Access the pdf of this correspondence here
Access the pdf of the February commentary on RUTF here

Sir: I welcome the commentary in the February issue of WN by Michael Latham and colleagues on ready-to-use therapeutic food (1). It provides a valuable perspective on the issue of micronutrient fortification of baby foods. The authors rightly recognise the importance of RUTF when appropriate, but have highlighted some of the risks. My concern is that fascination with fortification is starting to distort nutrition and public health policies and practice, creating dependence on expensive imported processed foods, and sidelining continued breastfeeding after 6 months together with appropriate, locally sourced complementary foods.

The latest IBFAN monitoring report, Breaking the Rules 2010 (2), shows how industry is exploiting this interest to the full, with grossly misleading health and nutrition claims for micronutrients – added to all manner of 'designer' and 'value added' baby formulas and foods. The same manufacturers are pushing 'better for you' fortified junk foods for older children, with the market leader Nestlé now creating a new 'Institute of Health Science' to develop foods that will supposedly 'treat and prevent illness' and 'improve health and prolong life'.

At the last Codex Alimentarius Nutrition meeting in Chile, we saw how skilfully they lobbied for global standards that would give them freedom to market fortified products to 'prevent' malnutrition, disguising this market-led approach as genuine care about development and hunger and yes, even breastfeeding (3). It is sickening to see how the poor are being used to boost the economies of rich nations and companies.

I hope that all those interested in nutrition will join IBFAN in insisting that RUTF in all its forms and variations is used only where necessary and appropriate and not promoted on the open market, especially with health and nutrition claims. Instead, as the authors say, we should focus on 'a people-centred community-based approach to nutrition, in which the capacities of those who live in poverty are strengthened in such a way that they can develop themselves'.

Patti Rundall
Policy Director, Baby Milk Action
Email: prundall@babymilkaction.org

References

1. Latham MC, Jonsson U, Sterken E, Kent G. RUTF stuff. Can the children be saved with fortified peanut paste? [Commentary] World Nutrition, February 2011, 2, 2: 62-85. Obtainable at www.wphna.org
2. Baby Milk Action. Breaking the Rules – Stretching the Rules 2010 www.ibfan.org/icdc
3. Codex Alimentarius. Report of the 32nd Codex Committee on Nutrition and Foods for Special Dietary Uses. Santiago, Chile, 1-5 November 2010: ftp://ftp.fao.org/codex/Reports_2011/REP11_NFe.pdf

Please cite as: Rundall P. Who cares for the poor? [Letter] World Nutrition, March 2011, 2, 3: 148-149 Obtainable at www.wphna.org

Sir: Your commentary (1) is a comprehensive review of the battle for and against the market-led use of ready-to-use therapeutic food for child malnutrition. The accompanying editorial outlines the underlying factors creating the 'need' for such products (2).

We are not convinced that RUTF is ever a successful approach. The research studies on which this conclusion has been drawn were not optimally designed. Also, available studies on the use of RUTF have shown on average, a weight gain of between 3.5g/kg/day to 8 g/kg/day (3,4). The highest weight gain, reported only once with this product, was 15.6g/kg/day in a hospital setting (5).

But in the Asian context, studies from Bangladesh provide evidence of the efficacy of home food in treating severe acute malnutrition. One study has shown that even without any food supplements being given, intensive nutrition counselling during home visits can produce a weight gain of 9.9g/kg/day (6). Another study has shown that the alternative product F100, given along with home food, can result in weight gains of 7.7g/kg/day (7).

The well-known economist Jeffrey Sachs has questioned RUTF, because it addresses only one kind of hunger – acute episodes of extreme food deprivation or illness, the kind mainly associated with famines and conflicts and not the chronic hunger of 925 million people due to long-term poor diets (8,9). We believe widespread use of RUTF has not reduced absolute numbers of severe acute malnutrition.

A UNICEF report, Tracking Progress on Child and Maternal Nutrition: A Survival and Development Priority (10) indicates that the strategy failed in Niger, where a lot of resources have been put in by several agencies. The report says: 'Although significant progress has been made since 2005 in Niger's ability to effectively treat severely acutely malnourished children through the community-based approach, the prevalence of acute malnutrition remains high. The challenge is to scale up such preventive practices as breastfeeding and improving complementary feeding, which would significantly improve child nutrition and contribute to lowering the numbers of children with moderate or severe acute malnutrition'.

