Alternative RUTF formulations (Special Supplement 2)
By Steve Collins & Jeya Henry
Developing CTC programmes that use Ready to Use Therapeutic Food (RUTF) made locally, from locally available produce, and used to treat malnutrition and HIV amongst the local population, is an important vision for the future of CTC. This article describes research work into developing new RUTFs.
Basis of RUTF
To date, the commercial forms of RUTF are either BP100, a compressed biscuit made by Compact, or Plumpy nut, an oil based paste developed by IRD and Nutriset in France (22). Technology to make compressed biscuits is complicated and expensive and not transferable to small scale manufacturers in developing countries. By contrast, oil based pastes such as Plumpy'Nut can be made using simple technology that is easily transferable to small scale local producers in developing countries. Plumpy'Nut is made from peanuts, sugar, milk powder, vegetable oil and a vitamin mineral mixture. Although this combination of ingredients produces a product that is very well suited to the treatment of acute malnutrition, the recipe has several features that decrease its suitability as a candidate for widespread local production. Milk powder is expensive and often must be imported - in Malawi the cost of milk powder represents over half the cost of the final RUTF. Peanuts are also notorious for being contaminated with aflatoxin and this greatly complicates the quality control of small scale production. There is also growing concern about allergic reaction to peanut and their high phytate:zinc ratio (which increases the risks of binding all micronutrients) thereby reducing their suitability.
The idea of developing local, low cost RUTF, rich in protein, energy dense and suitable for feeding to young children and other vulnerable groups, arose in the early 1950s largely due to the work of Jelliffe (1955) and Brock (1961). The simplest recipe for RUTF is one which has only two ingredients, for example a cereal or root mixed with a legume. However, other foods must be added to this basic mix in order to make a multimix that is nutritionally suitable for the treatment of acute malnutrition. A nutritionally suitable multimix for RUTF has four basic ingredients:
- A staple as the main ingredient - preferably a cereal.
- A protein supplement from a plant or animal food - beans, groundnuts, milks, meats, chicken, fish, eggs, etc. To be practical such foods must be low-cost, and this requirement has pushed development towards legumes and oilseed as these are cheaper than products containing milk or other animal products.
- A vitamin and mineral supplement - a vegetable and/or fruit.
- An energy supplement - fat, oil or sugar to increase the energy concentration of the mix.
In addition, an ideal RUTF formulation must have the following attributes:
- Good nutritional quality (i.e. protein, energy and micronutrient content)
- Long shelf life
- Highly palatable with a good taste
- A consistency and texture suitable for feeding to children
- Require no additional processing prior to feeding
- Amino acid complementation for maximum protein quality
- Product stability
- Ingredients should be easily available in developing countries
Numerous cereal, legume and oilseed mixtures were evaluated on the basis of the above criteria. In particular, efforts were made to combine the various cereal, legume and oilseed mixtures to maximise the protein quality, attempting to offset any essential amino acid deficiencies in one ingredient by combining it with another ingredient that was high in that particular amino acid. This process led to a list of 13 products that had reasonable theoretical properties. Following numerous products development trials, the list was reduced to three potential alternatives. The foods were prepared from roasted or processed ingredients with total exclusion of water. They had low dietary bulk, low potential for bacterial contamination and were ready to eat without cooking. Similarly, the commodities chosen had the most appropriate energy density and high biological value of protein. Moreover, the proposed foods had an optimal physical characteristic of being soft in consistency, easy to swallow and suitable for infant feeding1. The three most suitable recipes were:
Rice - Sesame' RUTF 1
Ingredients: Roasted rice flour, roasted sesame seeds paste, Soyamin 90, sunflower oil, icing sugar, vitamin and mineral premix (CMV therapeutique, Nutriset).
|Roasted rice flour||20.0 %|
|Soyamin 90||8.0 %|
|Roasted sesame seeds paste||29.0 %|
|Sunflower oil||19.4 %|
|Icing sugar||22.0 %|
'Barley - Sesame' RUTF 2
Ingredients: Roasted pearl barley flour, roasted sesame seeds paste, Soyamin 90, sunflower oil, icing sugar, vitamin and mineral premix (CMV therapeutique, Nutriset).
|Roasted pearl barley flour||15.0 %|
|Soyamin 90||9.0 %|
|Roasted sesame seeds paste||27.0 %|
|Sunflower oil||24.0 %|
|Icing sugar||23.4 %|
'Maize - Sesame' RUTF 3
Ingredients: Roasted sesame seeds paste, roasted maize flour, roasted chickpeas flour, sunflower oil, icing sugar, vitamin and mineral premix (CMV therapeutique, Nutriset).
