[pronut-hiv] Supplemental food for a long term program

["Zeina Makhoul" <zeinamakhoul@yahoo.com>]

Dear all,
   
  I want to thank everyone for their great feedback. I sure did learn A LOT from all of your emails. 
  
One point that I did not mention is that we are not trying to find a supplemental food for a long term program. We are conducting a pilot study in Kenya with a small group of moderately malnourished children 2-5 years to study the effect of nutrition rehabilitation on the efficacy of ARVs. Our primary outcomes are changes in CD4 and viral load, weight gain and the nature of weight gain (ie, fat versus fat-free mass). So, our question is not what RUTF is best but what is available for a short term period to help children within a controlled environment. 
   
  These children are more likely to tolerate small quantities of food. Therefore, we are looking for a palatable, high energy and nutrient-dense supplement that can deliver enough energy and nutrients in small quantities to achieve catch-up growth.  We want the supplement to compliment their habitual diet and not replace it. We want the supplement to be ready-to-eat and not require preparation like mixing with water or milk. I read studies that used peanut paste -based supplements with favorable outcomes as far as weight gain. But most of these studies provided the supplement by kg and the children were severely malnourished,  I'm afraid with moderately malnourished we will be overfeeding them, given the metabolism derangement observed in HIV+ individuals (the reason we are measuring nature of weight gain). It doesn't seem that there are clear guidelines to manage moderate manutrition as there are with severe acute malnutrition. Would the 175 kcal/kg/d used in these RUTF
 studies still hold for moderately malnourished children? Should a food suppplement provide 30% of the RDA, for example? Should the amount provided differ by age? Do 5 year old children get more supplement than 2 year olds? What exactly are the guidelines?

  Also, we are open to using any food supplement that fits the characteristics I mentionned above. And of course if it's a food supplement used locally in Kenya that has these criteria, it's even better. We are not trying to promote any products. 
   
  Thanks again for all your feedback and time and for those who wrote me back with recommendations and suggestions.  I'm looking forward to hearing more ideas and comments. 
   
  Zeina
  



-------Basil Kransdorff <basilb@iafrica.com> wrote:
  Reply to request for information from Zeina and 
comments made by both Geofrey Douglas and George

Dear Zeina, Geoffrey and George,

Zeina - the 'official' answers you seek sit in 
the WHO and UNICEF manuals of products specified 
for malnourished children. Whether these 
specifications are the correct approach - is in 
my view - a debate that needs to be revisited.

We are the formulators and manufacturers of e'Pap 
to which Geoffrey refers and which has been 
available across the continent for the past 8 
years. We have had many positive feed back 
reports where e'Pap has been used successfully on 
highly malnourished and moderately malnourished 
children including from highly malnourished children from Uganda.

I have for years questioned and to this day do 
not understand the technical approach as 
specified by organizations such as the WHO UNICEF 
and the WFP. I question the specifications of 
products that are specified for - extreme 
malnourished conditions. It is our view that 
high levels of protein, sugar and cereal fat are 
the wrong approach for these situations. 
Certainly, if there is some 'expert' out there 
that could explain why this approach is used - I 
would be interested from a technical point of 
view. Our experience has been - high levels of 
protein on a malnourished stomach causes 
diarrhea. High levels of protein are useful for 
well nourished sportsman pumping steel - not 
malnourished children who cannot absorb the 
protein. In the case of a highly malnourished 
compromised stomach lining, most of the protein 
will be wasted as it cannot be absorbed. The 
diarrhea issue is confirmed in the WHO manuals 
who warn - stop the use of these products if 
diarrhea is observed. The high levels of refined 
sugar are a similar mystery to me as the 
available data highlights many health hazards 
created by such high levels including a lack of 
absorption of micro nutrients which is just one 
of 124 such health hazards. The high levels of 
cereal fat specified on the basis I presume to 
try to address the energy intake are in our view 
- technically flawed as this would contribute to 
other interrelated nutritional problems.

