Should Commercially produced or Home-based Ready to Use Therapeutic Foods (RUTF) be used to treat Severe Acute Malnutrition
Dear Colleagues
This topic has come up for discussions following a recent article published by Dr Prasad and colleagues against “The current thinking – that a centrally produced and processed Ready-to-Use Therapeutic Food (RUTF) should supplant the locally prepared indigenous foods in treatment of SAM in India". This according to the authors would ignore the multiple causes of malnutrition and destroy the diversity of potential solutions based on locally available foods.
According to the paper, Plumpy Nut produced by Nutriset in France is being imported by several states in India for the treatment of SAM and there is a proposal to make it the “prescribed treatment” for SAM.
However there are many locally produced/producible foods that are culturally acceptable and relatively low cost and have been used for SAM in India for many decades by reliable academic and medical institutions as well as by non-governmental groups.
We believe this is a very important and stimulating topic for us to discuss in a wider forum. There are some of us with experiences to share as well. Let us know what you think regarding this topic by adding your comments.
Download the full artitcle.
This document is what Stephane Doyon referred to in her comment and sent to us.
Hello!
A short introduction of myself. I'm currently completing a master course on human right to adequate food: I'm not a nutritionist, my professional background is rather in health economics and in health system development. So I would like to apologise in advance if my questions seem maybe somehow "uninformed".
For this master course I'm looking at the debates around RUF and RUTF in child malnutrition prevention. I'm also looking at the specific case of Niger, a very different situation than that of India. Niger has in a sense been a "laboratory" on the subject.
I've read with great interest all interventions in the debate on this site. It seems to me that three issues emerge from this debate and others on the subject for which I would greatly appreciate your views.
1) The possible need to produce guidelines and maybe a code of conduct with regard to the use of RUTF in preventing moderate acute malnutrition. How and where a dialogue on this issue could be held? Do you see it as a pressing objective to achieve?
2) Local control. While in Dr Prasad's & colleagues' position paper it is clear that local control is a reality in relation to RUF and RUTF in India and should be supported and documented more widely, I would be interested to know your opinion about the prospect of supporting similar approaches in Niger. Are you aware if the national or even sub-national authorities in Niger are involved in a debate or dialogue about local control over the RUTF strategy for MAM? Are you aware of processes in which the population benefiting from the prevention and treatment protocols are involved in defining their perception and solutions for progressively ending malnutrition?
3) A significant portion of the debate around the use of RUF and RUTF for malnutrition prevention highlights the risk of breastfeeding displacement. Dr Prasad and colleagues highlight the fact that there are too few studies comparing Plumpy'nut with locally produced SAM, the same holding true with regard to comparisons between Indian locally produced complementary foods. Are you aware of existing studies (or ongoing, or forthcoming for that matter) comparing Indian locally produced supplementary food with improved BF practice and studies comparing commercially produced RUTF with improved BF practice?
I'm looking forward to your valuable comments.
Best regards. Caroline
Comment by Caroline Knepper — 2009-05-16 15:57 | # - re
When we see a coin on a table from above, we might think that it only has two dimensions, only one face. But if we take it in our hand we realize that it has indeed another face, and that uniting those two faces there is an edge. If we use our hand to turn the coin in both directions we get to contemplate the two faces and the edge, the depth. But a coin without a context is nothing but a piece of metal. A coin is a symbol of the wealth, the currency of a given country, and then of the economic system as a whole.
We could do a similar analogy to child malnutrition in general and SAM in particular. Malnutrition is a symbol, a sign and symptom of a disease that the body of our humanity suffers.
When a patient goes to a doctor for consultation, the physician not only asks for symptoms, checks for signs and prescribes a treatment to ail them. A doctor would try to seek whether those manifestations are indeed associated with a syndrome or a disease that may have not been diagnosed yet. A patient not only needs relief to pain and other symptoms, a patient needs to know whether those symptoms mean something else. We need to ail the symptoms of malnutrition, we need to help those children that are now malnourished to recover their nutritional status as soon as possible, regardless the circumstances that prompted it. But we also need to study “the patient” better; we need to analyze the systemic disease that our humanity has, and that includes the local, cultural and global contexts; though we already know many things about the possible syndrome that our planet is suffering from.
We need immediate solutions for some symptoms but we need to be careful so those remedies do not hide the wider context. An ailment is not a cure for a disease. We need to embrace a more responsible approach to ensure that “the patient” gets a general check up and that a change in the way of living, the habits (including dietary), attitudes, and even emotions achieve a better systemic coherence.
