Case Against Product Based Nutrition Therapy for SAM

Children

Arun Gupta MD FIAP with Inputs from

Dr Vandana Prasad, Radha Holla, JP Dadhich.

Nov 26-27 2009

Workshop on Severe Acute Malnutrition

Can we talk like this?

• cRUTF : (commercial)

• Commercially controlled and distributed, centrally produced

• E.g PlumpyNut etc.

• pRUTF:(People’s)

Prepared, distributed controlled by the people, decentralised production(if a packaged product), local foods, natural foods and education

E.g Bengal, Gujarat, Maharshtra, Karnataka

BANANANutritional Value( per 100 grams)

Vitamin A 430 i.u.Vitamin B

Thiamin 0.04 mgRiboflavin 0.05 mgNiacin 0.70 mg

Vitamin C 10 mgCalcium 8 mgIron 6 mgPhosphorus 28 mgPotassium 260 mgFat 0.2 gramCarbohydrates 23 gramsProtein 1.2 gramsCalories 88

The Myth of Unparalleled Weight GainIn 2003, a study by Diop in Senegal on 35 children showed that RUTF can give a weight gain of 15.6g/kg/day.

This has not been equalled since either by Diop or by any other researcher.

A comparison of weight gains with different foods shows that locally made pRUTF or even feeding from the modified family pot has similar or sometimes even better weight gains:

cRUTF

Collins 2002 – 4.8g/kg/day (for the highest group

Diop 2003 – 15.6 g/kg/day

Diop 2004 – 7.9-8.1g/kg/day

Sandige 2004 – 5.6g/kg/day

Manary 2004 – 5.1g/kg/day

Ciliberto 2005 – 3.5g/kg/day

Patel 2005 0- 3.5g/kg/day

Isanaka 2006 – 5.6-5.9g/kg/day

Gaboulaud 2006 - >8g/kg/day

Eklund 2006 – 5-6g/kg/day

pRUTF=local foods/ family foods/nutrition counselling

Khannum 1994-1998 – 4g/kg/day

Ahmed 2002 (no food was given) 9.9g/kg/day

Hossein 2006 (F100 + home food) – 7.7g/kg/day

NIN 2009 – (local foods) 5-7 gms/day

The Myth of Unparalleled Weight Gain with cRUTF

• cRUTF programme level

• Govt and Unicef Bihar 5gms/day

• Govt and Unicef MP

• pRUTF• CINI (Nutrimix and local food) 6-

9 gm/kg/day• CDC Mission Maharashtra(local

foods) – 4-14g/kg/day• Gujarat model 7 gms/day

More…

pRUTF• Prepared by local people• Reinforces the idea of giving

energy dense foods• Can be managed with current

costs of public programmes, sustainable

• Huge shelf life not needed for local foods

• Vitamins and minerals can be added , does not require central production

• Allows community monitoring for quality

cRUTF• Perceived as the solution

even if you call it medicine• Safety is questionable :

Salmonella in peanut butter, aflatoxins.

• Long term impact ?

More Concerns• Feeding vs food. Typhoid or malaria, you get medicine. If

Malnutrition becomes a disease cRUTF becomes a good medicine without any governments and people’s role

• Have you known that cRUTF can add to complexity of feeding behaviour, especially exclusive breastfeeding for the first six months, and adequate complementary feeding along with breastfeeding thereafter(6-24 months), which is underlying factor for most of undernutrition

• Commercial pressure of formula feeding destroyed breastfeeding by undermining confidence of women

• Program costs for RUTFs will reduce funding for other actions to prevent and reduce malnutrition and child deaths

• cRUTFs now being promoted also to prevent malnutrition in 6-24 month old children not just for therapy to cure SAM.( UNICEF and MSF both have done this)

• A huge leap to use cRUTFs for prevention– Is this medicalizing and commercializing young child

feeding??

• A “medicine” replacing family foods and sometimes threatening breastfeeding

RUTFs for Prevention Not Treatment

• As we move on to a new year in our fight against global poverty and hunger, UNICEF is introducing an innovative food supplement — “Plumpy’Doz” — to very young children in Somalia.

• The brown paste supplement is made from vegetable fat, peanut butter, sugar, milk, and other nutrients, and is designed to taste good to kid. Critically, it also has a longer shelf life than previous diet supplements and doesn’t need to be mixed with water.

