Putting nutrition products in their place: ACF position paper

Summary of position paper¹

Action Against Hunger | ACF International has recently produced a position paper on the role of products in the treatment and prevention of global acute malnutrition (GAM). The paper focuses on the treatment of severe acute malnutrition (SAM), looks at the prevention and treatment of moderate acute malnutrition (MAM) and considers the role of nutritional products as part of broader strategies to build resilience to, and prevent, under-nutrition. The paper is written to be accessible to field staff requiring guidance on whether or not to use a certain type of product, and also to provide clear guidance on ACF’s position for policymakers. The following is a summary of the key points in this paper.

The role of management within protocols addressing SAM

Action Against Hunger | ACF International recognises that there are multiple factors that contribute towards recovery of patients from SAM. Whilst therapeutic products, including Ready to Use Therapeutic Foods (RUTF), have been a proven key element of success, it is important to note at the outset that the supply of a product is accompanied by other components. A medical protocol is used to tackle underlying infections and to respond to new or worsening symptoms appropriately. Within outpatient care, weekly follow-up is essential, with criteria of how to respond to patients who are not recovering properly. Inpatient care requires continuous observations by qualified medical personnel. Continual emphasis is placed on the role of appropriate infant and young child feeding (IYCF) within sustainable recovery. A number of ACF missions have found it helpful to introduce focus groups, individual counselling and home follow-up of non-responders and defaulters as ways of improving recovery rates and reducing the proportion of defaulters. In ACF’s experience, even if the supply chain of RUTF is disrupted temporarily, the continuation of good management procedures that emphasise these other programme elements can help ensure successful outcomes.

RUTF local production and validation

ACF procures RUTF directly from a variety of suppliers. However, many projects receive inkind contributions from UNICEF, which may be sourced from further suppliers. ACF is in the process of validating several suppliers and is designing its own approval protocol following UNICEF and Médecins Sans Frontières (MSF) validation mechanisms. ACF would support the establishment of an independent approval board so that it is not only the main RUTF customers who are the quality regulators.

ACF see the potential advantages of procuring RUTF from local suppliers based in developing countries using local food products wherever possible, and is therefore fully supportive of this approach. ACF will be pursuing a validation process with local suppliers where product efficacy, safety and quality have been demonstrated.

RUTF and patents

ACF acknowledges that the global demand for RUTF will continue to increase, particularly as RUTF usage becomes integrated into existing health systems. No single producer can be relied upon, due to constraints in production capacity and in the global supply chain. ACF therefore welcomes the steps Nutriset have taken recently to make the patent agreement more accessible to local producers. ACF does not consider patents as inherently wrong, recognising the role they can play in protecting RUTF quality and local producer viability, so long as measures continue to be put in place to ensure a sustainable global supply chain of RUTF.

RUTF acceptance

ACF encourages governments to evaluate the wealth of existing data that supports use of RUTF in the treatment for SAM. ACF supports widespread uptake of the community based management of acute malnutrition (CMAM) approach by health facilities and communities through government management, and the local production of RUTF to meet the demand. The scale-up of CMAM should be alongside (and not replace) initiatives that look at all forms of malnutrition.

Cost of RUTF

Since the cost of many RUTF products is highly linked to fluctuating milk powder prices, ACF welcomes continued research into lower cost alternatives using locally available products. ACF also recognise that locally-made RUTF products may not be inexpensive, due to lack of subsidies for key ingredients as found in some developed countries. However, ACF feels the added benefit to the local economy brought about by local factories should be factored into any cost-benefit analysis when choosing products, and suggests that quantitative research into such local benefits is continued and published. ACF believes that for now, RUTF is the most effective treatment for SAM when used with proper management and medical protocols, and should be continued despite the higher product costs in comparison to other nutrition interventions. ACF advocate for the scale-up of the treatment of SAM.

Coverage and funding of SAM treatment

ACF fully supports the scaling up of CMAM activities for the treatment of SAM. RUTF production and the CMAM approach needs to be dramatically increased if all children with SAM are to be reached. ACF believe that the only way to achieve substantial coverage is through supporting governments to integrate the CMAM approach into existing health facilities where possible.

RUTF and impact on breastfeeding

ACF fully supports and agrees that exclusive breastfeeding for infants less than 6 months of age is essential for optimum child health. ACF actively promotes this best practice, as well as advocating for sustained breastfeeding for children aged 6-24 months and beyond. As a treatment for SAM, ACF does not consider that the use of RUTF undermines breastfeeding, but acknowledges that careful follow-up should monitor this risk. If international protocols are followed, then no RUTF should be given to infants below 6 months. For children aged 6-24 months, breastfeeding is actively encouraged before the child is offered RUTF.