This is an invitation then to take the coin in our hands so we all start to see its two faces but also the edge that unites them.
We need to achieve results, yes; but sometimes we think that performance indicators are the only way of measuring success. We need to start to have other additional ways of diagnosing, reporting and “measuring” other aspects, other faces of the coin, that need to be considered and embraced if we want to be more systemic in our approach in walking towards a sustainable healing process of our humanity, and finding ailments to the symptoms and hidden causes of the malnutrition problem. And we need to do this with a deep concern and respect for the immense cultural diversity, local circumstances and world views that co-exist in our planet.
Comment by Daniel Gallego — 2009-05-08 15:15 | # - re
The debate is good and the replies by those with field experience are very useful. I feel that looking at social issues, economic issues, moral issues and cultural sensitivities are important in solving the world's problems. No technical fix will work in a failed system. We need to support the good in the Indian system. I hope Leena will withdraw unscientific terms like "False Debate" and comments like "At the end the debate raised by Mr. Prasad is a false debate".
Otherwise one agrees that first India must decide to solve the problem and that those in arm chairs who quibblie over the question as to what India will use for the therapeutic treatment of SAM children will not really help.
Comment by Prabir — 2009-05-05 15:22 | # - re
Dear all those engaged in the debate on SAM,
I have not been privy to the conversations happening on the IMTF, but since some communications refer to me, the position paper and the ‘Hyderabad meeting’ quite selectively, I feel constrained to respond, just to put some records straight. Obviously the debate is not ‘false’, if so many are spending their valuable time on it, and I value the perspectives that have been placed on board even if I do not necessarily agree. I am avoiding the technical and management related details of why the scaled-up use of a plumpy nut prototype RUTF is problematic in India since it would require too many words but I would be happy to share them at other non e-group fora. We are all greatly concerned that children are dying needlessly of hunger and malnutrition. For us, SAM is the tip of that particular iceberg. There are lakhs of children dying indirectly or directly from hunger and malnutrition – a huge 46%, and we have been advocating for a comprehensive package of care, health care and food support for children under six for some time. We have also made very specific recommendations for comprehensive services for children under two as referred to my colleague by Mr Biraj Patnaik. The management of SAM is, for us, part of that package and RUTF one element within that package. The figures of 20 – 30% SAM seem inflated and one would like to know the source since India doesn’t have a way of measuring SAM as it is defined by the WHO. They are very likely to be correct for some pockets where overall malnutrition is also likely to be extremely high. UNICEF places severe malnutrition at about 5% in India and all the presentations in Hyderabad placed it at about that too. Dr Briend places SAM in India at about 3% if I remember correctly. This is not to say that we should not be concerned or defend inaction for SAM. There is no need for inflation to be able to say the situation is very bad. We are saying it is worse; we want recourse for 75 – 90% poor children who have malnutrition (read hunger), not just 3-5% children who have SAM. We have been consistently arguing for better services for the children of this country as part of their rights. Therefore, we consider it somewhat facetious, small hearted and unethical to speak only of children suffering from SAM.
The argument for giving priority to SAM is that these children are at the highest risk of mortality. Here too, India has some peculiarities. India has very high rates of malnutrition and relatively low rates of mortality (the South Asian Enigma) and Indian children tend to live sadly with malnutrition than die of it as compared to Sub Saharan children. Child deaths tend to come from all ends of the malnutrition spectrum in our experience, and we would value further studies on this. Furthermore, if mortality is the prime concern, the maximum number of children die during the neonatal period – not subject to recovery using RUTF type strategies. This, again, is not to say that the situation of SAM should not be deplored
For children under two and malnutrition, – care and care giving is the essential issue in combination with access to food (one of the hypotheses for the South Asian enigma). Thus, the best food supplement is pretty useless in the absence of care, yet if care is taken, a not- so- good food supplement (in terms of calorie density) would certainly save lives. In the context of setting policy, there are always choices to be made and they are not as black and white as implied by some. Universal and comprehensive services for all poor malnourished children ensure there is little slippage into SAM, and we see no sense for a strategy to start at the wrong end of the spectrum.
We also feel there are severe limitations to handling SAM merely as a biomedical condition and not catering to its roots. The best parallel we can draw for RUTF’s relationship with SAM is that of Packet ORS to diarrhoea; both are potentially life saving, both have the potential of displacing community based alternatives, both need comprehensive systems within which to be effective and, as seen with ORS which has been used for years – overall impact is simply not seen without the systemic and socio-economic strategies in place.
