfully yogurt to treat severely malnourished children for years, but never compared its efficacy to non fermented milk. WHO does recommend yogurt in case of persistent diarrhoea, but to my knowledge, this recommendation is based on only one study. Clearly, more data and research are needed in the field.

Dr. Andre' Briend

Date: Sun, 20 Sep 1998 13:12:16 +0100

From: George Fuchs <gfuchsatcitechco.net>

Subject: Re: Ngonut: lactose and yogurt


Dear NGOnuts,

I have just returned home and have been reviewing the discussion about lactose intolerance with interest. Some good points have been raised about lactose-yogurt. In addition, there seems to be some confusion by some in this discourse between lactase deficiency and lactose intolerance. Lactase deficiency is not necessarily an "all or none" phenomenon. While some degree of lactase deficiency is extremely common among certain populations (for example, as diagnosed by lactose breath hydrogen testing), many and perhaps most of those with some lactase deficiency are quite tolerant and even asymptomatic with dietary lactose. In such cases, at least in young children, there is even "colonic salvage" of much of the malabsorbed energy (i.e. related to malabsorbed lactose). Sorry if this comes too late in the discussion to be of much use.


George Fuchs

Date: Mon, 21 Sep 1998 09:42:24 +0100

From: "Dr. Nevin Scrimshaw" <nevinatcyberportal.net>

Subject: Re: Ngonut: lactose and yogurt


George Fuchs is quite correct. Even with both primary and secondary lactose malabsorption (due to loss of lactase activity), most individuals can tolerate small amounts of milk products. Dividing the dose or using yogurt products or adding the lactase enzyme increasing the amount of milk products that can be tolerated by those who are lactose intolerant by definition (Marked G.I. symptoms after consuming the lactose equivalent of a liter of milk without food). Moreover, with continued exposure to small amounts of lactose, tolerance increases, presumably due to a shift to more favorable colonic flora.

See our monograph published as a supplement to the A.J.C.N,.:

Scrimshaw NS, Murray LB. Acceptability of Milk and Milk Products in Populations with a High Prevalence of Lactose Intolerance. Am. J. Clin. Nutr. 1988, 118 (4) 1083-1159


Johnson, Semenya, Maciej, Enwonwu and Scrimshaw. Adaptation of Lactose Maldigesters to Continued Milk Intakes. Am. J. Clin. Nutr. 1992, 58 (6) 879-881

Ibid, . Correlation of Lactose Malabsorption, Lactose Intolerance and Milk Intolerance. Am. J. C;lin. Nutr. 1993:57:399-401.


Nevin Scrimshaw