Menu ENN Search

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):

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

Show footnotes

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

More like this

FEX: ComPAS trial in South Sudan and Kenya: Headline findings and experiences

View this article as a pdf Lisez cet article en français ici By Bethany Marron, Pamela Onyo, Eunice N Musyoki, Susan Were Adongo and Jeanette Bailey Bethany Marron is...

en-net: Simplified protocol - RUSF SAM treatment

As per the MAM Decision Tool, there is a recommendation to use expanded admissions criteria to admit children 6-59 months classified with MAM into the OTP (MUAC <125mm), or...

FEX: Ready-to-use therapeutic food and the WHO list of essential medicines

By Aurélie du Châtelet, Anne-Dominique Israel, Elise Rodriguez, Wisdom Dube, Laetitia Battisti, Magali Garcia, Coline Morin and Natalie Sessions. Aurélie...

FEX: Increasing Access to Ready-to-use Therapeutic Foods (RUTF)

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: Recovery rate of children with moderate acute malnutrition treated with ready-to-use supplementary food (RUSF) or improved corn-soya blend (CSB+)

Summary of research * Location: Cameroon. What we know: A wide range of nutritional products are currently used to treat MAM; there is no definitive consensus on the most...

FEX: Adaptations to community-based acute malnutrition treatment during the COVID-19 pandemic

View this article as a pdf Lisez cet article en français ici By Maria Wrabel, Sarah King and Heather Stobaugh Maria Wrabel is CMAM Adaptations Project Officer with...

FEX: Comparison of treatment of severe acute malnutrition with ready-to-use therapeutic food and ready-to-use-supplementary food: Research plans in Pakistan

View this article as a pdf By Sumra Kureishy, Meghan Callaghan-Gillespie, Gul Nawaz Khan, Atif Habib, Mica Jenkins, Khawaja Masuood Ahmed, Baseer Achakzai, Saskia de Pee, Mark...

FEX: ACF application to add RUTF to EML sparks lively discussion on en-net

By Tamsin Walters, en-net moderator Contributions on en-net from Sameh Al-Awlaqi, Dr. Charulatha Banerjee, Paul Binns, Bindi Borg, Jessica Bourdaire, Chris, Suzanne Fuhrman,...

en-net: RUSF and RUTF - malnourished PLW

Can plumpysup and plumpynut be used to treat acutely malnourished pregnant and lactating women? RUSF can also be used in management of Moderate Acute Malnutrition. we have...

en-net: Simplified Approaches in the context of COVID 19 (questions escalated to the GTAM Wasting TWG)

a. What can we do to quickly communicate that this [simplified approaches] is an acceptable adaptation to make in the circumstances to enable governments to make this...

FEX: OptiMA study in Burkina Faso: Emerging findings and additional insights

View this article as a pdf Lisez cet article en français ici By Kevin PQ Phelan Kevin PQ Phelan is Nutrition Advisor at ALIMA, the Alliance for International Medical...

en-net: Guidance for CMAM expanded admissions criteria

From Jeanette Bailey: Dear colleagues, In recent months a number of agencies have come together to consider simplified and temporary measures to expand their reach to...

FEX: Combined protocol for SAM/MAM treatment: The ComPAS study

By Jeanette Bailey, Rachel Chase, Marko Kerac, André Briend, Mark Manary, Charles Opondo, Maureen Gallagher and Anna Kim Jeanette Bailey is the Project Director for...

FEX: New sachet/carton sizes for F75 and F100 therapeutic milks

Old versus new F100 sachets Substantial changes have been made to the sachet sizes for F-75 and F-100 therapeutic milk as well as to the carton sizes. Therapeutic milks F-75...

en-net: Is MAM treatment still relevant ?

Given the available knowledge on the impact of MAM treatment vs nutrition prevention activities on the reduction of child undernutrition and mortality, and the huge investment...

FEX: Treatment of SAM and MAM in low- and middle-income settings: a systematic review

Summary of research1 Location: Global What we know: Worldwide, 33 million children under 5 years are moderately malnourished and 19 million are severely malnourished. The...

en-net: Nutrition RUTF expert needed for consultancy

https://www.cdcgroup.com/en/about/careers/vacancies/ https://medaccess.org/about/careers/ TERMS OF REFERENCE, September 2019 Clinical assessment of alternative...

en-net: RUTF made with locally available products

The majority of RUTF being used in CMAM programmes are peanut and milk based pastes. I am aware of several groups who are working on developing RUTF pastes using locally...

FEX: Editorial perspective on the continuum of care for children with acute malnutrition

View this article as a pdf Lisez cet article en français ici By Jeremy Shoham and Marie McGrath, Field Exchange Co-Editors Rationale for FEX special edition We are...

FEX: Development and use of alternative nutrient-dense foods for management of acute malnutrition in India

View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Raja Sriswan Mamidi, N Arlappa, Khyati Tiwari, Shivani Rohatgi, G Sarika, Dripta Roy...

Close

Reference this page

Putting nutrition products in their place: ACF position paper. Field Exchange 42, January 2012. p57. www.ennonline.net/fex/42/putting

(ENN_4273)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.