|Plumpynut||Rafah S. Aziz||09.06.2001|
|Re: Plumpynut||S.K Roy||09.06.2001|
|Re: Plumpynut||Smita Ghosh||09.06.2001|
|RUTF (Plumpy'nut)||André Briend||26.07.2001|
Date: Mon, 9 Jul 2001 15:04:57
From: razizatunicef.org (Rafah Aziz)
Dear Michael and colleagues,
Greetings from Sudan
As you know malnutrition rate among children under five is high in Sudan. Areas hit by drought created an emergency within the chronic situation in the country.
Some NGOs have started using the product " Plumpynut" for supplementry feeding programmes.. We are seeking information on the use/marketing/availability of the product and how it would fit within the standard method of management of maluntirtion as per WHO module.
SAY YES FOR CHILDREN
Rafah S. Aziz, Chief Health & Nutrition Section
Khartoum - Sudan P.O. Box 1358
Fax : (249 11) 471126
Tel.: (249 11) 471835 - 37- 38
Mobile : 249-(0)12309412
e-mail : razizatunicef.org
Date: Mon, 09 Jul 2001 19:27:06
From: "Dr.S.K Roy" <skroyaticddrb.org>
Subject: Re: Plumpynut
can you send me the formula and daily supplemented amount.
GPO Box 128
From: "Smita Ghosh" <smita_ghathotmail.com>
Subject: Re: Plumpynut
Date: Mon, 09 Jul 2001 13:26:13 -0400
Dear Dr. Roy and Dr. Aziz,
I just did a quick search on Plumpynut and it is proposed to be used in therapeutic feeding by Unicef Angola and Ethiopia. It costs US$350,000 per year.
I would like to point out an email exchange a few months back between Dr. Andre Briend (CNAM, ISTNA, France) and Brita Schumacher (WFP, Guinea) on peanut milk? Is Plumynut a name given to that?
I am copying the email for details. I am curious
to know the difference and what is being used in the field.
Smita Ghosh, M.S.
Tufts School of Nutrition Science and Policy USA
A colleague of mine who works in health centres in east Guinea, West Africa, is frequently confronted with severely malnourished children who are not able to eat even mash. They are aware of the WHO recommendations but face the problem that milk products are not affordable nor available in the area concerned.
Due to this situation they started giving children between eight months and five years in the initial phase a what they call "peanut milk" made from 90 g peanut paste and 70 g sugar per one litre of water. The children receive six meals per day.
Still, they are uncertain about the appropriateness of this diet since they have not found any indication in the available literature and would thus like to have some professional back-stopping. Their queries in detail are the following:
1. Are there known experiences with "peanut milk" in the initial phase of treatment of severely malnourished children and is there written evidence on this (documents, reports, any kind of literature)?
2. Is there evidence on side effects of a peanut-based diet in this context or are these to be expected? (If yes: which?)
3. Should the peanut milk be cooked for a long time or only heated (regarding exploitation of nutrients, digestibility)?
We would be grateful if you could share your experience with us and give us your advice.
Date: Fri, 17 Nov 2000 11:52:23 +0100
From: "André Briend" briendaatcnam.frbriendaatcnam.fr
Subject: peanut based diet for severely malnourished children
Some comments to Britta's queries.
Peanuts are better than no food, or than a plain cereal based porridge with 90% water, but not ideal to be used in isolation for feeding severely malnourished children. Several reasons for that.
1- Peanuts do not have a good amino acid profile, and in particular have a low lysin content. As a result, they do not provide a good complement to cereal based diets in contrast to other legumes.
2- Peanuts have a very high phytate content, about 1% weight / weight. As a result, their phytate zinc ratio is very high, above 30, whereas a phytate zinc ratio above 15 means poor mineral absorption.
3- Peanuts have a high concentration of anti nutrient factors (this problem can be partially solved by using a spread prepared by cooked peanuts)
4- They may contain aflatoxin
5- They may induce allergy (although this is not usually reported in Africa, and may represent a minor problem compared to life threatening malnutrition).
In conclusion, if you feed a severely malnourished child with peanut only (or peanut + sugar) he will put on fat, and little else, because he will not get some key nutrients (Class 2 nutrient in Mike's classification) needed for lean tissues synthesis : balanced proteins + zinc in particular.
This is worrying because some lean tissues are very important for survival, in particular immune cells and muscle. Weight gain will be poor in relation to energy intake because synthesis of fat tissue requires much more energy than lean tissues.
Having said that, peanut used in combination with other foods may be very useful. You may have heard from previous NGOnut contributions about the Ready to Use Therapeutic Food (plumpy'nut) which contains peanuts and apparently gives very good results in terms of weight gain, comparable to WHO F100 (of which it is a copy in terms of nutritonal formulation). The difference, however, is that RUTF contains a lot of milk proteins, which balance the amino acid profile. Moreover, it is highly fortified with zinc and other minerals and peanut makes only a small part of the product (about 25%) and as a result, it has a very low phytate/zinc ratio. Incidentally, this food is very well accepted by children and is eaten without addition of water. Bacteria cannot grow in it which makes this food safe for community based treatment of severe malnutrition.
