Stephanie Jilcott, Scott Ickes, Alice Ammerman,Heidi Lutjens, Jennifer Myhre

THE UGANDA NUTRITION CONGRESS  February 19th-20th 2009  ‘The Challenges, Successes and Opportunities to Improve Nutrition’

Munyonyo Commonwealth Speke Resort Hotel Kampala, Uganda

Malnutrition is a global public health problem, contributing to 50% of child deaths.

Stunted linear growth is associated with lower academic achievement and cognitive function.◦ Stunting prevalence in Bundibugyo (45%).

Supplemental feeding (SF) programs are one strategy to combat malnutrition/ stunting.

Introduction

Ready-to-use-therapeutic food (RUTF) is often used in supplemental feeding programs.

The high cost of imported RUTF has prompted attention to local RUTF/RUF (ready-to-use food) production.

Ideally RUF should be:◦ Made from local food sources ◦ Made by community members◦ Distributed by local health workers

Introduction

4

In November 2007, World Harvest Mission (WHM) established a community-based supplemental feeding program that provides a locally-sourced and produced ready-to-use-food and complementary feeding education to underweight children ages 6-59 months.

Inclusion criteria:Weight < 3rd percentile weight-for-ageMUAC < 12cmNo severe concurrent illness

10 week program provides:Weekly growth monitoringWeekly complementary feeding education680 kcal per day RUFDe-worming pillVitamin AMultivitamin with iron

The BBB Program was designed to: (1)increase sustainability by using local food and local

health workers, (2)increase RUF production capacity for women’s groups,(3)empower caregivers by providing nutrition education, (4)provide RUF and community-based care for

underweight children.

Aims

Conceptual Framework

To describe the WHM supplemental feeding (BBB) program design, implementation, and

preliminary program evaluation.

Purpose

Initially, WHM staff: ◦ (1) trained local health workers to administer

the program and provide nutrition information to caregivers,

◦ (2) identified and trained local women’s groups to produce RUF (“production teams”),

◦ (3) established the two SF programs◦ (4) conducted qualitative interviews with

caregivers and members of RUF production teams, and

◦ (5) examined RUF nutrient analysis.

Methods Overview

Screening days were announced at each health center, local schools, and churches.

Eligible if:◦ Weight-for-age was < the lowest line (3rd percentile line)

on the standard Ugandan immunization card and/or ◦ Mid-upper arm circumference (MUAC) < 12 cm or ◦ Referred from the WHM inpatient feeding program.

Initial enrollment target of 20 children per site.◦ Busunga Health Center◦ Busaru Health Center◦ Both ~2 miles from Nyahuka Health Center

Methods: Enrollment

Weight, height, MUAC, birth date, and age recorded.

Growth velocity was calculated in terms of grams per kilogram of weight gain per day◦ Final weight (g) – initial weight (g)/ initial weight

(kg)/ # days

Growth velocities (SE) calculated using the mean function in STATA 9.0.

Methods: Quantitative Data Collection and Analysis

Conducted in-depth interviews with production team chairpersons◦ Detailed notes were taken and reviewed by

investigators following the interviews.

Conducted nine structured caregiver interviews and home feeding observations.

Methods: Qualitative Data Collection and Analysis

Production Team Chairperson Questions: What are the benefits of being on this production team? What are the difficult things about being on this production

team? Have there been problems on your team? Does anyone from the community come to use the grinder? Do you and your family enjoy the product?

Caregiver Questions: How do you prepare the BBB food? Please show me. What do you enjoy about the BBB program? Tell me about

that. What is hard for you about the BBB program? Tell me about

that. Is there anything that you would like the BBB program to

change about the food you receive? Tell me about that.

Methods: Qualitative Data Collection and Analysis

The RUF was prepared by roasting groundnuts and soybeans in a metal pot over a charcoal fire, then hand-grinding them.

Moringa oleifera leaves were mixed into the groundnut paste.

Methods: RUF Preparation

Participants were provided 2 separate 450 g bags of roasted soybean flour and groundnut paste mixed with moringa leaf powder.

Samples of the groundnut paste and moringa powder (without the soy flour) were analyzed at the Department of Food Science and Technology, Makerere University.

Methods: RUF Nutrient Analysis

Production team chairpersons reported the benefit of increased knowledge of healthy foods to feed young children:

“Being on the production team, we have learned how to care for our families.”

An additional benefit to having a production team in the community was an increase in community members’ motivation to cultivate groundnuts and soybeans for grinding. 

Results: Production Team interviews

  Chairpersons noted the challenge of grinding

and lack of acceptable financial incentives for production. For instance, one older production team member said:

“Grinding is hard for some of us. We are becoming old.”

Regarding financial incentives, teams noted a preference for getting paid directly for the work instead of in-kind compensation initially provided:

“We are working for free with no allowance…it is making some members leave the work.”

Results: Production Team interviews

Caregivers often prepared the BBB supplement as a dilute sauce for staple food versus using as RUF.◦ Educational message added to encourage

caregivers to use a 2:1 ratio of BBB supplement to staple.

Often, the BBB supplement components were not consumed together, affecting nutrient composition. ◦ Educational message added to educate

caregivers on importance of mixing groundnut paste and soy flour bags together immediately after returning home.

