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Ready to Use Therapeutic Foods (RUTF) improves undernutrition among ART-treated, HIV-positive children in Dar es Salaam, Tanzania

In Under-nutrition on September 1, 2012 at 3:31 pm

Bruno F Sunguya, Krishna C Poudel, Linda B Mlunde, Keiko Otsuka, Junko Yasuoka, David P Urassa, Namala P Mkopi and Masamine Jimba

Nutrition Journal 2012, 11:60 

(entire doc)

Abstract

Background

HIV/AIDS is associated with an increased burden of undernutrition among children even under antiretroviral therapy (ART). To treat undernutrition, WHO endorsed the use of Ready to Use Therapeutic Foods (RUTF) that can reduce case fatality and undernutrition among ART-naive HIV-positive children. However, its effects are not studied among ART-treated, HIV-positive children. Therefore, we examined the association between RUTF use with underweight, wasting, and stunting statuses among ART-treated HIV-positive children in Dar es Salaam, Tanzania.

Methods

This cross-sectional study was conducted from September-October 2010. The target population was 219 ART-treated, HIV-positive children and the same number of their caregivers. We used questionnaires to measure socio-economic factors, food security, RUTF-use, and ART-duration. Our outcome variables were underweight, wasting, and stunting statuses.

Results

Of 219 ART-treated, HIV-positive children, 140 (63.9%) had received RUTF intervention prior to the interview. The percentages of underweight and wasting among non-RUTF-receivers were 12.4% and 16.5%; whereas those of RUTF-receivers were 3.0% (P = 0.006) and 2.8% (P = 0.001), respectively. RUTF-receivers were less likely to have underweight (Adjusted Odd Ratio (AOR) =0.19, CI: 0.04, 0.78), and wasting (AOR = 0.24, CI: 0.07, 0.81), compared to non RUTF-receivers. Among RUTF receivers, children treated for at least four months (n = 84) were less likely to have underweight (P = 0.049), wasting (P = 0.049) and stunting (P < 0.001).

Conclusions

Among HIV-positive children under ART, the provision of RUTF for at least four months was associated with low proportions of undernutrition status. RUTF has a potential to improve undernutrition among HIV-positive children under ART in the clinical settings in Dar es Salaam, Tanzania.

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How to design, pre-test and trial low cost, local RUTF products to rehabilitate severely malnourished children and adults

In Under-nutrition on August 9, 2012 at 3:55 pm

The latest number of Field Exchange, a journal published by ENN, contains a summary of a recent research paper describing how to use “Linear programming to design low cost, local RUTF” with the aid of Microsoft Excel software.

Whereas the original paper abstract can be found on The Journal of Nutrition web site, in the Field Exchange journal (issue 43, part 1), the article summary is available (for free) at page 36, including an “adapted” flow chart with the step sequence proposed for the design (see beneath), the pre-testing and the trialling of these products, currently in high demand in feeding programmes around the world.

The authors of the original paper are Filippo Dibari (author also of this blog), El Hadji I. Diop, Steven Collins, and Andrew Seal from Valid International and the University College of London.

More information about the Linear Programming, applied to the field of nutrition, is also available from another post in this same blog.

VALID Nutrition’s inspiring and innovative research is unveiled at IUNS 21st International Conference of Nutrition in Buenos Aires

In Under-nutrition on October 27, 2017 at 6:46 pm

by Ciara O’Brien | Oct 25, 2017  (Valid Nutrition)

VALID Nutrition’s inspiring and innovative research is unveiled at IUNS 21st International Conference of Nutrition in Buenos Aires

The ground-breaking results from a clinical trial of a Ready-to-Use Therapeutic Food (RUTF) product made without milk or animal source protein and undertaken in Malawi in 2016, were unveiled by VALID Nutrition’s Founder, Dr Steve Collins, at the IUNS 21st International Conference on Nutrition (15th – 20th October 2017). The Soy-Maize-Sorghum (SMS) based recipe has been in development for over ten years, involving three large randomised controlled clinical trials and considerable investment from several stakeholders including Japan’s International Cooperation Agency, the Global Innovation Fund, Irish Aid and the PRANA Foundation.