|Roasted maize flour||33.4 %|
|Roasted sesame seeds paste||27.0 %|
|Roasted chick peas flour||25.0 %|
|Sunflower oil||12.0 %|
|Icing sugar||15.0 %|
It is important to emphasise that the cereals, legumes and oilseeds were all roasted prior to the milling into flour, as the use of raw non-roasted commodities could lead to the presence of potentially high levels of anti-nutritional factors and phytates. In keeping with the recommendation of the UN nutritional standards (Codex) sunflower oil was used in all products in order to meet (n-3) and (n-6) fatty acids requirement. It is usually specified that at least 3 to 10% of total energy should be provided by (n-6) fatty acids and 0.3 to 2.5% by (n-3) fatty acids.
|Table15: RUTF-1, RUTF-2, RUTF-3 and Nutriset Plumpy'nut® nutritional composition per 100g and percentage contribution to energy|
*Protein and fat are reported to contribute 11% and 57% in energy input. Total energy is reported to be 530 kcal/100g and moisture < 5%.
**The energy has been calculated using Atwater factors.
***Carbohydrate is by difference assuming protein to be nitrogen (N) times 6.25.
|Table 16: Mineral analysis for RUTF products|
|Table 17: Water activity (aw) in 3 RUTF samples|
|RUTF samples||Water activity|
To ensure that the products were safe and appropriate for field testing, macro nutrient and micronutrient composition, water activity, levels of microbial contamination and indices of rancidity (free fatty acids and peroxide values) were tested. The results (presented in tables 15, 16, 17 and 18) demonstrated that the nutritional composition, with the exception of iron, of each of the new RUTFs is close to Nutriset's Plumpy'Nut®. The products are palatable, stable and microbiologically safe.
Using the basic formulation outlined above, it would be easy to alter the amount of macronutrient and/or micronutrient of the products by varying the oilseed-cereal-legume combinations and/or the mineral and vitamin mixture. The low level of iron could be easily rectified by increasing the level of iron added to the premix. Table 18 demonstrates that the three new products have low water activity, similar to that of dried coffee, and below the level required to support any form of bacterial or even fungal growth. This finding was supported by bacterial analysis that demonstrated that for all the pathogens tested, the results were within microbial specification for this type of food.
These studies demonstrate the potential of new RUTF, produced from locally available grains and legumes, without the addition of milk powder or peanuts. Eliminating milk powder and peanuts and using local grains should allow these products to be made very much more cheaply than the $3,500 USD / MT that Nutriset charge for Plumpy´nut®, and more cheaply than the $2,000 USD / MT cost of the locally made peanut-based equivalent in Malawi (see section 5.21). Clinical field trials are now being conducted in Malawi, to compare the effectiveness of these new RUTFs with locally made RUTFs that include peanuts and milk powder, in treating severely malnourished children.
|Table 18: Interaction between aw and microbial proliferation in some foods|
|0.98||Fresh meats, Fish, vegetables, Milk||Most food spoilage and food-borne pathogenic organisms grow|
|0.85 - 0.60||Flour, cereals, Nuts||No pathogenic bacteria grow|
|0.60||Confectionery, noodles, dried Milk||Microorganisms do not multiply but can remain viable for long period|
|0.30 - 0.20||Biscuits, Instant coffee||No viable microbial growth|
Source: Peter Fellows (2000)
These new RUTFs are eaten uncooked and have a low water content. This makes them suitable vehicles to deliver not only vitamins/antioxidants, but also probiotics and prebiotics (see box).
Synbiotic enhanced RUTF, designed with high levels of certain micronutrients, have recently been shown to slow the progression of HIV/AIDS. These may have huge potential in the treatment of HIV/AIDS, as well as acute malnutrition and a whole range of other illnesses and post operative conditions associated with diarrhoea and wasting, in particular. The current trial in Malawi is therefore also examining the effect of adding a mixture of probiotic and prebiotics called Synbiotic 2000 forte (Medipharm AB, Kågeröd, Sweden) into the new RUTF. In this study it is planned to test the effectiveness of synbiotics in combination with RUTF, in the treatment of patients recovering from severe malnutrition. As severe acutely malnourished children have features of immuno-suppression similar to some of those found in HIV/AIDS, it is hoped that this study will also provide initial evidence into the feasibility of using RUTF-synbiotic combinations, to slow the progression of HIV.
What are probiotics and prebiotics?
Probiotics are usually bacteria from the lactobacillus family
that have at least five beneficial therapeutic functions:
They reduce or eliminate a range of potentially pathogenic micro-organisms
They reduce or eliminate various toxins, mutagens, carcinogens, etc.