On the PLUMPINUT issue - I have raised many 
questions not only in this forum but also 
directly to the academics/medics who claim to 
have tested its use. The WHO UNICEF and the WFP 
recommend its use but do not answer my 
concerns. I have not received a satisfactory 
reply to any of my questions raised which makes 
me even more concerned especially when I come 
across large Foundations such as the Clinton 
Foundation handing it out free - just because it 
has been promoted by International UN 
Agencies. Until I receive satisfactory answers 
or any answer from my emails from researchers 
such as Professor Mark J. Manary, M.D from 
Washington University School of Medicine in St. 
Louis who claim to have investigated PLUMPINUT - 
my view on PLUMPINUT is one of extreme concern.

Our approach in formulating e'Pap as an African 
nutritional solution has been very different to 
the PLUMPINUT type approach. The many positive 
feed back testimonies we receive from across the 
continent highlight the effectiveness of our 
approach. We 'speculate' - the sledge hammer 
approach used in PLUMPINUT in formulating with 
high levels of refined sugar cooking oil and 
protein could only exasperate the nutritional condition.

We formulate e'Pap along the lines of trying to 
deliver the nutrients contained in a well 
balanced diet and use the KISS principle and no 
excesses or extremes. We concentrate on helping 
the stomach to repair their compromised condition 
by focusing on nutrient repleteness. To do this 
we have formulated with healthy levels of 
prebiotics and full RDA's of one of the most 
bio-available forms of zinc to help get the 
enzymic processes working again - especially in 
the stomach. We keep protein levels down at a 
level of about 12% within a delivery base food 
matrix of fully converted carbohydrate from 
either maize millet or sorghum. We convert the 
carbohydrate in a cooking process to about 98% to 
help conversion in highly malnourished 
stomachs. We process the soya component (main 
source of protein) at low temperatures to help 
preserve the amino acids. We use a unique 
cooking process that destroys the ureases even at 
the very low temperate levels used. High level 
temperature spiking of the protein content where 
soya based proteins are used are not useful in 
our view because of the potential damage to amino 
acids. Most important, we retain all the natural 
cereal fat (aprox 6%) contained in both the maize 
and soya as they are essential for nutritional 
process to take place. To maximize digestion to 
help get malnourished stomachs back to nutrient 
repleteness, we process e'Pap in a way that we 
are able top keep CFU counts to as low as 500.

We all know that the nutrition processes that 
take place in the body are complex and 
interactive and so the other approach we take is 
to add as many micro nutrients as is 
affordable. We have focused especially on the 
ones we know that have been removed from local 
diets. We fortify with these important essential 
nutrients at full RDA levels because we take into 
account the reality that there is little or no 
chance to get them from any other sources. An 
important issue is we have focused the e'Pap 
technology approach on is the issue of bio 
availability of the nutrients used. We therefore 
fortify with nutrients that have extensive 
clinical evidence that show interactions are 
reduced to a minimum and absorption factors are 
high based on a cost dose response.

It is a total mystery to me why International 
initiatives specify fortification nutrients that 
are known to have little value from a bio 
availability perspective. The nutritional 
explanation that a little is better than nothing 
because 'immediate' cost is the deciding factor - 
is not a view or approach we support. Failure of 
the objective to achieve nutrient repleteness 
only adds more cost from the health and 
unsustainable development consequences and 
international programs that must return year 
after year. The argument from so called 
'international experts' that international agency 
specifications do not encourage fully converted 
(cooked) fortified foods based on the logic that 
cooking must be ensured in order to sterilize the 
water used to reconstitute the food is one of 
those bizarre inappropriate 'first world based 
logics that further destroy valuable sensitive 
nutrients such as vitamin A. Appropriate 
preparation of clean water is essential whether 
it is used for drinking cleaning or 
eating. Institutionalizing the destruction of 
valuable nutrients by specifying partly cooked 
fortified foods or formulated products such as 
Plumpinut that are formulated around donor funded 
expensive raw materials such as milk powder from 
(1st world surplus mountain stocks) or excess 
sugar and cooking oil because it does not require 
cooking - only ensures nutritional failure. What 
we see on the ground is that interventions that 
use nutrients that are either destroyed, not 
absorbed or are blocked by other nutrients 
because they are added in the wrong form 
- invariable leave human beings nutritionally disabled.