Now what can we do for children in Guinea ? Ideally they should receive the WHO recommended diets (F100 and F75) especially if they have a poor appetite at the beginning of treatement. I understand this is not possible.
Another alternative would be to improve the peanut based diet propsoed by Britta. This can be done by mixing dried skimmed milk with groundnut + sugar to improve the amino acid profile and add minereals and vitamins. Is it really not possible that WFP gets some powdered skimmed milk in Guinea to try this approach ? This would be surprising. If DSM is really not available, the amino acid balance could also be imprioved by mixing groundunt with soy flour. This is not ideal because soy has a high phytate content, but this should be an improvement. Minerals and vitamins should be added too (not the same mix). I suggest the resulting diet should be given directly, without addition of water, to take advantage of the absence of water in the resulting spread and keep it resistant to bacterial contamination.
For your information, Nutriset, the company which developed RUTF and produces it commercially (and for which I am a consultant) would be ready to help any NGO interested in developing a locally produced spread-like food derived from the RUTF recipe. This local appraoch is not yet field tested, and interested NGO's should be ready to accept a road with trial and errors.
Some ingredients and processes used during the industrial preparation of RUTF are not easy or impossible to transfer at the local level and the resulting product will not have the same taste, will have a shorter shelf life... but it might help.
I believe that this innovative approach should help us to move away from the traditonal TFC / SFP programmes, which seem little effective outside the emergency setting (and even then are far from ideal; see previous mails from Steve). Looking forward to getting feedback from interested innovative NGO's.
With best regards,
Date: Thu, 26 Jul 2001 13:57:26
From: "André Briend" <briendaatcnam.fr>
Subject: RUTF (Plumpy'nut)
A few comments about plumpy' nut following the mails that came up recently on ngo nut.
As pointed out by Smita Ghosh, I already commented about this product on a previous mail to NGO nut that he copied in his last contribution. I copy again the relevant part at the end of this mail.
Plumpy'nut is a ready to use therapeutic food (RUTF). The idea is to copy the WHO F100 formula but present it in a different physical form. In a nutshell, p'nut is a spread that can be consumed directly by the child whereas classical WHO F100 is powdered milk-based food to which water must be added before use. The advantage of this spread is that since it does not contain any water, bacteria do not grow in it. It can be recommended for home based rehabilitation of severely malnourished children without any worry regarding bacterial proliferation. This is very valuable in unhygienic situations.
Plumy'nut is commercially produced by Nutriset in France (nutrisetatnutriset.fr, for which I am a consultant) and is the only widely used ready to use therapeutic food so far. It contains about 25% peanut butter, but a similar product without peanut can also be obtained in countries where peanut allergy is a concern. I also heard that Compact is now developing / testing a modified version of BP5 which could be used as RUTF.
RUTF are designed to treat severely malnourished children. There is no risk in giving RUTF to moderately malnourished children, but these products are still expensive, and it is highly recommended to restrict their use to those who need it most. A promising approach is to use it in communitiy treatment centres (CTC) as discussed by Steve Collins (Valid International) also on ngo nut a while ago (I cannot track his E mail on CTC but Steve might come back to Ngo nut to give the latest infos on this topic). CTC is quite different from classical supplementary feeding programmes where large quantities of food are given to moderately malnourished children.
The whole idea about the ready to use therapeutic foods (RUTF) is to have a treatment for severe malnutrition which is more sustainable than the now recommended WHO protocol. In brief, the WHO protocol is efficacious, but very labour intensive. In a typical emergency therapeutic feeding centre caring for 100 severely malnourished kids one needs a total staff of about 40 people to follow the WHO protocol. The number decrease in non emergency situation when there are less patients, but the ratio staff / children must be high to implement the WHO protocol. No surprise this is very expensive to run and cannot be sustained on the long term in many situations. The use of RUTF should make possible to use in-patient care only for the acute phase for a few days, having the +/- 3 weeks rehabilitation phase taking place at home, reducing dramatically the need for staff/ cost and stress to the family.
The use of RUTF is new and still under evaluation. Protocols for home use are not yet standardised. Yet, feedback from the field about p'nut is that it is very well accepted by children and as efficacious as WHO F100 to promote weight gain. Indeed it is increasingly used in places where the use of the standard WHO protocol cannot be implemented for whatever reason.
I hope this helps.
André Briend, MD, PhD
U 557 INSERM (UMR INSERM/INRA/CNAM)
5 rue du Vertbois,
75003 Paris, France
tel : 33-1-53 01 80 36
fax : 33-1 53 01 80 05