They modulate the innate and adaptive immune defence mechanisms.
They promote apoptosis (the process of programmed cell death or cell suicide).
They release numerous nutrient, antioxidant, growth, coagulation and other factors necessary for recovery (28). Prebiotics are generally polysaccharides, plant fibres that are resistant to digestion by human digestive enzymes.
They exhibit strong bio-activity, exerting their effect through increasing the adherence of non-pathogenic bacteria to intestinal mucosal cells and via the generation of beneficial short chain fatty acids in the large intestine. Recent studies have demonstrated that when taken orally prebiotics can assist in recovery from infectious diarrhoea (29).
Recent results from prospective controlled trials in post operative surgical patients and after transplantation and immuno suppression, suggest that combinations of pre and probiotics, referred to as 'synbiotics', can reduce greatly the incidence of post operative infection, shorten recovery times and reduce the need for antibiotics (24;25). Other researchers have demonstrated benefits of probiotics in the treatment of lactose intolerance, viral diarrhoea and antibiotics-associated diarrhoea (26).
1Infants over six months.
More like this
4.1 CTC from Scratch - Tear Fund in South Sudan By Ed Walker (Tearfund) Beneficiaries collecting their general ration in South Sudan. Tearfund has been working in Northern...
By Tina Krumbein, Veronika Scherbaum, and Hans Konrad Biesalski Tina Krumbein is a graduate nutritionist. This article forms part of her diploma thesis submitted to the...
By Filippo Dibari, Valid International Filippo Dibari studied Food Science and Technology and more recently Public Health Nutrition at the London School of Hygiene Tropical...
Summary of research1 Location: Global What we know: RUTF is as effective as F100 in treating SAM, where weight gain is the recovery outcome. Food supplements for moderate...
Ann Ashworth Hill, Professor of Community Nutrition Public Health Nutrition Unit, London School Hygiene and Tropical Medicine International NGOs usually provide better...
Based on the nutritional information of the two products, there is no difference in nutritional composion (energy,protein, Fat, and micronutritient) except plumy nut has animal...
By Dr. Mark Manary and Heidi Sandige Dr. Mark Manary is an Associate Professor of Paediatrics at Washington University School of Medicine and Lecturer at Malawi School of...
We have OTP program with SAM kids enrolled. the shipment of Plumpy Nut will take sometime to reach the county? what to do in the meantime?I think that Mark's first...
We are having shortages and cannot find in-country sources for some our needed products. The shortage is expected to last until next year. In particular, I need to know how I...
Published on behalf of the Nutrition cluster in Syria: "There are some partners starting work in IMAM in the besieged areas of Homs. There is no way that RUTF or F75/100 can be...
Summary of research1 Ready to Use Therapeutic Food (RUTF) is not always available where needed. In India, where the need is enormous, it has not been possible to legally import...
By Dr Peter Fellows Introduction The development of RUTF has been an important factor facilitating the development of CTC. However at the moment, most RUTF is made in France,...
Circumstances leading to the setting up of SFPs (from WFP guidelines) Blanket SFP Targeted SFP A generalised SFP for prevention purposes maybe implemented in the absence of a...
We have a problem of access to one area in Darfur and are asking for feedback on how to either convert F100 to be equivalent to F75 OR how to prepare F75 from locally available...
By Jan Komrska Jan Komrska is a pharmacist working at UNICEF Supply Division leading Nutrition unit and responsible for procurement of products related to nutrition...
FEX: Letter on local v imported therapeutic milk, by Rebecca Norton and Jean-Pierre Papart (with responses by Mike Golden, Ann Ashworth, Mary Lung'aho and David Sanders)
Recently, ENN was party to an exchange of questions and discussion between field staff and 'experts' relating to decisions on the use of readymade therapeutic products versus...
By Yuki Isogai Yuki Isogai is Operations Officer for the Ethiopia Nutrition Project/Private Sector Development Specialist with the World Bank. She has a wide range of...
Summary of meetinga The World Health Organisation (WHO) convened a meeting in Geneva (September 30th - October 3rd, 2008) with the overall aim of answering the question, 'What...
what home made food for baby is equal to plumpy nut? Can they make it in their homes ???? Tell me detail which ingredients may be included and quantity. I think you are...
en-net: Ready to Use Supplementary Food
I can't find any research related abstracts on the use of soy based RUSF Vs groundnut based RUSF for management of moderately malnourished children. If someone in the forum has...
Reference this page
Steve Collins and Jeya Henry (2004). Alternative RUTF formulations (Special Supplement 2). Supplement 2: Community-based Therapeutic Care (CTC), November 2004. p35. www.ennonline.net/fex/102/4-3-2