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[pronut-hiv] Plumpy, food of choice for malnutrition in emergency settings
- From: "Billing, Nathan" <Nathan.Billing@chelwest.nhs.uk>
- Date: Wed, 12 Dec 2007 17:54:08 -0000
Basil,
My understanding from the initial communications around Plumpy nut was
that it was the food of choice for malnutrition in emergency settings.
I also understand that the conversation has moved on to cover some
really interesting local alternatives that should be the first choice as
they do not discourage staple foods and would be more sustainable in the
long term. However these foods would require space and a secure safe
water supply in order to prepare them and these may be difficult to
obtain in overcrowded refugee camps.
Having a supplementary product that does not require any reconstitution
minimises the chance of contamination occurring from either
* the water source used to reconstitute
* from errors/unhygienic practices during reconstitution e.g.
contamination from dirty utensils, unsafe hand hygiene etc
I am not sure I can comment on the relevance of Colony forming Units
(CFU) in Plumpy nut, I do not make these food products and your company
Econocom Foods does. (http://www.epap.co.za/celanem.html)
But I do agree that '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', but this could be where
all that sugar comes into play.
By having a high sugar content you will be able to reduce the water
activity level of the supplement thereby preventing the colonies within
the supplement growing. Also because you are not reconstituting it I
assume you can get away with a slightly higher CFU count.
There is more about water activity here
http://www.decagon.com/aw/fundamentals3
I hope that answers your questions and if I am wrong in my assumptions
then I would be grateful to hear from others why plumpy nut has such a
high sugar content.
It would also be interesting to find out more about how you practically
go about avoiding the re-feeding syndrome when you are using such and
energy dense food in severely malnourished patients and do not have
regular blood biochemistry tests available.
http://www.medscape.com/viewarticle/489090_4
http://ncp.aspenjournals.org/cgi/content/abstract/20/6/625
Kind regards,
Nathan Billing RD
Specialist HIV Dietitian
Chelsea and Westminster NHS Foundation Trust
<http://www.chelwest.nhs.uk/hiv-sexual-health/choose-us-for-hiv-services
.html>
Direct Line Tel: 020 8746 8176 or
Tel: 020 8846 1000 Bleep 4150
-----Basil Kransdorff wrote:
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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