Read more

UNICEF – 2013 Global: Evaluation of Community Management of Acute Malnutrition (CMAM): Global Synthesis Report

In Under-nutrition on March 29, 2014 at 5:29 am

from UNICEF web page

Executive summary

(download)

Background:

Approximately 20 million children are affected by severe acute malnutrition (SAM) worldwide – some residing in countries facing emergencies and many others in non-emergency situations. Children suffering from malnutrition are susceptible to death and disease and they are also at greater risk of developmental delays.
Treatment of SAM has evolved as a major development intervention over several decades. Alongside other partners, UNICEF works to ensure that women and children have access to services, including through timely provision of essential supplies – especially therapeutic foods for the treatment of SAM. The advent of ready to use therapeutic food (RUTF) and a community-based approach – community management of acute malnutrition (CMAM) – has made it possible to treat the majority of children in their homes.
CMAM is generally a preventive continuum with four components: 1) community outreach as the basis; 2) management of moderate acute malnutrition (MAM); 3) outpatient treatment for children with SAM with a good appetite and without medical complications; and, 4) inpatient treatment for children with SAM and medical complications and/or no appetite. A key objective of CMAM is progressive integration of all four preventive components into national health systems. By the end of 2012, governments in 63 countries had established partnerships with UNICEF, WFP, WHO, donors, and NGO implementing partners (IPs) for CMAM. The Ministries of Health (MoH) assume leadership and coordination roles and provide the health facilities.
UNICEF’s inputs for CMAM include policy development, commitment of funds, coordination, and technical support available to the MoH and other implementing partners. UNICEF has made significant investments to scale up treatment of SAM through CMAM including procurement of therapeutic foods, medicines, and equipment. UNICEF currently procures approximately 32,000 MT of RUTF annually which represents an investment of over 100 million dollars.

Purpose/ Objective:

This evaluation is the first systematic effort by UNICEF to generate evidence on how well its global as well as country level CMAM strategies have worked, including their acceptance and ownership in various contexts and appropriateness of investments in capacity development and supply components. The evaluation was conducted by a team of independent external evaluators and included comprehensive assessments of CMAM in five countries (Chad, Ethiopia, Kenya, Nepal and Pakistan) and drawing synthesized findings and recommendations based on broader research and a global internet survey targeting all countries implementing CMAM. A wide range of stakeholders, including national and international partners, beneficiaries, and donors, participated in the exercise. The resulting conclusions and recommendations are intended to strengthen UNICEF’s contributions to CMAM and to support governments, UN agencies, NGOs and other stakeholders in modifying CMAM policy and technical guidance for both emergency and non-emergency contexts.

Methodology:

The evaluation scope consists of two interrelated components. First, the evaluation undertook detailed analyses of CMAM in Chad, Ethiopia, Kenya, Nepal and Pakistan. The criteria of relevance, effectiveness, efficiency, sustainability and scaling up were applied to CMAM components and to cross-cutting issues. Data were obtained from secondary sources, health system databases, and observations during visits to CMAM intervention areas. The community perspective was analysed through collection of opinions from caretakers, extended family, community leaders, and community-based health workers in addition to stakeholders from government and assistance agencies. Quantitative data were analysed to determine whether performance targets were met and qualitative data supported the analysis. Secondly, building upon case study evidence, broader research resulted in compiled lessons, good practices and recommendations for UNICEF and partners globally. A global internet survey targeting all 63 countries implementing CMAM, helped to triangulate and validate conclusions from the five country case studies.

Findings and Conclusions:

1. Relevance of CMAM Guidance and Technical Assistance
• The CMAM approach is appropriate to address acute malnutrition, particularly to the degree that CMAM is being sustainably integrated into the national health system.
• Demand for CMAM services has increased; efficient use of community resources for prevention and identification and referral of children with MAM and SAM contributes to demand.
• National contributions to CMAM are growing but scale up (expansion) is challenged by funding constraints for regular programming and reliance on emergency funds and external sources of assistance.
• Global UNICEF and WHO guidance for SAM treatment has contributed to development of national guidelines which offer high value in promoting district ownership. However, lack of agreement on the best approach to address MAM has contributed to inconsistency among countries for MAM management and concomitantly, prevention of SAM.
• Global and national guidance is generally adequate for treatment protocols but lacking or fragmented regarding: planning and monitoring, integration of CMAM, equity and gender, community assessment and mobilization, and MAM management.
• Technical support has resulted in significant gains in process, coverage and outcomes; creation of parallel systems is not sustainable and slows national ownership.
• Within UNICEF overall, there has been effective support for fund mobilization, emergency nutrition response, and supporting nutrition protocols; expansion of regional roles is important to meet national technical assistance needs.
• Capacity development has significantly promoted quality of services […]