The official jargon is that such interventions 
(food aid) leaves people lazy and not wanting to 
take responsibility for their own food security 
and result in International agencies having to 
return year after year. I have a different 
view. It is my belief that it is not 'just' the 
'free handouts' of donor funded food that is the 
socio physiological cause of the problem but 
rather the lack of effectiveness from a 
nutritional point of view that leaves people 'partly disabled".

The other issue that is raised by Geoffrey 
Douglas of why International Agencies do not 
utilize or promote state of the art locally 
available knowledge and local nutritional 
initiatives that have proved to be effective 
could perhaps one day become the subject of a 
much bigger debate and international 
investigation on the technical, commercial and 
political issues that drive aid and emergency 
relief. As somebody with a vested commercial 
interest, perhaps my theories and speculations 
would not be appropriate. However, I believe 
that very soon - this issue is going to be the 
subject of an independent investigation that will 
hopefully research and investigate what 
international agencies have done and are doing 
from a technical and commercial perspective. 
These truths need to be independently researched 
and exposed so that future interventions are made 
to be more effective to ensure our continent can 
get on with the job of effectively saving itself 
from the inevitable path of destruction that 40 
years of disastrous failed nutritional interventions have created.

Kind Regards,

Basil Kransdorff
basilb@iafrica.com







----Geoff Douglas wrote:

>[Zeina Makhoul of Washington who writes:
>Does anyone know what is the best approach to supplement moderately
>malnourished (weight for age z score between -2 and -3) HIV-infected
>children with PlumpyNut or Supplementary Plumpy? I read papers where they
>did it per kg body weight but the children were severely malnourished. Are
>there age-specific guidelines for moderate malnutrition where RUTF is used
>as a supplement instead of therapeutic food? Or are there any guidelines for
>treatment of moderate malnutrition?]
>
>
>I am frankly appalled that anyone would even think of promoting or using
>PlumpyNut (30% full fat milk powder, 28% icing sugar, 15% cottonseed oil,
>25% salt free peanut butter and 1.6% multivitamins and minerals in chemical
>isolate form) as a suitable food for children. It may have a place (for 2 &shy;
>4 weeks) in managing starvation in refugee camps, but it is not what hungry
>children need (high fat, high sugar, high protein). If anyone recommended it
>as a children's food in the West, they would be shot.
>
>There is no way that you can make a child nutrient replete with PlumpyNut
>and, as an African citizen, I am not just saddened, I am angry at the way
>the powers-that-be play with my continent, imposing solutions that would
>never be accepted in the West and making people increasingly dependent,
>whilst millions die. It saddens me even more that where local people have
>developed appropriate and empowering interventions, they are often ignored
>or even castigated by International Agencies who have their own agendas.
>
>Children everywhere, malnourished or not, need a diet that is based on whole
>grains. It should be low in fat and sugar. It should contain all the
>vitamins and minerals that would ideally be sourced from fruit and
>vegetables in a form that is bioavailable. Such a product (e'Pap) has been
>available in Africa for years, and has been used successfully with
>malnourished children.
>
>Geoff Douglas
>
>CEO &shy; Health Empowerment Through Nutrition
>
>www.hetn.org
>
>
>------ Zeina Makhoul wrote:
> >
> > Hello,
> >
> > Does anyone know:
> >
> > What is the best approach to supplement moderately malnourished (weight
> > for age z score between -2 and -3) HIV-infected children with PlumpyNut or
> > Supplementary Plumpy? I read papers where they did it per kg body weight
> > but the children were severely malnourished. Are there age-specific
> > guidelines for moderate malnutrition where RUTF is used as a supplement
> > instead of therapeutic food? Or are there any guidelines for treatment of
> > moderate malnutrition?
> >
> > Thanks!!
> >
> > Zeina Makhoul
> > Postdoctoral Research Fellow
> > Fred Hutchinson Cancer Research Center
> > Seattle, Washington
> >
> >
>