The only way in which a community based RUTF programme specifically for SAM can work, is when it is housed in a comprehensive programme for all children with malnutrition. Thus, we have requested all those passionately demanding RUTF for SAM to speak of the entire set of strategies and position SAM logically within those.
To come to the issue of the position paper specifically – any one who has actually read the position paper would see immediately that all it is saying is that locally available foods should be explored and local recipes should be researched. It is far simpler to find an ‘ideal’ product and transplant it to all corners of the world, we know, but – in our experience, and in our understanding as public health and community development people, we need to factor in local control, support to local livelihoods, agriculture and local economies, as well as sustainable availability and cultural acceptance. Otherwise we make mockery of community partnership, decentralisation, social determinants etc as just buzz words to be bandied about at Alma Atas, but conveniently forgotten when it comes to the crunch of taking top-down action. We have chosen the issue, we have chosen the strategy, we have chosen the standard and we have chosen the product which comes with a pre decided mode of production …we have decided that other alternatives cannot live up to the standard thus they are not true alternatives.
It is ridiculous to throw at the authors of the position paper that there is no evidence in favour of the local foods that are being used as RUTF. Producing evidence is evidently not an apolitical thing; the only studies we found prior to the Hyderabad meeting showed comparisons either with nothing (!!) or with a variety of thin gruel we have been protesting for years. This, in my opinion, is not fair research. In contrast, small studies were presented by many in Hyderabad that provided anecdotal evidence in favour of many other foods that were local. We expect these good, strong, well resourced agencies – WHO, UNICEF and MSF to produce evidence in favour of or against local foods and not prescribe without even exploring these options. That is, if at all they care about decentralisation and community control as an ingredient in managing SAM or any other form of malnutrition. We have said it would not take too much time or resources for them to do so. We are concerned that they did not consider these options and make choices available for the country to take a call on, considering their stated positions on respect for the local, the diverse and the decentralised.
We do have some amount of confidence that thanks to the control exerted by the Supreme Court, it would not be easy for a centralised RUTF to come through in India (though by no means impossible…). That does not reduce the import or relevance of this discussion. This is the age old debate between the comprehensive and the selective in contemporary garb, and we are glad to be keeping it alive. I hope you will recognise its kinship to other valid debates such as the discussions on ART on the one hand, and WHO recommended ‘evidence based’ strategies like circumcision for AIDS prevention and universal pneumococcal vaccination or even pulse-polio, on the other.
Finally, Dr Briend is correct to state that no one ever suggested that plumpy nut should be imported. Nor have I or the working group ever said that anyone from WHO, UNICEF or MSF suggested it should be. That it has been is another story in the real world. Plumpy nut is still, I believe, in use, as are many other technological child–health related products, on grounds of standards and quality, all leading straight to those who retain the monopolies on both. Tomorrow it may well be produced by an MNC in the country, or even by a public sector organisation. In my opinion, that still does not answer questions and concerns raised above on the weakness of a strategy for SAM that rests on the distribution of a packaged product.
Many of us have been attacked recently as ‘anti child’ with the spectre of dying children held up against us. This is quite common whenever any one questions a child health strategy and we are well used to it. Should we say the same of those who hold back from advocating for comprehensive strategies for the entire lot of malnourished children when they speak of SAM? With regards Vandana Prasad (Jt Convenor PHM-India, Working Group for CU6, Community Paediatrician)
Comment by vandana prasad — 2009-05-01 03:51 | # - re
Dear Friends,
Since I have been marked into the mail by Leena, here goes my response:
Firstly, I presume that the paper that is being quoted is the one authored by my colleagues in the Working Group for Children Under Six, Dr.Vandana Prasad, Dr.Arun Gupta and Radha Holla. This paper was subsequently endorsed by the Working Group by a number of other organizations working on the issue of child malnutrition in India.
It is important to clarify at the outset that both UNICEF and MSF are looking towards local production of RUTF and the imports that were made by them was in response to the emergency in the States of Bihar and starvation deaths in Madhya Pradesh. This has been clarified by both agencies on a number of occasions in the past and I personally see no reason for not taking this on face value. Amongst other things, the scale of the problem is so extensive in India that using an imported product would not be economically feasible for any private agency to continue imports. Besides, Government of India is unlikely to allow such imports in a public programme.