2. CMAM Effectiveness and Quality of Services

3. Promoting Equity in Access

4. Progress and Issues related to National Ownership

5. Efficiency – Costs, Supply and Delivery of RUTF

6. Sustainability and Scaling Up (Expansion of CMAM)

[see Executive Summary for more information]

Recommendations:

Overall, the evaluation recommends that UNICEF continue to promote and support CMAM as a viable approach to preventing and addressing SAM, with an emphasis on prevention through strengthening community outreach and integrating CMAM into national health systems and with other interventions.

Ownership and Integration, Strategy and Policy, Guidelines
• UNICEF should continue to work with governments, WFP, WHO, IPs, and other stakeholders to secure a common understanding on the most effective means of addressing MAM in order to unify approaches, to strengthen community-based preventive measures, and to prevent SAM and relapses into SAM.
• Establish a guideline or framework for integration of CMAM into the health system and with other interventions that is useful at national level when based on capacity assessments and integrated with national health, nutrition and community development strategies.
• Facilitate coordination and technical support at regional/national level to expand or develop national CMAM guidelines as CMAM is integrated with other interventions such as IYCF.

Performance and Quality of Services
• Strengthen community outreach by ensuring adequate investment in CMAM awareness raising activities and their integration with outreach for other public health interventions.
• Decentralize nutrition information systems to strengthen data collection and analysis at district level supporting and reinforcing the MoHs’ lead role and joint accountability among the MoH and partners for improving quality.
• Define a standardized monitoring system to assess the quality of the CMAM services to inform the MoH, UN partners, IPs and other stakeholders where more capacity is needed.

Equity in Planning and Coverage
• Strengthen planning for CMAM through conducting community assessments, and greater use of joint integrated results-based planning exercises and mapping information […].

Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial

In Under-nutrition on July 7, 2013 at 12:33 pm

by Irena AH, Bahwere P, Owino VO, Diop EI, Bachmann MO, Mbwili-Muleya C, Dibari F, Sadler K, Collins S.

Matern Child Nutr. 2013 Jun 18.

Abstract

Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto.

This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome.

The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group.

In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.

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Locally-Prepared Ready-to-Use Therapeutic Food for Children with Severe Acute Malnutrition: A Controlled Trial

In Under-nutrition on June 4, 2013 at 8:14 pm

by Govind Singh Thakur, HP Singhand Chhavi Patel

Indian Pediatrics – Vol. 50, March 16 2013

(download the paper)

Abstract

Objective: To compare the efficacy of locally-prepared ready-to-use therapeutic food (LRUTF) and locally-prepared F100 diet in promoting weight-gain in children with severe acute malnutrition during rehabilitation phase in hospital.

Study design: Non-randomized Controlled trial.
Setting: Pediatric ward of tertiary care public hospital in Central India.
Study period: 1 October, 2009 to 30th May, 2010.
Subjects: Children aged 6 to 60 months, diagnosed as severe acute malnutrition and hospitalized during study period.

Intervention: Random group allocation followed for selection of intervention and control cohorts. The control cohort enrolled during October 1, 2009 to January 31, 2010 received F100 while the intervention cohort enrolled during 1 February to 15 May 2010 received LRUTF. Subjects receiving either of the two therapeutic foods were temporally separated to minimize the spillover effect. The study subjects and the technician delegated for measuring weight was blinded for type of intervention.

Primary outcome variable: Rate of weight-gain/kg/day.

Results: There were 49 subjects in each group. Both groups were comparable. Rate of weight-gain was found to be (9.59±3.39 g/kg/d) in LRUTF group and (5.41 ± 1.05 g/kg/d) in locally prepared F100 group. Significant difference in rate of weight gain was observed in LRUTF group (P<0.0001; 95% CI 3.17-5.19). No serious adverse effect was observed with use of LRUTF.
Conclusion: LRUTF promotes more rapid weight-gain when compared with F100 in patients with severe acute malnutrition during rehabilitation phase.

