Menu ENN Search

Acceptability of peanut-based RUTF to malnourished pregnant and lactating women in Bangladesh

Summary of research1

Location: Bangladesh

What we know: Malnutrition prevalence is high among pregnant and lactating women in Bangladesh. Nutrition rehabilitation programmes use peanut-based RUTF in their treatment, however acceptability and tolerance in this population group is poorly researched.

What this article adds: A cross-sectional study was conducted by MSF to assess acceptability and tolerance of peanut RUTF amongst 248 pregnant and lactating women attending two MSF supported primary health care centres in an urban slum in Bangladesh. While the majority appreciated the therapeutic benefits, 22% rejected peanut based RUTF completely and the remaining 78% found it unacceptable (undesirable taste, smell and side effects). Thirty-nine per cent reported side-effects. This explained the MSF programme experiences which had high loss-to-follow-up and non-responder rates. Thirty three per cent found the instructions inconspicuous and 8% could not read them. Ways forward include concerted effort for alternative formulations of RTUF based on local pulses, preferences and awareness of adult palatability needs.

Malnutrition prevalence among pregnant and lactating women (PLW) in Bangladesh is one of the highest in the world2. The Demographic Health Survey in 2007 showed that 30% of women of childbearing age (15–45 years) were undernourished (Body Mass Index (BMI) <18.5).

One of the commonly used Ready to Use Therapeutic Foods (RUTF) in Africa is Plumpy’nut® (PPN; Nutriset, Malaunay, France). Médecins Sans Frontières (MSF) implemented a PPN-based nutrition programme for malnourished PLW in Kamrangirchar slum setting in Dhaka, Bangladesh. During implementation, many women complained of the taste and peanut-associated smell of PPN. The programme also experienced a high loss-to follow-up rate (25–30%) and a high non-respondent rate (32–35%) despite women being on PPN for a period up to five months.. A study was therefore conducted to assess acceptability and tolerance of PPN among PLW in Kamrangirchar slum in Bangladesh.

Method

The study involved a cross-sectional survey using a semi-structured questionnaire. It was conducted between May and July 2011 in Kamrangirchar, an urban slum setting in Dhaka, Bangladesh. The slum has an estimated population of 400,000 inhabitants living within an area of 3.1 km2. MSF health services in Kamrangirchar were provided through two primary health care (PHC) clinics. The nutrition programme for PLW started in August 2010. The study included all PLW who were either malnourished or at risk of malnutrition, and who had received PPN for at least 4 weeks at the time of the study.

PLW were admitted to the nutrition programme if they were found with severe acute malnutrition (SAM) [mid-upper arm circumference (MUAC) <170 mm or the presence of severe nutritional oedema ≥ grade three] or were at risk of malnutrition (MUAC<210 mm). Based on the measured MUAC threshold, PPN daily dose was prescribed (one to three packs per day) for 2–5 months. Along with the nutritional support, PLW were offered antenatal and postnatal care.

Nutritional follow-up assessments were done monthly within the community. Women who recorded complete rejection of PPN were switched to another RUTF (BP100 – high-energy biscuit bars). Women were discharged from the programme when they attained a MUAC >220 mm, oedema less than grade two and were assessed as being of good clinical status for at least two consecutive visits. PLW who did not recover after receiving PPN for five months were switched to a multiple micronutrient powder (MNP) supplement.

A semi-structured questionnaire was used to gather socio-demographic information, perceptions of PPN (taste, smell, consistency, colour, side effects), packaging, consumption of PPN (accepted readily, forced to ingest it, rejected completely), general appreciation of PPN and suggestions to improve it. Independent home visits were arranged to conduct the interviews. PPN was considered acceptable if PLW did not perceive problems of undesirable taste, smell, colour, consistency or side effects at any time during the course of intake. Unacceptability was defined if PLW perceived any of the previously mentioned problems, felt that they were being forced to take PPN, or completely rejected PPN after four weeks of intake.