However, the point that was made in the paper and subsequently reiterated in the Hyderabad meeting that Andre refers to is that the use of RUTF for the treatment of SAM in India should be done with much greater caution than has been exercised in other contexts. There is no doubt that the RUTF formulation currently in use is a technically appropriate for dealing with SAM. However, it has been tried in emergency contexts in Africa where the role of the State in dealing with malnutrition is negligible and these contexts cannot really be compared to India for replication. India does have an institutional response by the Government in the form of the Integrated Child Development Services (ICDS). It is a Government programme to deliver six essential services to children under the age of six including supplementary nutrition. It also provides services to all pregnant and nursing mothers. The programme operates through a network of nearly 1.4 million ICDS centres spread across the entire country. Expenditure on this programme in the current Five Year Plan Period would be in the range of around USD$10 billion.
Most of us who are working on Child Nutrition in India have been working primarily to strengthen the state response to malnutrition within a rights based framework where we see the State as the principal duty-bearer of rights. The ongoing Right to Food case in the Supreme Court of India (CWP 196/ 2001) which is the longest continuing mandamus anywhere in the world, has provided a fresh impetus against malnutrition and hunger in India and seeks to enforce state accountability by making the right to food a fundamental right that would be justiciable. The role of agencies like UNICEF and MSF is very minimal in the overall context of India and quite sub-critical given the scale of the problem. I do not think either agency harbours the notion that they can go it alone and make large scale private interventions successfully, at a national level in India, as they have done in other contexts. Indeed, my experience has been that MSF has chosen consciously to engage civil society actively in this debate in India and there paper that was circulated was one amongst many responses.
Public programmes bring with them much larger challenges than smaller NGO programmes and one of the principal challenges in the Supplementary Nutrition Component of the ICDS has been to ensure that the food actually reaches the ICDS centres. We have had more than two decades of “worst practice” to learn from this since procurement, production and distribution of the supplementary nutrition was centralized and made through a chain of private contractors, there were large scale leakages along the way. The Supreme Court of India stepped in and banned the use of contractors for the supply of food in October 2004 and this has been now decentralised to village communities and local bodies. This was also endorsed by the Union Cabinet last year and there is no scope therefore left for any centralized procurement, production or supply of supplementary nutrition. While much of this has happened in the arena of RUF (complementary food) rather than RUTF, there is a need to ensure that we do not make the same mistakes this time around. The debate in India therefore needs to be contextualized with this background.
The other important issue is that of looking at SAM isolation or looking at it more comprehensively in the overall continuum of the treatment of malnutrition in children. Civil Society efforts in India have been focused on strengthening the state response to the treatment of malnutrition by addressing some of the structural challenges that communities face in doing so. Essential components of this approach include, inter-alia, the appointment of a second worker at the ICDS Centre to address the needs of children under two, conversion of the existing ICDS centres into crèches by extending the working hours, provision of maternity entitlements, creation of a network of Nutritional Rehabilitation Centres at public health facilities for the facility-based treatment of SAM for children who need medical attention and raising awareness of SAM treatment protocol in communities for providing appropriate local, calorie dense, energy rich foods to children with SAM. Needless to add, all of this must happen while we continuously work towards the aim of food security of communities.
The discussion on RUTF in India that is on-going therefore reflects many of these complexities. It would be simplistic to reduce this debate to one just on the use of RUTF in the small pilot/ project sites and posit it as one between civil society and international agencies like MSF/ UNICEF. That would trivialize this issue completely and I am sure that everyone appreciates the nuances of these positions and are working towards resolving these issues. Essentially as I understand it, most civil society organizations are not challenging the composition of the RUTF that is currently used by MSF/ UNICEF. The challenge really is to develop local formulations that are culturally appropriate and acceptable and can be produced at the level of the district/ sub-district with the possible involvement of local communities or even farmers co-operatives. In the context of India, we may not end up with a single formulation but can possibly have multiple ones including separate formulations for facility-based and home-based treatment options.
It is also true that we do not have “a” Government of India protocol for the treatment of SAM. What we do have however is different state agencies redressing the issue, with varying degrees of success in different states and contexts using their own protocols or those developed by the Indian Association of Pediatrics. There is certainly a need for a critical examination and of these approaches and short-listing those with the potential of wider replication. The National Institute of Nutrition (NIN) in Hyderabad hosted the first workshop in SAM (supported by MSF) which brought together a large number of practitioners and policy makers from India and abroad to deliberate on this. It was a small but significant step in widening this debate and moving towards a position of consensus. Even a tiny fraction of the cost that was used to develop, evaluate and create the evidence on the efficacy of RUTF would suffice to work out the protocol and local formulations for India. And I see now that because of the debate in India many Government institutions like NIN and civil society organizations are now working coherently towards addressing this challenge.
