RE: [pronut-hiv] Safe water and malnutrition in children (2)

["Quick, Timothy C (GH/OHA/TLR)" <TQuick@usaid.gov>]

A food product that requires reconstitution with water is very unlikely
to introduce contamination/infection to infants and other members of the
family since they are very likely already drinking and consuming
contaminated water in other foods.  It seems more practical to make sure
that these families have access to point-of-use treatment (POUT) of
household water -- chlorine/WaterGuard, boiling, filtration, etc.
Families need both nutrition foods and clean water.

Tim Quick, PhD, MS
Senior Technical Advisor for HIV/AIDS & Nutrition
Co-Chair, PEPFAR Food & Nutrition Technical Working Group
USAID Office of HIV/AIDS, 5.10.20
1300 Pennsylvania Avenue NW
Washington, DC 20523
1-202-712-0974 (office)
1-301-275-6652 (cell)
1-202-216-3015 (fax)
tquick@usaid.gov
 
 

-----Mundi Stella wrote:

  Basil Kransdorff wrote:
  "...The argument that it is not the product that is not safe but 
  potential contamination of water  that is the reason that such a 
  solution cannot be used is not in my view a  valid approach to 
  addressing the problem" 
   
  Access to a clean and safe source of water is an important factor to
take into consideration when promoting any type of supplement for infant
feeding.   It is not just about the energy and nutrient density of the
supplement. If access to safe water is limited, which is often the case
in most settings in Africa, and if the supplement has to be
reconstituted with water,  the supplement should NOT be
introduced/promoted. Diarrhea is one of the first causes of child
mortality in Africa and contaminated water and food contribute to this.
When addressing malnutrition, we should have UNICEF framework of
malnutrition (feeding practice + care + hygiene) in mind.  Most people
in resource limited settings cannot afford all these supplements. 
   
  Stella
   
  -------------------------------------------------------
  Hi Nathan,
  I refer to your quote - I guess the major draw back of these 
  supplements is the fact that they need to be reconstituted with 
  water, which may not safe and one of the
  reasons people are going for plumpy nut (which given its high fat and 
  sugar content probably has a low water activity level and is less 
  prone to bacterial contamination
  This issue you raise is in my view not a valid argument because 
  people need water daily to survive.
  Arguing that the water might not be safe is NOT an argument NOT to 
  utilize a piece of good technology and an approach that has the 
  ability to deliver solutions to nutrient deficiencies in the form of 
  a pre-cooked food that requires water for reconstitution. I have 
  been given this argument by OXFAM who argue that they are not able to 
  fund good nutrition in the form of a pre-cooked nutrified food that 
  requires reconstitution with water because of the issue you raise.
  The argument that it is not the product that is not safe but 
  potential contamination of water that is the reason that such a 
  solution cannot be used is not in my view a valid approach to 
  addressing the problem. If one takes this argument to its ridicules 
  conclusion - why not argue and tell those unfortunate victims of 
  poverty that they must also STOP drinking water in case the water is 
  contaminated. It is not an argument that a product like PLUMPINUT - 
  just because it does not require reconstitution that somehow it will 
  have a low CFU count. CFU counts are a product of how the raw 
  materials are prepared mixed and packaged. Any nutrient dense food 
  is liable to be contaminated in the production process. Peanuts are 
  an ideal source of contamination especially if the products used are 
  not properly controlled to ensure only 1st grade peanuts must be 
  used. The point is - bacterial contamination is not just caused by 
  reconstitution - it is also created by the choice of raw materials 
  and their preparation and how they are packaged. What is more 
  important is what they contain and once again - like a scratched 
  record - WHY add large quantities of refined sugar?
  We manufacture a peanut butter nutrified with 28 nutrients. We DO 
  not add 30% sugar. We focus on bio-availability of the nutrients and 
  therefore make a big issue on the form of the nutrients we add. The 
  product is NOT sold as a miracle RUTF food (see CNN) that can 
  address malnutrition - it is a line extension that can deliver 
  nutrients that have clinical data to show it is a product that can 
  support and address nutrient deficiencies. The product has very low 
  CFU counts - not because it does not need to be reconstituted but 
  because of the way it is prepared.
  Basil Kransdorff
  At 12:42 PM 12/6/2007, you wrote:
  >George,
  >
  > There are a number of companies that make nutritional support
products
  >that we use here in the U.K. and as health professionals we do not
  >necessarily endorse the products, in fact against our code of conduct
to
  >endorse one product over another as state registered dieticians.
  >
  >However we do have the range of products available to prescribe
  >controlled within the NHS by the Advisory Committee on Borderline
  >Substances.
 
