Case Against Product Based Nutrition Therapy for SAM Children

1. 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

3. 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 Can we talk like this?

4. BANANA Nutritional Value ( per 100 grams) Vitamin A 430 i.u. Vitamin B Thiamin 0.04 mg Riboflavin 0.05 mg Niacin 0.70 mg Vitamin C 10 mg Calcium 8 mg Iron 6 mg Phosphorus 28 mg Potassium 260 mg Fat 0.2 gram Carbohydrates 23 grams Protein 1.2 grams Calories 88

5. The Myth of Unparalleled Weight Gain 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 In 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:

6. 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 The Myth of Unparalleled Weight Gain with cRUTF

7. 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…

8. 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

9. 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

10. 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.”

11. 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.”

12. 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?

13. Bottle baby disease ..

14. Conceptual Framework of Causes of Malnutrition Malnutrition Manifestation Inadequate Dietary Intake Disease Immediate Causes Inadequate access to food Inadequate care for children and women Insufficient health services & unhealthy environment Underlying Causes Inadequate Education Basic Causes Resources and Control Human, economic and organizational resources

15. 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….”

16. 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.

17. 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…

18. 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