The battle against SAM in India is very crucial and I think it needs all of us to work much closer together. Agencies like MSF have brought the treatment of SAM to the centre of the discourse and most importantly created an argument in other contexts of the importance of high quality food, rich in animal proteins for children. RUTF will hopefully continue to make a dent on SAM in Africa and other emergency situations. However, even in these contexts we must be very cautious before trying to extend RUTF into RUF, from the treatment of SAM to the prevention of malnutrition, as was perceived to have been suggested by the JAMA paper, since that would displace local foods and medicalise the prevention of malnutrition. This would be a setback for right to food movements worldwide. I hope this note will help inform your debate better. For more information on the programme that I have discussed and the work of the RTF Campaign as well as the Supreme Court Commissioners Office do please visit: www.wcd.nic.in ; www.righttofoodindia.org and www.sccommissioners.org .
I would be happy to provide any further clarifications.
Warmly, Biraj
Comment by Biraj Patnaik — 2009-04-28 15:03 | # - re
I wanted to participate in the discussion sharing our experience with the treatment of SAM and the context within we started using RUTF.
I worked as medical doctor and nutrition coordinator in a refugee settlement in Ghana. This community shares characteristics of both “protracted refugee situation” (as many of the refugees have been there for almost 20 years) and “emergency situations” (since until recently, refugees were still arriving).
In 2005 we started with a SFP (mainly targeted to moderately malnourished children), and even though we had a significant number of children with SAM we couldn’t set up a fully operational TFP because we had several limitations including space and financial ones. So we had to manage the children with SAM who were not complicated as outpatients (we included them in the SFP, and set up a special monitoring system for them). -The complicated ones were managed in the pediatric ward of our clinic or referred to a reference hospital-. At the time we did not have RUTF; so we stressed on nutrition education promoting adequate use of family foods and supplementing with micronutrients and the food provided at the SFP.
That strategy helped to prevent further deterioration of the non-complicated children with SAM but there were limitations to achieve timely nutrition rehabilitation given the local conditions of food insecurity. Even though the mothers/caretakers and families had culturally relevant nutrition education many simply couldn’t provide a balanced diet due to the prevalent household food insecurity and rely mainly on food aid.
We tried to develop several strategies to support the community-based treatment of those SAM children including the setting up of a Day Care Center and skills training/economic empowerment for the most vulnerable families, among others. In some point we also prepared F100 locally (though we couldn’t get the vitamin and mineral mix, but we used commercially available syrup distributed to each child); it was very difficult to manage it logistically speaking.
We started to receive RUTF at the end of 2008, and we have seen that it has boosted the recovery of the children. In our setting the RUTF have been well accepted, and it is promoted as a temporary measure to prevent deterioration of the clinical condition and to promptly recover the nutritional status of the SAM children, it is seen as both food and medicine; but we stress on creating awareness among the community on the actual causes of malnutrition and the ways to prevent it. It is well known that the RUTF have several advantages, and its efficacy has been proven in diverse situations; but as we are also aware it is neither the only option nor a single solution to the SAM treatment problem. We also have to remember that its indiscriminate use poses some risks.
In my opinion the use of RUTF is perfectly compatible with the use of other local formulations for the treatment of SAM and should always go along culturally-sensitive nutrition education. It would be wonderful if we could find a locally designed formulation with the advantages of the currently used RUTF suitable to each circumstance where children with SAM are to be treated. We must keep in mind the root causes of malnutrition and the complexity of them; but we need to balance this with the fact that we have the responsibility to ensure the prompt recovery of children who are SAM and to use what is on our hands to ensure that it is done in a timely and safe manner.
We most see the RUTF as an important tool but not as a magic bullet, and to use it accordingly, evaluating the suitability in each context and adapting the protocols to the local needs.
Comment by Daniel Gallego — 2009-04-27 22:49 | # - re
Hello
I am Leena and I work on issues related to SAM treatment in India. I am responding to your email below which was forwarded to me by Dr. Briend.
You have highlighted the need for IMTF to discuss Dr. Prasad's article based on the fact that he suggests that India is going to replace a previous SAM treatment protocol based on locally available foods with a protocol for SAM treatment which will be based on central procurement of RUTF.
There are several issues and facts that have to be kept in mind for the discussion. The most important of those is the fact is that India has completely failed in responding to this health emergency of millions of children at risk of dying each year from SAM.