>http://www.pasa.nhs.uk/PASAWeb/Productsandservices/Pharmaceuticals/ACBS
.
  >htm. Maybe there needs to be similar consensus amongst the
nutritional
  >community at large as to which products would be preferred to be used
  >for malnutrition programmes.
  >
  >Also although some companies have done significant damage in
developing
  >countries through aggressive marketing of their products I do not
feel
  >that this is the forum to debate why companies listed on the stock
  >exchange main ethical responsibility are to it's share holders rather
  >than the greater community they work in. If they did not make profits
  >they would be out of business and we would not have their products to
  >use.
  >
  > Anyway back to the question at hand "which is best approach to
  >supplement moderately malnourished HIV-infected children?"
  >
  > There are a number of products other than e-pap or plumpy Nut that
are
  >available that I have had the experience of using while working in
South
  >Africa that have not been mentioned in this forum.
  >
  >http://www.diva.co.za/product_info.php?product=Nutri-mil 
  >
  >The complete range
  >
  >http://www.diva.co.za/product_category.php?cat=Supplemental 
  >
  >I guess the major draw back of these supplements is the fact that
they
  >need to be reconstituted with water, which may not safe and one of
the
  >reasons people are going for plumpy nut (which given its high fat and
  >sugar content probably has a low water activity level and is less
prone
  >to bacterial contamination).
  >
  >Bacterial contamination is a huge problem when it comes to
  >reconstituting feed was demonstrated earlier this year in a study by
  >Marino et al S Afr Med J. 2007 Jul;97(7):534-7.
 
><http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&;
T 
 
>ermToSearch=17805457&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pu
b
  >med_ResultsPanel.Pubmed_RVDocSum> . They concluded 'Ready to use
  >infant feeds are sterile and are recommended for use in all
hospitalised
  >infants. The results of this study indicate that even when milk is
  >prepared in a controlled environment there is significant bacterial
  >contamination of paediatric infant feeds post production.'
  >
  >I look forward to hearing of other potential solutions to this
problem
  >and to further lively debate.
  >
  > Nathan Billing
  >
  >Specialist HIV Dietitian
  >
  >Chelsea and Westminster NHS Foundation Trust
  >
  >Direct Line Tel: 020 8746 8176 or
  >
  >Tel: 020 8846 1000 Bleep 4150
  >
  >
  >----- George Carter wrote:
  >
  >
  >Ross Labs is owned by Abbott which manufactures the Ensure.
  >
  >
  >
  >Then there is always Nestle, another DEAR friend of the African
  >
  >people. See, e.g., http://www.ibfan.org/english/news/press/ 
  >
  >press15may01.html
  >
  >
  >
  >They make Nutren which is little better than the Ensure sugar/water/
  >
  >bad fat fiasco. And claim a doctor is needed to figure out who to
  >
  >give this garbage to.
  >
  >
  >
  >and another here:
  >
  >http://www.babymilkaction.org/CEM/compapr00.html 
  >
  >
  >
  >and yet another--
  >
  >http://www.westonaprice.org/children/tricks.html 
  >
  >
  >
  >Quote: The baby food industry has used and needs health professionals
  >
  >to endorse, distribute and sell its products. According to an Abbott
  >
  >Labs publication, "As the voice of Abbott, Abbott Topics can be a
  >
  >positive force molding the physicians' opinion of Abbott. In effect
  >
  >we are striving to make the physician a low-pressure salesman of
  >
  >Abbott."
  >
  >
  >
  >These companies really do not seem to give a damn who or how many
  >
  >they harm or kill as long as profits, profits, profits are increasing
  >
  >exponentially to keep the parasites on Wall Street happy. I'm
  >
  >grateful to the moderators for having galvanized me into examining
  >
  >these practices more carefully. I think it behooves everyone on this
  >
  >list to be extremely doubtful of claims made by second rate salesmen
  >
  >from the industry that has sought so assiduously to cause enormous
  >
  >suffering and death by blocking access to generic HIV and other
  >
  >medications. (A happy note: Pharmaceutical company Matrix
  >
  >Laboratories said it has received tentative approval from the US Food
  >
  >and Drug Administration (FDA) for Tenofovir Disoproxil Fumarate
  >
  >tablets, used for the treatment of HIV infection.)
  >
  >
  >
  >Realizing that the US and European "private sector" has nothing to
  >
  >offer Africa and developing nations but more rape, let us return to
  >
  >the discussion with renewed vigor on local, sustainable and healthful
  >
  >programs of nutrition for children and mothers with and without HIV
  >
  >infection. I think the data from this past year's Retrovirus
  >
  >conference further underscored the safety and practicality of
  >
  >exclusive breastfeeding for HIV+ mothers, where and whenever that is
  >
  >feasible.
  >
  >
  >
  >George M. Carter
  >

       
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