RE: [pronut-hiv] Supplementation for moderately malnourished HIV-infected children - Most practical food related interventions (2)

["Muehlhoff, Ellen (AGNP)" <Ellen.Muehlhoff@fao.org>]

Dear colleagues,

I would like to share with you a booklet that gives guidance on how to
improve the energy, protein and micronutrient density of complementary foods,using locally available and affordabel foods only. This was developed by FAO in Zambia,in collaboration with the National Food and Nutrition Commission and support from UNICEF Zambia. Although we have data on a small amount of data so far, far, this approach is proving very popular withmothers/caretakers and children. You can access the booklet on Improved Complementary Foods at the following url:

http://www.fao.org/docrep/010/ai208e/ai208e00.htm

The booklet's focus is on the prevention of malnutrition, where I feel we
need to invest much more substantively in order to ensure that we have impact on reducing levels of malnutrition that are sustainable in the longer term.  

We are about to publish similar more extensive guiding materials for use in
Afghanistan, based on local food and eating patterns and available foods in
different regions and seasons. 

Please get in touch with me if you are interested to learn more about work in this area.

Best regards,

Ellen Muehlhoff
Nutrition Education and Consumer Awareness Group
Nutrition and Consumer Protection Division
Food and Agriculture Organization of the UN
Rome, Italy
Tel. 0039-06- 5705 4113
www.fao.org

-----zohra lukmanji wrote:
  
 This  is  a  great debate and food for thought for those of working in
   the  field  and  always thinking about the most practical food related
   intervention to  manage  severe  and  moderate  malnutrition  in  both
   malnourished  hiv  infected  children  and adults both at the hospital
   inpatient and home level.

    With  relation  to  the  management of severe malnutrition in kids in
   inital  stage  and  thereafter  at the hospital level, we need to have
   something  which  is  energy  dense  and can be tolerated well and can
   promote   some   weight   gain   within   a  short  time.   Right  now
   therapeutic feeds   F75   and  F100  are  widely  used  at the initial
   stage.   It would  be  good to have something else other than milk ( a
   local  product)  in  the stage that follows.  This is a big challenge,
   not only to have an ideal food supplement but also for a peadiatrician
   in charge to accept it.

   As  Ted  pointed  out  it  would be useful to have more information on
   e'pap.  At  present  most of us seem to assume or know of plumpynut as
   RUTF  which  may  not  be  as beneficial in the long run as as already
   indicated by Ted and Basil and others.

   I would really appreicate to hear of any successful initiatives (which
   havde  not  used  plumpunut) with relation to the management of severe
   and  moderate  malnutrion  of  both  hiv  infected adults and children
   anywhere.

   Zohra Lukmanji

   MDH care and treatment for PLWHA

   Dar es Salaam, Tanzania

   Tanzania

---- Ted Greiner" wrote:
   >Dear Basil,
   >
   >    Is  there  a  website  about  e'Pap,  in  particular  giving  its
   ingredients  and  nutrient  composition?  Where is it made? The food I
   could  find reference to on the website Geoff gives www.hetn.org seems
   to be made by a company in New Jersey.
   >
   >    What  are  the  nutrients whose bioavailability you believe e'Pap
   improves compared to other fortified food supplements?
   >
   >    There  is  no longer any surplus mountain of dried milk. It's now
   extremely  expensive  to  buy  powdered  milk, and plumpynut and other
   supplements  include  it only because studies show its addition speeds
   up rehabilitation from malnutrition.
   >
   >    There's  now  a good deal of research and experience in emergency
   settings  with plumpynut and other energy dense heavily fortified food
   products  showing  that it greatly decreases the case fatality rate in
   real  life  settings  for  malnourished  children, allowing them to be
   treated  at home instead of hospital at an earlier stage, saving money
   and  difficulties  for  the families and the childhood victims. MSF is
   strongly  promoting  it  for  use  with  not  just  severely, but also
   moderately  malnourished  children  (based,  as far as I can see, on a
   single large study they did in Niger). See
   http://www.msf.org/msfinternational/invoke.cfm?objectid=88BFF62D-15C5-
   F00A-2541FCBC25DD29EA&component=toolkit.article&method=full_html
   >
   >    That said, I am concerned, as you are, about the high sugar level
   in  plumpynut and some other products--for several reasons. In general
   I feel like young children are introduced to sugar at far too young an
   age all over the world, with a number of harmful effects.
   >
   >   I am concerned also about peanuts, not due to allergy as Naureen M
   Butt told us she is worried about (because I don't think it's actually
   very  common  in populations vulnerable to undernutrition--though this
   may  not  be  completely  true in India, where even well-off families'
   children  often  suffer  from  it),  but  because  if fortified peanut
   spreads get rolled out on the huge scale MSF is calling for, there are
   risks  that  quality  control will get too lax to prevent dangers from
   aflatoxin  exposure  (an  extremely  powerful  carcinogen),  which are
   greater for peanuts than almost any other common food.
   >
   >    More  importantly,  I am quite concerned about overestimating the
   potential  for  such  foods  to  PREVENT  malnutrition  in  real  life
   settings,  no  matter how effective they may be for treatment and even
   for prevention on a small scale. I believe that the activist community
   is  perhaps getting a bit confused by the seeming precedent set by the
   donor  world's  decision  to  provide  universal  access  to  ARVs  --
   something  that is ethically fantastic, but obviously unsustainable in
   low-income  using  only  local  resources. The hundreds of millions of
   children  in low-income settings vulnerable to malnutrition will NEVER
   be  protected  by foods provided from outside the community unless the
   world  decides  that  the  rich  countries  should virtually take over
   control of the entire world's food supply.
   >
   >    Similarly,  there  are  calls,  particularly  by  Paul Farmer and
   Partners  in Health, for treating infant formula the same way as ARVs,
   as  some  kind  of  human  right.  They underestimate the much greater
   complexity surrounding the achievement of safe artificial feeding from
   birth,  which  among  a  large range of other things (clean water is a
   crucial  but  in  fact  minor component of what is required; access to
   close by and free high quality health care is the most important one).
   See
   http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10
   .1371/journal.pmed.0040087
   >
   >    I am copying to Mamane Zeilani at Nutriset (thanks Karine Coudert
   for  providing  us with this email address) and hereby offer to convey
   any response he cares to send to me to this list serve.
   >
   >   Best regards,
   >
   >Ted Greiner, PhD
   >   PATH
   >
   >
   >----Basil Kransdorff 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
   >