No government medical protocol for SAM treatment- Firstly that there is no government protocol on SAM treatment either from the Health Ministry or the Dept of Women and Child development which runs the prevention programme on malnutrition.
- The guidelines that are being discussed are those laid down by the Indian Association of Pediatrics. It is not a government body and therefore these guidelines cannot be taken to be as that of the government. These guidelines themselves acknowledge that in India the mortality amongst children with SAMN is high (typically 20- 30%), and has mostly remained unchangeded.
- In fact there is NO government initiative to set standards, protocols or guidelines for SAM treatment let alone any debate on the kind of F 100 formulation that is best suited to the Indian context. Therefore NO decision has been taken vis-à-vis procurement – whether that will be central, state level, district level.
Failure to treat SAM despite high SAM related mortalityThere is little political commitment to save the millions of children at risk of dying from SAM in India. Most treatment initiatives are from NGOs such as CINI Asha in West Bengal and Jijau Mission in Maharashtra. Others in medical colleges are not SAM treatment initiatives but is the treatment that the pediatric wards of few and far between governmental medical hospitals that get the most complicated cases. They treat the infection, food is given to child as long as he is admitted into the ward, do vitamin supplementation and then the child is discharged after a few days or weeks.
More recently in the last two years few Nutrition Rehabilitation Centres (NRCs) have been set up in some districts with high mortality. All of them are facility based and treat a very limited number in the districts where they are located. Many women, whom I spoke to when I travelled to the NRCs, also mentioned that they would not be able to complete the treatment of the child as they could not afford to leave their homes, livelihoods for a long period.
Another additional factor that is being ignored is that in the areas/districts/states that have where there is high mortality in children with SAM, the public health care infrastructure is poor and fails to respond to the health emergency of these children. The angadwadi worker who documents the grade of the child (Grade I, II, III, IV) vis-à-vis malnutrition in the absence of health facilities cannot report or refer the children with SAM in her centre for treatment.
Therefore even the basic WHO protocol for treatment with F100 is inaccessible and unavailable to these children who are at risk of dying.
Replicable model in the most resource poor settingsOne of the key issues in India is the requirement that it must be replicable model of treatment i.e. millions of children in the most remote and neglected areas should be able to access treatment.
Besides early case detection, a key issue for upscaling treatment in the community will be the most appropiate RUTF that complies with the WHO standard of F100. I assure you that India has the capacity to produce the RUTF with local ingredients.
Urgent need for research and evidence on what works in IndiaIn the email below you mention that Dr. Prasad in his paper feels that there are many locally produced/producible foods that are culturally acceptable and relatively low cost and have been used for SAM in India for many decades by reliable academic and medical institutions as well as by non-governmental groups.
At a recent meeting at the National Institute of Nutrition where most of these stakeholders were present, (medical institutions, NGOs in India who have been providing facility based SAM treatment) themselves acknowledged the need to create evidence regarding these recipes.
False DebateAt the end the debate raised by Mr. Prasad is a false debate, as first India must decide to treat and then comes the question as to what it will use for the therapeutic treatment of SAM children.
For your reference and more information on the SAM treatment situation in India, I also copy Mr. Biraj Patnaik from the right to food movement – a key civil society actor in India on issues related to malnutrition in children. Please feel free to contact me for any further information or clarification.
Regards,
Leena Menghaney
Comment by Leena — 2009-04-27 13:24 | # - re
I strongly believe that locally-produced home-based RUFT be encouraged in all areas where the required food constituents for the RUFT is easily available for the following reasons:
Commercially produced RUFT using foods that may not be locally available can easily bring suspicions on the contents of the food and can be rejected as soon as the child begin to show signs of improvement but before full recovery and in case of recurrance of the problem, the mother/guardian will have to look for the product that previously cured the 'illness'.
In many Sub Saharan countries this may involve travelling to cover long distances to sites that previously supplied it. This site may have been used only in an emergency situation and the humanitarian agency may have relocated elsewhere.
Dr Vincent Oryem-Yooman
Comment by Dr Vincent Oryem-Yooman — 2009-04-23 11:47 | # - re
I do confirm what André is saying. No States in India are importing (and ever did) these products.
There were imported for pilot project to treat SAM (a pathology which remain untreated there at the exception of small pilot project) in order to show evidence on the strategy of home based treatment therapy. In the same lines of the outcomes of the workshop on SAM home based treatment organised in 2005 by the Indian Paediatric Association (IPA) as stated in the document attached.
