Osendarp, S., Rogers, B., Ryan, K., Manary, M., Akomo, P., Bahwere, P., … de Pee, S. (2015). Ready-to-Use Foods for Management of Moderate Acute Malnutrition: Considerations for Scaling up Production and Use in Programs. Food and Nutrition Bulletin, 36(1_suppl1), S59–S64. https://doi.org/10.1177/15648265150361S110

Introduction

Saskia Osendarp et al.’s article, “Ready-to-Use-Foods for Management of Moderate Acute Malnutrition: Considerations for Scaling up Production and Use in Programs” will be analysed in this essay. This article was published in the Food and Nutrition Bulletin (impact factor 1.9), that publishes articles related to policy analysis, scientific and social research and academic reviews. The readers of the journal are primarily researchers and academics related to human nutrition and malnutrition. In this paper, the authors focus on the bottlenecks and provide evidence to locally produce Ready-to-use Therapeutic foods (RUTF) to treat moderate malnutrition. Ready-to-use therapeutic food (RUTF) are energy dense nutritious foods that is used to enhance the nutrition to treat children suffering from severe acute malnutrition (SAM) (UNICEF, 2013). In 2017, 51 million children under five were with acute malnutrition of which 16 million children were severely undernourished (UNICEF/ WHO/ World Bank, 2018). According to the Lancet Series on Maternal and Child Nutrition, management of acute malnutrition as community-based intervention has a high impact reducing child undernutrition and is therefore essential. This is also evidenced by the meta-analysis conducted by (Lenters, Wazny, Webb, Ahmed, & Bhutta, 2013) in which, community-based treatment of severe acute malnutrition is compared with standard inpatient treatment of malnutrition. This systematic study shows that children who were given RUTF were 51 per cent more likely to recover (Lenters et al., 2013). The main ingredients for conventional RUTF are peanuts, oil, sugar, milk solids and premix vitamin and mineral supplements to increase the bioavailability of micronutrients (WHO, 2013) and requires strong packaging materials to maintain the shelf life of the product and maintain its safety. Due to the high cost of production and lack of required technology in developing countries, RUTFs are generally imported. One of the widely used RUTF is Plumpy’ Nut, which is a peanut based product. However, a recent study conducted in Cambodia on the acceptance of Plumpy’ Nut showed that it was not readily accepted by children and parents due to its varying organoleptic qualities compared to their local foods (Nga et al., 2013). The authors of this paper aim to encourage a locally produced RUTF that is adapted to the local taste with similar nutrition bioavailability.

Content of the article and its evaluation

According to the authors the production of RUTF is standardized and with clear guidelines on the quality and content by the WHO. The authors focus on the sustainability of the RUTF and its use to treat moderate acute malnutrition. The energy and nutrient requirement for moderate acute malnutrition (MAM) is lesser than for treatment of severe acute malnutrition. Consumption of RUTF for MAM is in smaller quantities that also includes appropriate complementary feeding (WHO, 2005). Since treatment of MAM also includes intake of breastmilk in combination of local foods, the ready-to-use foods need to balance out adequate dietary needs to treat MAM.  (Osendarp et al., 2015). Two of the concerns highlighted are the requirement of financially sustainable locally produced RUTF and effective use of the it when produced at larger scale. The authors suggest two tools that can be utilized in the production of local RUTF which is essential in order to produce quality and hygienic RUTF without compromising its nutrient level.