Peanut-based ready-to-use therapeutic food: how acceptable and tolerated is it among malnourished pregnant and lactating women in Bangladesh?

In Under-nutrition on June 1, 2013 at 9:45 am

by Ali E, Zachariah R, Shams Z, Manzi M, Akter T, Alders P, Allaouna M, Delchevalerie P, Harries AD.

Matern Child Nutr. 2013 May 6

Abstract

Within a Medecins Sans Frontieres’s nutrition programme in Kamrangirchar slum, Dhaka, Bangladesh this study was conducted to assess the acceptability of a peanut-based ready-to-use therapeutic food (RUTF) – Plumpy’nut® (PPN) among malnourished pregnant and lactating women (PLW). This was a cross-sectional survey using semi-structure questionnaire that included all PLW admitted in the nutrition programme, who were either malnourished or at risk of malnutrition and who had received PPN for at least 4 weeks. A total of 248 women were interviewed of whom 99.6% were at risk of malnutrition. Overall, 212 (85%) perceived a therapeutic benefit. Despite this finding, 193 (78%) women found PPN unacceptable, of whom 12 (5%) completely rejected it after 4 weeks of intake. Reasons for unacceptability included undesirable taste (60%) and unwelcome smell (43%) – more than half of the latter was due to the peanut-based smell. Overall, 39% attributed side effects to PPN intake including nausea, vomiting, diarrhoea, abdominal distension and pain. Nearly 80% of women felt a need to improve PPN – 82% desiring a change in taste and 48% desiring a change in smell. Overall, only 146 (59%) understood the illustrated instructions on the package. Despite a perceived beneficial therapeutic effect, only two in 10 women found PPN acceptable for nutritional rehabilitation. We urge nutritional agencies and manufacturers to intensify their efforts towards developing more RUTF alternatives that have improved palatability and smell for adults and that have adequate therapeutic contents for treating malnourished PLW in Bangladesh.

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State of the art of Ready-to-Use Therapeutic Food: A tool for nutraceuticals addition to foodstuff

In Under-nutrition on June 1, 2013 at 8:25 am

by Santini A, Novellino E, Armini V, Ritieni A.

Food Chem. 2013 Oct 15;140(4):843-9

Abstract

Therapeutic foodstuff are a challenge for the use of food and functional food ingredients in the therapy of different pathologies. Ready-to-Use Therapeutic Food (RUTF) are a mixture of nutrients designed and primarily addressed to the therapy of the severe acute malnutrition. The main ingredients of the formulation are powdered milk, peanuts butter, vegetal oil, sugar, and a mix of vitamins, salts, and minerals. The potential of this food are the low percentage of free water and the high energy and nutritional density. The high cost of the powdered milk, and the food safety problems connected to the onset of toxigenic moulds on the peanuts butter, slowed down considerably the widespread and homogenous diffusion of this product. This paper presents the state of the art of RUTF, reviews the different proposed recipes, suggests some possible new formulations as an alternative of novel recipes for this promising food.

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Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia

In Under-nutrition on October 25, 2012 at 8:50 am

Tekeste AWondafrash MAzene GDeribe K.

Cost Eff Resour Alloc. 2012 Mar 19;10:4

 

Abstract

BACKGROUND:

This study estimated the cost effectiveness of community-based therapeutic care (CTC) for children with severe acute malnutrition (SAM) in Sidama Zone, Ethiopia compared to facility based therapeutic feeding center (TFC).

METHODS:

A cost effectiveness analysis comparing costs and outcomes of two treatment programmes was conducted. The societal perspective, which considers costs to all sectors of the society, was employed. Outcomes and health service costs of CTC and TFC were obtained from Save the Children USA (SC/USA) CTC and TFC programme, government health services and UNICEF(in kind supplies) cost estimates of unit costs. Parental costs were estimated through interviewing 306 caretakers. Cost categories were compared and a single cost effectiveness ratio of costs to treat a child with SAM in each program (regardless of outcome) was computed and compared.