So the purpose of the use was in pilot project limited geographically as per there volume of activity, to show evidence of such therapy. Then to consider them, there is the need to respond to the different ask as written in the IPA document. One of them being that product should be locally produced, the other is that it should show evidence of its effectiveness as of the feasibility to integrate it to Indian health delivery system. If this is shown and documented (then "evidenced") then there could be the consideration to adopt such strategies. As any change, this one should also be challenge by current practice to see what is the most adapted one.(this was the summary of the meeting where CSO were present - including the author of the article- as members of the governement and academician).
Then this intervention, as any, is not to substitute all the other intervention (especially the ones on prevention provided by the ICDS system) but on addition to those ones. As nutrition strategies to be effective need holistic approach.
Best regards,
*************************
Stéphane Doyon
Comment by Stéphane Doyon — 2009-04-23 11:45 | # - re
I have been reading comments from colleagues on the topic of use of externally produced food product as the sole means of tackling SAM.
My experience is that in 1997 we attempted to asseess the impact of such externally produced meals for intervention in similar situations. It was done on pilot bases and the programme was very successful in improving the nutritional status in the population studied within four weeks. The product was code name NUFU cereal meal. It was made up of fermented cereal base dough with fish mix but had high level of vitamin A, Iodine and Iron and good source of protein.
The programme could not continue because attempt to continue to produce it in Norway and transport it to Ghana while the technology could easily be transferred so that the product is developed in Ghana was not accepted by the donors. So if we are talking about using foreign based product we must be very conscious of the fact that several interests will be at stake.
I am solidly of the view that local food based product will become more sustainable as it also improves the local economy of the people. Poverty is one reason for the SAM in the first place so holistic approach to tackling the problem may be more long lasting.
Tom
Comment by Tom Nadu — 2009-04-23 11:42 | # - re
Thanks Andre for the clarification as this puts the whole discussion into perspective. I am happy to learn the over whelming consensus was for the use of locally produced RUTF as lets face it, the clinical team working among SAM individuals would better be able to handle the multiple causes of malnutrition and make recommendations of the relevant nutritional prescription rather than a "blanket product" that would cover for the treatment of all cases of SAM. Francis
Comment by Francis Zotor — 2009-04-23 11:11 | # - re
To have the discussion starting on the right track, a short clarification.
In your mail you say:
"According to the paper, Plumpy Nut produced by Nutriset in France is being imported by several states in India for the treatment of SAM and there is a proposal to make it the “prescribed treatment” for SAM."
I attended a meeting in India early this month on SAM treatment in Hyderabad at the National Institute of Nutrition and nobody there was in favour of using imported "plumpy nut" for large scale SAM treatment. All participants were in favour of using locally produced RUTF, if the RUTF option was chosen. I am afraid there is a major risk of misunderstanding here. I am not aware of any stakeholder in favour of this option.
Maybe there is some confusion, because, as I understand, some RUTF was imported for pilot projects and studies by MSF and UNICEF, but it was very clear during the meeting that none of these organisations was in favour of imported products. And would readily switch to a locally produced equivalent as soon as available.
So I suggest the sentence I quote from your mail should be removed to have the discussion starting in the right direction.
Best regards,
Andre Briend
Comment by Andre Briend — 2009-04-23 11:10 | # - re
The question of using therapeutic foods, such as F-75, F-100, and F-135, or using RUTF for the rehabilitation of children with SAM has more than one dimension:
In all protocols which I am aware of the use of artificial formula or RUTF is not the last step in nutrition rehabilitation: children should be growing on a diet which the family purchases and/or prepares for them from accessible food sources. Therefore, I don´t see formula or RUTF as more than a short term interim means to overcome severe (complicated) malnutrition – eventually with exception of continuing emergency situations.
The question from where nutritionally adequate and safe RUTFs should be procured needs to be answered in the context of the geographical, economic, and social situation. Where such RUTFs can be produced locally or be obtained from a regional provider at achievable prices they have the advantage of stimulating local farmers, processors, and traders. Where such RUTFs cannot be produced locally imported stuff maybe needed. To me, it seems not to be wrong that industrial companies offer a commercial product like PlumpyNut. Local or regional producers may offer competitive products. Marketing strategies may respect the constraints of the nutrition and health workers, and not just go for maximizing profits.