Potential negative impacts of rapid weight gain following RUTF treatment

There is research indicating an association between rapid childhood weight gain of thin children and later chronic disease. It is not clear whether the short period of weight gain seen in SAM children would have any negative consequences later in life, particularly if the child returned to a normal weight after recovery. Rapid early weight gain and then continued obesity for childhood would seem to be a greater cause for concern, although more research is needed to verify this. ACF will continue to treat SAM children with RUTF as part of the management protocol due to the elevated risk of immediate mortality, but acknowledges the clear need for further research.

Summary of ACF position on products designed for the treatment of MAM

Regarding the use of products for treating MAM (which is not the only available approach):

• ACF acknowledges that programmes involving traditional corn soya blend (CSB) have not been highly effective, and that the general trend coming out of recent research shows ready to use supplementary foods (RUSF) may be a viable and potentially more effective alternative.
• Much of the research involving RUSF has come out of Malawi and Niger, and ACF welcomes further research in different settings to help validate RUSF for international use. ACF will also continue with its own research on the topic.
• CSB++ is a promising product that has been re-designed to take account of many of the nutritional limitations of traditional CSB. Lack of field-based evidence surrounding CSB++ makes it difficult to take a position on it at this stage, but ACF welcomes further research on it.
• Fortified blended foods with the addition of oil can be effective if efforts are made to minimise defaulting. ACF recommends continuing use of such products due to their lower cost and often local availability. If CSB++ is not available, and fortified oil is not available to accompany other fortified blended products, then effectiveness will be compromised. In this scenario, ACF recommends the use of a RUSF.
• ACF notes the potential effectiveness of RUTF in treating MAM but does not support this practice. If given a choice between RUTF and RUSF for the treatment of MAM, ACF recommend using RUSF due to the importance of keeping a sustainable pipeline of RUTF for those who most need it and its sometimes lower cost. It is important to avoid any potential confusion in the community regarding the use of RUTF as part of treatment and not as a food which should be shared or sold.
• Good management of programmes, including close follow-up of children, and counselling in relation to caring and feeding practices is just as important as the choice of product. Further research is needed on this topic.
• ACF stresses the need to remember that products given for the treatment of MAM should be given in conjunction with the international medical protocol and close follow-up.

Summary of ACF position on products designed for the prevention of acute malnutrition

ACF regards IYCF best practices as crucial in the effort to prevent malnutrition. Every effort should be made to ensure that the introduction of products does not undermine breastfeeding, and any focus on a product intervention should always be accompanied by adequate IYCF work. This should include the promotion of, and support to, appropriate caring practices and understanding what the barriers are to good IYCF and caring practices.

There are many approaches to preventing acute malnutrition, of which the provision of products is just one option. Preventing malnutrition requires a multi-sectoral approach and therefore, even if products are used, they should only form one part of the response.

Where it has been determined that a direct nutritional intervention is required, a food-based approach should be used where possible to prevent acute malnutrition because of its lower cost, better sustainability and cultural appropriateness. However, in contexts of displacement or natural disasters where food supplies have been cut off, products may be the only viable option to prevent a high caseload of patients with acute malnutrition. In this scenario, Ready to Use Complementary Foods (RUCF) could be used. ACF consider that RUTF or RUSF should not be used in prevention due to their overlap with treatment of SAM and MAM.

ACF acknowledges that there is not enough evidence in the field of products and preventative malnutrition and is continuing to conduct its own research in the field.

Overall summary

The solution to the management of acute malnutrition does not lie with products alone. Nutrition causal analysis should be used to determine which integrated approach should be used. Products can play a supporting role, but need to be considered as part of a wider package of support. Indeed, periods when there are temporarily reduced or interrupted supplies of therapeutic products emphasize the importance of continued medical monitoring and management to contribute to successful outcomes for the affected individuals and their families.

Treatment of SAM requires the use of therapeutic milks and RUTF in accordance with the CMAM approach.

The management of MAM is less clearcut. There is often an artificial divide between treatment and prevention, and approaches designed for one can have an impact on the other.

If a direct nutrition intervention involving supplementation of diets is required, the choice between products and a food-based approach depends on the context and take into consideration nutrition requirements, nutritional quality, time frame, sustainability, programme setting, available funding and cultural acceptability.

The field of nutrition products is rapidly evolving. ACF will continue to conduct relevant research to help inform programme policy. A continual review of ACF positions will be needed as more products become available and as more research findings are shared.

For more information on ACFs position, contact: Sandra Mutuma, email: s.mutuma@actionagainsthunger.org.uk

ACF are not alone in having to consider how and when to use various products in programmes that prevent or manage MAM in different contexts. We would welcome your thoughts and experiences on this topic and have opened an ennet discussion around this at http://www.en-net.org.uk under ‘Prevention and treatment of moderate acute malnutrition’. Letters to Field Exchange on this topic are also welcome. Send to: marie@ennonline.net

¹AAH/ACF International (2011). Products are not enough: Putting nutrition products in their proper place in the treatment and prevention of global acute malnutrition. Summary Paper, November 2011