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Putting Nutrition Products in Their Proper Place in the Treatment and Prevention of Global Acute Malnutrition Briefing and Position Paper

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Putting Nutrition Products in Their Proper Place in the Treatment and Prevention of Global Acute Malnutrition Briefing and Position Paper Products are not enough: Putting nutrition products in their proper place in the treatment and prevention of global acute malnutrition Briefing and Position Paper Action Contre la Faim International December 2011 Acknowledgements This paper has been written and edited by Philip James, emergency nutrition coordinator for Action Against Hunger. ACF International would like to thank all those who have given their help in putting this document together: To Sandra Mutuma for the original vision for the paper, coordinating the collaborative effort and for the continuous guidance and support. To Rebecca Brown for her considerable guidance on the structure and content of the guide. To the Senior Nutrition Advisors for their comments and editing: Anne-Dominique Israël, Elisa Domínguez, Marie-Sophie Whitney, Asmaa Ibnouzahir and Yara Sfeir. To all who reviewed sections of the documents and provided additional information: Sophie Llobell, Cécile Salpeteur, Julien Morel, Paul Murphy, Mike Mellace, Tandi Matoti-Mvalo, Martin Histand, Rolf Campbell, Jan Komrska, Pamella Zayas, Mamane Zeilani and Ojaswi Acharya. 2 Contents Acknowledgements .................................................................................................................... 2 Introduction .............................................................................................................................. 5 1.1 Structure and remit of paper ................................................................................................. 5 1.2 Intended audience ................................................................................................................ 5 1.3 Some definitions .................................................................................................................. 5 PART A: Products & Severe Acute Malnutrition ...................................................................11 A.1 RUTF: a brief overview ...................................................................................................14 A.2 Main RUTF products and producers ...............................................................................16 A.3 Local production .............................................................................................................17 A.4 Validation process ..........................................................................................................19 A.5 Future developments for RUTF ......................................................................................20 A.6 Patents and Plumpy’nut® ................................................................................................21 A.7 Acceptance issues .........................................................................................................23 A.8 Cost ................................................................................................................................26 A.9 Coverage and funding ....................................................................................................27 A.10 Sustainability ...............................................................................................................28 A.11 Impact on breastfeeding .............................................................................................29 A.12 Potential negative consequences of rapid re-feeding ..................................................30 Part B: Products for the prevention and treatment of Moderate Acute Malnutrition (MAM) .................................................................................................................................................31 B.1 Products designed to treat MAM cases ..........................................................................31 B.2 Evidence base for treating MAM through products .........................................................34 B.3 Products designed for the prevention of acute malnutrition ............................................38 B.4 Evidence base for prevention of acute malnutrition using products.................................40 B.5 Alternative nutrition-oriented approaches for treatment and prevention of MAM .............41 Part C: Products are not enough ...........................................................................................46 C.1 An integrated approach to tackling under-nutrition ..........................................................46 3 C.2 How do we decide what approach to use? .....................................................................48 C.3 Towards a decision-making framework...........................................................................51 Annex 1: IPC Classification Table ............................................................................................52 Annex 2: Nutritional Quality Considerations .............................................................................53 Annex 3: ACF suggested framework for direct nutrition interventions .......................................55 Annex 4: WFP decision-making tables .....................................................................................56 Annex 5: MAM task force list of further resources. ...................................................................58 References ..............................................................................................................................59 4 1. Introduction The management of acute malnutrition has been revolutionized in recent years, fuelled by innovations in nutrition products. Initially designed to treat severe acute malnutrition, there is now an expanding range used to prevent acute malnutrition, treat moderate acute malnutrition, and tackle stunting and micronutrient deficiencies. The growing options can present opportunities to improve nutrition programming, but also introduce potential confusion and challenges related to which product to use, cost-effectiveness, local production, sustainability, patents, ethics and the evidence-base for impact. This paper aims to help policy makers and field practitioners understand the role products can play in nutrition programming and ACF’s position on key issues. 1.1 Structure and remit of paper The paper is designed not only to provide a briefing on the different types of nutrition product available, but also to provide ACF’s position on a number of key related issues. Whilst chronic under-nutrition and the prevention of micronutrient deficiencies are hugely important, this paper focuses on the use of products in the prevention and treatment of acute malnutrition. Part A focuses on the treatment of severe acute malnutrition. Part B looks at the prevention and treatment of moderate acute malnutrition and Part C considers the role of nutritional products as part of broader strategies to build resilience to, and prevent, under-nutrition. The paper focuses on children aged 6-59 months, which represent the majority of beneficiaries within ACF’s global programmes. ACF interventions also focus on other sub-groups such as pregnant and lactating women, children under 6 months, adolescents and HIV-infected patients, for which separate guidance is available. 1.2 Intended audience 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 policy makers. 1.3 Some definitions There are many different types of nutrition product in use. The relevant nutritional product depends on the type of under-nutrition and whether the aim is treatment or prevention. It is therefore useful to briefly summarise the main types of under-nutrition and product categories to set the scene for more detailed discussions later in the paper (see Box 1 & 2 and Table 1). 5 Box 1: Nutrition Definitions Chronic Undernutrition: This is where insufficient dietary intake occurs over a long period of time. If not corrected within the first two years of a child’s life (including the antenatal period) this can lead to ‘stunting’ (low height for age), resulting in decreased physical and cognitive development, lower work capacity, and an increased risk of a range of chronic health problems. The same symptoms can be seen with repeated episodes of acute malnutrition or infections. Acute Malnutrition: This occurs over a short period of time. The symptoms are either a dramatic loss of weight (‘wasting’) or bilateral pitting oedema of the body (‘kwashiorkor’). Wasting results in extreme thinness, and severe forms of kwashiorkor result in swelling, tight, shiny skin, lesions and discoloured hair. Acute malnutrition is determined using anthropometric (body measurement) indicators: weight, height, mid-upper arm circumference and oedema check. Severe Acute Malnutrition (SAM): This is the stage where the body is so undernourished that the immune system becomes compromised, increasing risk of infection and prolonging existing infections, and the main internal control systems gradually shut down. Risk of mortality is highest in this phase, and recovery requires urgent use of medical treatment and special therapeutic foods. There are three main types of SAM: marasmus (severe wasting), kwashiorkor, or a combination of the two (marasmic kwashiorkor). The latter is the most difficult to treat. Moderate Acute Malnutrition (MAM): This stage is where the body is becoming seriously undernourished and starting to show signs through the loss of weight and increasing risk of infection. MAM needs treatment using
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