We rather face a lack of progress in overcoming childhood SAM than a lack of options. Under the goal to reduce the mortality from severe complicated childhood malnutrition I would urge all colleagues to make their choice toi use F-s or – locally produced or imported – RUTFs with regard to the 4 points mentioned above, and not along the line 'locally produced' or 'imported'.
Comment by Michael B. Krawinkel — 2009-04-22 14:14 | # - re
Dear colleagues, I wish to correct the first sentence of my earlier comments on this subject. The sentence should have read: "I couldn't agree more with ....
I did not mean to disagree with Andre's point of view. I rather support it but in typing my comments, I ommitted the word "more".
I hope this very debate would help us as nutritional scientists to explore and examine ways in which we can promote capacity building particularly with regards to nutritional support and the use of local food products in addition to other useful sources.
As I understand it, RUTF when mass produced is relatively cheap. Any compariosns wiuth local alternatives might include cost-benefit analyses?
Regards Paul .........
Comment by Paul Amuna — 2009-04-21 17:26 | # - re
Dear Colleagues,
I couldn't agree with André on the issue of local vs. external RUTF or its equivalent.
I am of the firm belief that using universal concepts and models to design and find local equivalents of food to solve local solutions is the best, most sensible and cost-effective and sustainable way to deal with nutritional management of SAM (and other similar conditions) particularly in resource-poor communities.
Where local food alternatives are not available and/or peole are relying largely on external sources e.g. food aid including RUTF or other similar formulas produced overseas, by all means these should continue to be used but in my opinion, as a stop-gap measure until such time that the community is capable of finding their own local alternatives.
There is absolutely no reason why we cannot train and equip people with the technical and food processing/manufacturing know-how to produce local alternatives of equivalent energy and micronutrient composition.
It is important that those who want to help deal with SAM (and other conditions requiring nutritional support) do not lend themselves to a notion of 'trying to profit from the vulnerable's predicament, in this case SAM by producing externally for imports. RUTF clearly has an important place in treatment but we ought to be careful how we promote it.
My expereince of working with colleagues in Africa tells me that many working in child health who have to deal with SAM on a daily basis would detest the preceiption of RUTF produced externally as the "only" or "main" product for SAM treatment when for many years, they have been using local sources.
What would be useful though would be to examine a number of these local alternatives and make comparisons of nutrient composition to identify the 'nutrient strengths' and/or limiting nutrients in local alternatives with the view to helping them to imrpove nutrient quality through optimisation. Apart from helping to inform, educate and build capacity, this would also provide opportunities for local cottage industry and create income sources for the people and help them become more self-reliant.
I would welcome other people's views and comments.
Kind regards
Paul Amuna .................
Comment by Paul Amuna — 2009-04-21 17:18 | # - re
At the turn of the millennia (the year 2000), the ACC/SCN stated: "To live a life without malnutrition is a fundamental human right. The persistence of malnutrition, especially among children and mothers, in this world of plenty is immoral. Nutrition improvement anywhere in the world is not a charity but a societal, household and individual right. It is the world community's responsibility to find effective ways and means to invest for better livelihood and to avoid future unnecessary social and economic burdens.
With collective efforts at international, national and community levels, ending malnutrition is both a credible and achievable goal." If this statement is anything to go by, then it is my personal view that the western world’s attempt to help communities affected by SAM may rather be counter-productive. I have no doubt some of the existing RUTF currently being prescribed for SAM cases may be useful in the short term (and I am a proponent of their use in emergencies), but when commercial entities flex their muscles and establish a monopoly to “milk the situation”, then I have a problem.
I couldn’t agree more with Dr Prasad and his team on the arguments being put forward in their position paper in favour for locally prepared indigenous foods for the treatment of SAM. From our experience, locally prepared indigenous foods, if rightly blended, and with the help of properly trained staff can draw on the “nutrient strengths” of each component of the mix in order to optimise the nutritive value of the end-product without the need for external fortification. Such a blend will be locally affordable, as well as culturally acceptable in communities where SAM may be rife. It is important in addressing nutritional needs within any community to first attempt to make better use of traditional food sources to meet community nutritional needs.
Where limited food resources exist, it may still be possible to harness whatever little of those foods may be available and draw on their nutrient strengths. Until we are able to employ empirical and scientific approach to the concept of food diversification and any traditional food technology within a social and cultural context, my view is to discourage “commercial pre-packed supplemented foods” which are then transported thousands of miles just to “fill stomachs” without considering the bioavailability of those nutrients as unnatural sources within the human body.
Comment by Francis Zotor — 2009-04-21 03:47 | # - re