• Three teaspoons of Plumpy’Doz three times a day provides each young child with additional energy, including fats, high-quality protein and all the essential minerals and vitamins required to ensure growth and a healthy immune system.

• Other partners, such as the World Food Programme and Doctors Without Borders, have already been using the supplement, but: “this is the first time that Plumpy’Doz will be distributed on such a large scale. UNICEF is working with partners to take proactive action to not only treat but prevent malnutrition,” said Christian Balslev-Olesen, said UNICEF Somalia Representative. “By adopting this new approach, we aim to reach children before they become malnourished.”

•As we move on to a new year in our fight against global poverty and hunger, UNICEF is introducing an innovative food supplement — “Plumpy’Doz” — to very young children in Somalia. •The brown paste supplement is made from vegetable fat, peanut butter, sugar, milk, and other nutrients, and is designed to taste good to kid. Critically, it also has a longer shelf life than previous diet supplements and doesn’t need to be mixed with water.•Three teaspoons of Plumpy’Doz three times a day provides each young child with additional energy, including fats, high-quality protein and all the essential minerals and vitamins required to ensure growth and a healthy immune system. •Other partners, such as the World Food Programme and Doctors Without Borders, have already been using the supplement, but: “this is the first time that Plumpy’Doz will be distributed on such a large scale. UNICEF is working with partners to take proactive action to not only treat but prevent malnutrition,” said Christian Balslev-Olesen, said UNICEF Somalia Representative. “By adopting this new approach, we aim to reach children before they become malnourished.”

Early Nutrition is critical

• Maximum incidence of SAM in 0-6 months 13% in 0-6 months (NFHS 3)

• Why do we want to shy away? We are not touching this age group just to justify that we don’t interfere with exclusive breastfeeding for the first six months

• Can we have age group wise solutions as well?

Conceptual Framework of Causes of Malnutrition

Inadequateaccess to food

Inadequate care forchildren and women

Insufficient health services & unhealthy

environment

InadequateDietary Intake

Disease

Malnutrition

Resources and ControlHuman, economic and

organizational resources

BasicCauses

UnderlyingCauses

ImmediateCauses

Manifestation

Inadequate Education

Right to food campaign, India: Position16 August 2009

“…it may well be true that products like Plumpy Nut are effective in specific circumstances, to treat severe acute malnutrition. However, interventions of this kind, involving branded and patented products, also tend to be linked with a dangerous invasion of corporate interests in food policy and nutrition programmes. This corporate intrusion is an abiding concern of the Right to Food Campaign….”

Concluding remarks

• Most commonly used studies as evidence show a weight gain almost similar with pRUTF and cRUTF(with some having conflicts of interests)

• cRUTF may be dangerous as the thin edge of the wedge for profiteering, irrational use, replacing local alternatives

• It is important to treat severely malnourished children as apart of policy framework for prevention and control.

• No dependence on imported products• Rely on diverse options not on commercially driven• The cRUTF is unsuiable in expense, supplies ( look at ORS and other

supplies)• Rely on what can be decentralised Not on Centralised options • Invest in reaserch and scaing of local solutions with pRUTF equally as

on cRUTF• Plan what will give achieve a short term gain only vs. Short term gain

plus a long term gain to people.

Recommendations

• Use Diverse pRUTF for treatment of severe malnutrition, policy should not be based on a single product, and be decentralised.

• Adopt measures to prevent malnutrition in 0-6 months and later through structured support including financial, to women to stay together with their babies at least for first six months.

• Adopt CDC/VCDC model of Mission in Maharshtra and scale up in other states: Convergence, community action, and based on food as fundamental principles.

• Avoid routine use of cRUTF in public programmes• pRUTF itself should be as good a product as can be produced

in a decentralised way (district or sub distt level) from locally available foods using appropriate technology. This is our prescription for all processed food…

Recommendations contd..

• The vitamin-mineral mix is the drug component and can be manufactured like a drug as is being done currently

• Drugs should not be mixed up with food• Zero tolerance for conflicts of interest in policy making• Overall system of prevention through provision of good

adequate diverse nutrition, comprehensive care and health care is a non negotiable for introduction of cRUTF