RESULTS:

A total of 328 patient cards/records of children treated in the programs were reviewed; out of which 306 (157 CTC and 149 TFC) were traced back to their households to interview their caretakers. The cure rate in TFC was 95.36% compared to 94.30% in CTC. The death rate in TFC was 0% and in CTC 1.2%. The mean cost per child treated was $284.56 in TFC and $134.88 in CTC. The institutional cost per child treated was $262.62 in TFC and $128.58 in CTC. Out of these institutional costs in TFC 46.6% was personnel cost. In contrast, majority (43.2%) of the institutional costs in CTC went to ready to use therapeutic food (RUTF). The opportunity cost per caretaker in the TFC was $21.01 whereas it was $5.87 in CTC. The result of this study shows that community based CTC was two times more cost effective than TFC.

CONCLUSION:

CTC was found to be relatively more cost effective than TFC in this setting. This indicates that CTC is a viable approach on just economic grounds in addition to other benefits such improved access, sustainability and appropriateness documented elsewhere. If costs of RUTF can be reduced such as through local production the CTC costs per child can be further reduced as RUTF constitutes the highest cost in these study settings.

 

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Two charities challenge company’s patent on Plumpy’Nut

In Under-nutrition on October 18, 2012 at 2:56 pm

by Clare Dyer

from the British Medical Journal (BMJ) 2010;340:c2510

“The US patent for a peanut based food product that has transformed the treatment of acute malnutrition in Africa has come under challenge by two US not for profit organisations that say they could produce similar products more cheaply.

“The California based Mama Cares Foundation and Breedlove Foods in Texas have filed a joint suit in the US District Court in the District of Columbia to try to overturn the patent held by the French company Nutriset.

“Nutriset’s Plumpy’Nut, a blend of peanut butter, powdered milk, vegetable oil, and sugar fortified with vitamins and minerals, is said by some experts to have revolutionised aid agencies’ response to malnutrition and become the standard “ready to use therapeutic food” (RUTF).

“It achieved dramatic results in Niger in 2005. Because it doesn’t need to be mixed with water, children who would previously have to be taken to hospital can be treated much more cheaply at home.

“Nutriset and its partners around the world provide the bulk of the world’s supply, but Mike Mellace, executive director of Mama Cares, said it was poised to ship its rival Re:vive product to Africa, Honduras, South East Asia, and other regions.

“The patent lawyer Robert Chiaviello is giving his services free of charge to the two organisations. Mr Mellace said that their main claim was that the patent should not have been granted because Plumpy’Nut was not novel or unique.

“If you grab a jar of Nutella and compare it to the ingredients statement on Plumpy’Nut you’ll find that it’s virtually identical. All that they’ve done is change the mixture round and have a higher vitamin and mineral mix to get to the proper WHO specifications, which anybody could do.”

“He said that Mama Cares, a non-profit offshoot of his family snack business, had managed to reduce its costs to $0.4 (£0.27; €0.78) a unit; Plumpy’Nut costs 0.55 a unit. “If you simply took the same aid dollars you could treat 30% more children because the product is cheaper.”

“Nutriset has recently started manufacturing Plumpy’Nut in the United States, in partnership with a non-profit body called Edesia. Its network of partner manufacturers also produce Plumpy’Nut locally in Niger, Ethiopia, Malawi, the Democratic Republic of the Congo, the Dominican Republic, India, Madagascar, and Mozambique.

“The company, which has registered patents in the European Union, the US, Canada, and 32 other countries, has sent legal letters to other producers of nut based RUTFs. It was criticised in an open letter last November by the international humanitarian organisation Médecins Sans Frontières for sending a letter asserting its intellectual property rights to the Indian and Norwegian manufacturer Compact.

“Adeline Lescanne, deputy general manager of Nutriset, said: “Some may pretend they are able to produce the equivalent of Plumpy’Nut at a cheaper price, but we fear that those solutions may not be [long lasting]. What should be the goal: to have companies manufacturing an RUTF in the North or to have them helping to develop local nutrition capacities, working with local health authorities, transferring competences to the South?

“It’s interesting to see the plaintiffs working on new products. Our patent on Plumpy’Nut gave them motivation to seek something else. What is really needed are increased efforts to prevent malnutrition. There are lots of things to do in the prevention field.”

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