Results

A total of 248 women [median age 20 years, interquartile range (IQR) 18–24] were interviewed. The majority (99.6%) were at risk of malnutrition on admission with a median MUAC of 202 mm (IQR 196– 206). Overall, 161 (65%) women were pregnant and 87 (35%) were lactating. Nearly 30% were illiterate while the remainder had a mean of four years education (SD 3.24). The overall median period of PPN intake was 16 weeks (IQR 10–20). At interview, 134 (54%) women were receiving PPN, 101 (41%) were switched to MNP and 13 (5%) to BP100.

Fifty-five (22%) women accepted PPN completely. The remaining 193 (78%) found PPN unacceptable, of whom 12 (5%) completely rejected PPN after four weeks of intake. The remaining 181 (73%) found PPN unacceptable because of undesirable taste, unwelcome smell or attributed side effects and stated that they forced themselves to take PPN. Overall, 149 (60%) women found the PPN taste unacceptable while 107 (43%) found the smell unwelcome – more than half complaining of the peanut-based smell. In an attempt to compensate for the unacceptable taste and smell, 133 (54%) mixed PPN with water and seven (3%) mixed it with other food such as chapatti and rice. A total of 97 (39%) women reported at least one side effect attributed to PPN, which included nausea (27%), vomiting (19%), diarrhoea (8%), abdominal distension (7%) and abdominal pain (3%). Most of the reported side effects were higher among pregnant than lactating women. Despite the mentioned limitations in PPN acceptability, 212 (85%) women perceived PPN to be beneficial as a therapeutic product for improving general health.

The majority (99%) of women found PPN package easy to open. Overall, 146 (59%) understood the illustrated instructions on the package, 81 (33%) found the instructions inconspicuous and 21 (8%) said they were illiterate. The majority (79%) felt that the overall PPN acceptability should be improved – 82% of them desired a change in taste and 48% desired a change in smell.

This study shows that despite a perceived therapeutic benefit, eight of every 10 PLW receiving PPN for nutritional rehabilitation in a slum setting in Bangladesh found problems related to RUTF acceptability.

Conclusions

The findings of this study raise a number of important considerations related to PPN acceptability. First, the fact that 60% of women found the taste of this ‘food product’ unacceptable is concerning. A considerable proportion also complained of its peanut-based smell. In Bangladesh, lentils constitute the main ‘pulse’ in the basic daily diet. Although peanuts are available in the local markets and are inexpensive, they are not used routinely as part of a Bangladeshi diet. The use of peanut as a core constituent in PPN needs to be re-examined, as undesirable taste and smell of any RUTF is likely to adversely influence acceptability and adherence, which eventually impact nutritional outcomes. Second, 39% of women attributed side effects to PPN intake, and these were higher among pregnant than lactating women. This issue merits further assessment and research. Third, 41% of women found the illustrations on the package inconspicuous and incomprehensible, which highlights the need to find more suitable ways of communicating the ‘instructions for use’ in such communities.

The ideal way forward would be the development of a RUTF that is adapted to adult’s expressed palatability preferences and based on locally available pulses. However, the nutritional contents of such recipes need to be carefully assessed for their potential use for therapeutic rehabilitation in PLW. The authors conclude by urging nutritional agencies and therapeutic food manufacturers to intensify their effort towards developing more RUTF alternatives with improved palatability and smell for adults, and with adequate therapeutic contents for treating malnourished PLW in Bangladesh.

Show footnotes

1 Ali. E et al (2013). Peanut-based ready-to-use therapeutic food: how acceptable and tolerated is it among malnourished pregnant and lactating women in Bangladesh. Maternal and Child Health, DOI: 10.1111/mcn.12050

2 WHO, 2007a. WHO Bangladesh Country Cooperation Strategy 2008–2013. WHO: New Delhi.Available at: http://www.ennonline.net/pool/files/ife/wfp-unhcr-sfp-guidelines.pdf (Accessed March 2012).

More like this

FEX: Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh

Summary of research1 Location: Urban slum, Bangladesh What we know already: Both severe acute malnutrition (wasting) and severe chronic malnutrition (stunting) are prevalent...