With the development of new technologies and ICT, novel foods can be designed to adapt regional requirements and taste. To identify the right proportion, ratio and combination of ingredients to be used in the production of RUTF, a linear programming tool can be utilized to maximize the formulation by choosing different combination of foods that are locally available and cost effective (Osendarp et al., 2015). Optifood developed by WHO in collaboration with London School of Hygiene and Tropical Medicine, FANTA and Blue-Infinity is one such tool that allows users and experts to formulate a diet recommendation by designing a combination of locally available ingredients to a desired nutrition requirement (USAID & FANTA Project, 2013). It also allows users to give recommendation based on cost analysis and feasibility with regards to acceptability and nutrition values. This tool has been successfully used to design locally made RUTF in Bangladesh, Pakistan and Ethiopia where the key ingredients for nutrition dense food is made to incorporate locally available crops such as rice, lentils and chickpeas, whereas east African countries and Malawi has incorporated staples such as sorghum, corn, sesame, chickpea and whey protein and in Afghanistan almond based RUTF formulation is created (Osendarp et al., 2015). Most of these locally created formulations avoids the use of milk-based ingredient to reduce the cost of production and tends to avoid peanuts as both requires special packaging techniques and storage conditions. Without proper packaging conditions and in a high moisture and temperature countries, peanuts have a high incidence of aflatoxin, a carcinogenic toxin that can pose a serious health risk (Department of Food Safety and Zoonoses, WHO, 2018).

The authors analyzed the limitations to using linear programming tools in developing countries. Considerations such as environmental factors affecting agricultural production, bioavailability of nutrients based on crop variety and agricultural practices can probe as challenges. Since most developing countries’ agriculture is rain-fed and dependent on climatic conditions, crop productions usually vary depending on the climatic conditions therefore affecting the production of local RUTF. Effective use of locally produced RUTF and inclusion within the health system will require scaling up of production.

Since 2000 when UNICEF first started procuring RUTF for the use of the treatment of acute malnutrition, the use and production of RUTF worldwide has expanded rapidly. In the paper the author mentions the urgency to scale the production of RUTF to meet the demand and supply gap. UNICEF is the largest procurer of RUTF. In 2016 UNICEF procured around 33,000 metric tons (MT) of RUTF and 35000 MT of RUTF in 2015 to treat around 2.5 million children each year (UNICEF, 2017) which is a six fold increment to the procurement done in 2009 (UNICEF, 2014). However, there is still a huge gap between the its production and coverage if every country incorporates the use of RUTF within their policy and health system to treat acute malnutrition. With only 3 countries utilizing RUTF in 2000 to currently over 60 countries, there are still gaps to cover. However, many Asian countries prefer RUTF that is not based on peanuts to incorporate within the local diet and organoleptic factors (UNICEF, 2017) where locally manufactured RUTF can provide coverage.

Scalability of productions at a community level to produce larger quantities can also be a challenge with lack of adequate technology and capacity. Even though production in developing countries have increased over the years especially from South Asia and African regions, procurement has either reduced by 25 per cent or remained stagnant (UNICEF, 2017) . This is due to the strict quality control and guidelines for the product which local suppliers are unable to adhere to. Therefore, imports from European manufactures are still required to fill the gap. Technical knowledge on food safety, good manufacturing practices, good agricultural practices, food safety and management system, HACCP needs to be adhered to ensure cost-effective, hygienic and safe product that can be utilized to treat children with acute malnutrition (Osendarp et al., 2015). Adherence to strict compliance should be mandated by local producers as children are most vulnerable to undernutrition and susceptible to harmful consequences of deficiencies, toxicity and diseases.

The authors of the article recommend the need for capacity building with the use of sound business plan and technical assistance to implement the process of scale-up with limited barriers. The authors report the need for private partnership and external support for technical assistance, technology transfer and marketing of the product to ensure effective use of the product at the initial phase of scale up (Osendarp et al., 2015). Health system strengthening with the support from various stakeholders and nutrition sensitive and specific interventions such as hygiene, good sanitation practices, promotion of breastfeeding, incorporation of complementary feeding, nutrition sensitive agricultural practices to support diet diversity are required.  In addition, a robust monitoring and evaluation framework for the quality and production as well as post production activities is required for the scaling up of local RUTF.

Conclusion

Globally with 51 million children facing undernutrition (UNICEF/ WHO/ World Bank, 2018), RUTF is the way forward to treat acute malnutrition in developing countries. With the use of ICT software and external support, developing countries can check the feasibility of the novel product and consider various challenges during the process, This article clearly develops the evidences to support the requirement of locally produced RUTF and considerations one might need to take if scaling up is conducted. With the demand increasing for familiar flavored RUTF as the local diet, countries must equip themselves with necessary support and institutional capacity for scale-up activities to improve child health and undernutrition.

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