Results: Caregiver interviews/ observations

Results: Nutrient analysis per 100 grams BBB RUF

Parameter Soy Flour BBB Paste Total BBB supplement

Plumpy'nut Corn Soy Blend

Total Energy (kcal) 439 623 531 543 376 Crude fat (g) 21 21 21 33 7 Crude protein (g) 38 21 30 13 17 Dietary fiber (g) 2 13 7 NA 9 Vitamin C (mg) 0 87 44 NA 40 Vitamin A (iu) 110 220 165 800 2612 Aflatoxin content (ppb)

NA 0 0 NA NA

Comparative selective nutrient analysis per 100 grams of soy flour, BBB peanut paste, total BBB food supplement (soy flour plus BBB paste), commercial ready-to-use therapeutic food (Plumpy’nut) and USAID corn soy blend.

Source: Jilcott, Ickes, Myhre & Ammerman. Mater Child Health J, 2009. Nutrient analysis performed by Dr. Archileo N. Kaaya, Department of Food Science and Technology, Makerere University, Kampala, Uganda.

Results: Growth VelocitiesResults: Growth Velocities

Cycle Number enrolled

Mean age (months)

Gender(%male)

WeightBaseline

(kg)

Height baseline

(cm)

MUAC baseline

(cm)

Weight gain (g/kg/d))

Busunga 1 21 18.5 (2.2) 40.0 6.8 (0.4) -- 11.5 (0.2) 6.0 (0.8)

Busaru 1 16 31.7 (4.5) 68.2 8.2 (0.5) 76.4 (2.5) 12.6 (2.5) 3.6 (1.0)

Busunga 2 16 16.7 (2.1) 52.4 6.4 (0.3) 63.7 (1.4) 11.7 (0.3) 3.3(0.8)

Busaru 2 21 -- 50.0 7.9 (0.5) -- -- 3.1 (1.1)

Busunga 3 25 20.0 (2.3) 41.6 6.6 (0.3) 69.0 (1.5) 11.6 (0.3) 1.3 (0.2)

Busaru 3 26 27.4 (2.8) 46.2 7.5 (0.3) 72.6 (1.6) 13.1 (0.3) 2.3 (0.5)

Busunga 4 22 13.5 (1.3) 61.1 5.8 (0.3) 62.5 (1.5) 11.9 (0.3) 1.7 (0.6)

Busaru 4 18 24.7 (2.8) 72.0 7.3 (0.3) 70.8 (1.5) 12.3 (0.3) 1.2 (0.6)

Busunga 5 25 18.7 (2.5) 32.0 6.9 (0.4) 69.3(1.9) 12.4(0.2) 1.9 (0.3)

Busaru 5 25 18.7 (3.0) 36.0 7.7 (0.6) 70.4 (2.2) 12.6 (0.4) 0.9 (0.3)

Mean (SE) = 2.5 (0.6) g/kg/dMean (SE) = 2.5 (0.6) g/kg/d

Mean (SE) = 7.4(7.3) g/dMean (SE) = 7.4(7.3) g/d

The BBB program model is a promising strategy for community-based care of moderately malnourished children. ◦ BBB supplement had similar protein and energy density

as commercial RUTF.◦ Chairpersons and caregivers appreciate the program.

Conclusions

◦ To draw comparison with similar programs, we calculated mean daily weight gain (SD) after the program duration changed to 10-week cycles (4 and 5)

◦ BBB program participants gained 7.4(7.3) g/day. Maleta et al (2004): 3.3 (3.4) g/day during 12-

week supplementation with 500 kcal/d of RUTF. Flax et al (2008): 11.9 (6.0) g/day with 12-week

supplementation with 250 kcal/d of RUTF.

Conclusions

The program was altered to address findings of preliminary analyses:◦ Production teams changed to the small business

model, providing financial incentive for continued RUF production.

◦ Educational messages regarding RUF preparation were emphasized to improve caregiver feeding practices.

Conclusions

Limitations:◦ Study was not powered to detect a particular effect. ◦ The interpretation of modest growth velocities is

complicated by the wide age range of participants.◦ It is impossible to separate out the effects of all program

components. ◦ No standard quality control measures for RUF

production.

Strengths: ◦ Use of weight-for-age criteria to enroll children, as it is

easily comprehended by local health workers. ◦ BBB supplement had no trace of aflatoxin and no

caregivers have reported peanut allergies.◦ High energy density of the BBB supplement.

Limitations and Strengths

Future efforts are needed to educate caregivers on correct RUF use, explore how RUF is incorporated into the local diet, and improve commercial viability of this energy-dense supplemental food in local markets.

See Scott Ickes’ poster: “FEEDING PRACTICES AND CONSUMPTION OF LOCALLY PRODUCED READY-TO-USE-FOOD AMONG UNDERWEIGHT CHILDREN AGES 6-59 MONTHS”

Conclusions & Next Steps

We would like to acknowledge the hard work of World Harvest Mission Agriculture Extension Agents Batisibwa Geofrey, Tugume Lamech, Kentaro Pauline, and Baguma Charles, and WHM staff, Karen Masso, Pat Abbot, Sarah Reber, Nathan Elwood.

Many thanks to staff and community health workers at Busunga and Busaru Health Centers.

We are also grateful for the hard work of BBB production teams and caregivers.

Roey Rosenblith of Village StartUp Jeff Rose of Full Belly Project Bert Rivers of Compatible Technology

Incorporated