FEX: Acceptability trial of a novel RUTF based on soy, lentils and rice

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...

FEX: RUTF use in adults in Kenya

Summary of meeting abstract1 A man enrolled in the RUTF acceptability programme Those who were sicker found it more difficult to eat RUTF and tended to mix it with other...

FEX: Locally produced RUTF in a hospital setting in Uganda

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...

en-net: Treatment of SAM in older people through outpatient

Treating older people (>=60 year old) with uncomplicated SAM with RUTF at home as out patients: which doses should we use? Some recommend 100kcal/kg/day. Should it be...

FEX: MUAC alone admission to SAM treatment in Bangladesh

Summary of research1 Location: Bangladesh What we know: MUAC and weight-for-height z score (WHZ) are common anthropometric criteria to diagnose severe acute malnutrition...

en-net: Allergic Reactions to RUTF

Dear experts,

Is there a standard that we can refer to regarding allergic reactions to RUTF? We have been implementing CMAM in the Philippines and have encountered...

en-net: RUTF taste and acceptability: children's perspective

Dear colleagues, we are preparing a RUTF taste testing questionnaire for children. Any feedback, comments or tips from your side are very welcome: your observations and...

FEX: Implications of 65 cm height cut-off as age proxy in Bangladesh

Summary of published research1 Location: Bangladesh What we know: Age data for children aged 6 to 59 months is often not available in poor, migrant or conflict affected...

FEX: Comparison of milk free v milk containing RUTF in SAM treatment in Zambia

Summary of published research1 Location: Zambia What we know: Global SAM treatment relies on internationally produced RUTF that is expensive. RUTF formulations that exclude...

en-net: Plumpy mum

Has anybody had any experience using the Plumpy Mum as a supplement for pregnant and lactating women ? what was the level of acceptance of the community about this product?...

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....

NEX: Delivering high-quality, locally produced and fortified blended food products in West Africa

Sofia Condes is a public health economist working for GAIN in the Food Policy and Finance Team, with a focus on francophone Africa and Latin America. Jennifer Dahdah is a...

FEX: Review of food security and nutrition amongst urban poor

Summary of review1 Location: Kenya, Niger, Bangladesh What we know: A significant and increasing proportion of the world population resides in urban slums. Achieving food...

FEX: Experiences of emergency nutrition programming in Jordan

By Ruba Ahmad Abu-Taleb Ruba Ahmad Abu-Taleb is Nutrition coordinator at Jordan Health Aid Society (JHAS). She liaises between national and international NGOs and JHAS...

FEX: Nutrition Supplement for People With HIV

Summary of unpublished research1 The BHC supervisor talks with a mother, who receives a HBCN kit Compact Norway has developed a new product called AFYA to be used as a...

en-net: Influence of cold on RUTF quality

Dear colleagues, I am currently working in a CMAM programme in Nepal and the difference of temperature between day and night has caused us some slight troubles. Although the...

en-net: replacement for Plumpy net

Dear colleges,

Greeting from Nini
Thanks for your kind answer for my previous question about CMAM guideline. Here again, I have another urgent question. We are...

FEX: Impact evaluation of a DFID programme to accelerate improved nutrition for the extreme poor in Bangladesh

Summary of evaluation1 Location: Bangladesh What we know: There is little evidence of the impact of integrated livelihoods and nutrition programmes. What this article adds:...

FEX: Spotting the invisible crisis: early warning indicators in urban slums of Nairobi, Kenya

By Lilly Schofield, Shukri F Mohamed, Elizabeth Wambui Kimani-Murage, Frederick Murunga Wekesah, Blessing Mberu and Thaddaeus Egondi, Catherine Kyobutungi and Remare Ettarh...

Close

Reference this page

Summary of research (2014). Acceptability of peanut-based RUTF to malnourished pregnant and lactating women in Bangladesh. Field Exchange 47, April 2014. p25. www.ennonline.net/fex/47/acceptability

(ENN_1068)

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.