Reservations and problems about the use of RUTF pointed out in the WN commentary underline the role of good food, health and care. We agree. We call upon countries to ensure implementation of the key World Health Assembly resolution 63.23 of 2010 (11). We call upon the UN to follow its own policies and take note in particular two operative clauses, 4 and 6.

'(4) To end inappropriate promotion of food for infants and young children and to ensure that nutrition and health claims shall not be permitted for foods for infants and young children, except where specifically provided for, in relevant Codex Alimentarius standards or national legislation'.

'(6) To scale up interventions to improve infant and young child nutrition in an integrated manner with the protection, promotion and support of breastfeeding and timely, safe and appropriate complementary feeding as core interventions; the implementation of interventions for the prevention and management of severe malnutrition; and the targeted control of vitamin and mineral deficiencies'.

Arun Gupta
Central Coordinator, Breastfeeding Promotion Network of India
Delhi, India
Email: arun.ibfan@gmail.com
JP Dadhich
National Coordinator, Breastfeeding Promotion Network of India
Delhi, India
Email: arun.ibfan@gmail.com

References

1. Latham MC, Jonsson U, Sterken E, Kent G. RUTF stuff. Can the children be saved with fortified peanut paste? [Commentary] World Nutrition, February 2011, 2, 2: 62-85. Obtainable at www.wphna.org
2. Anon. The global game plan of Big Snack [Editorial] World Nutrition February 2011, 2, 2, 55-61.
3. Patel MP, Sandige HL, Ndekha MJ, Briend A, Ashorn P, Manary MJ. Supplemental feeding with ready-to-use therapeutic food in Malawian children at risk of malnutrition. Journal of Health, Population, and Nutrition 2005, 23(4):351-357.
4. Gaboulaud V. Could nutritional rehabilitation at home complement or replace centre-based therapeutic feeding programmes for severe malnutrition. Journal of Tropical Pediatrics 2007, 53(1):49-51.
5. Diop el HI, Dossou N, Ndour M, Briend A, Wade S. Comparison of the efficacy of a solid ready-to-eat food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomized trial. American Journal of Clinical Nutrition 2003; 78(2): 302-307.
6. Ahmed T, Islam MM, Nahar B, Azam MA, Salam MA, Ashworth A et al. Home-based nutritional rehabilitation of severely-malnourished children recovering from diarrhea and other acute illnesses. Paper presented at the 10th Annual Scientific Conference, ICDDRB, Dhaka. 11-13 June 2002.
7. Iqbal Hossain M, Dodd N, Ahmed T, Golam G, Jamil K, Nahar B, Alam B, Mahmood C. Experience in managing severe malnutrition in a government tertiary treatment facility in Bangladesh. Journal of Health, Population, and Nutrition 2009, 27(1):72-80.
8. Sachs J. Saying 'Nuts' to hunger (5 September 2010).Available at: http://www.huffingtonpost.com/jeffrey-sachs/saying-nuts-to-hunger_b_706798.html
9. Food and Agriculture Organization of the United Nations. Global hunger declining, but still unacceptably high (2010). Available at: http://www.fao.org/docrep/012/al390e/al390e00.pdf
10. UNICEF. Tracking Progress on Child and Maternal Nutrition: A Survival and Development Priority. Available at: http://www.unicef.org/publications/files/Tracking_Progress_on_Child and_Maternal_Nutrition_EN_110309.pdf
11. World Health Organization. World Health Assembly Resolution 63.23, 2010. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R23-en.pdf

Please cite as: Gupta A, Dadhich JP. Is RUTF ever the right approach? [Letter] World Nutrition, March 2011, 2, 3: 149-152. Obtainable at www.wphna.org

Sir: As one of the authors of the WN February commentary on RUTF (1), I'd like to underline the views of the physician working in Darfur, Massimo Serventi (2). Treating an issue as a medical problem, when it does not need to be treated that way, disempowers people. RUTF should not be promoted where better breastfeeding practices and better use of local foods could address the issues just as well. In the same way, using capsules to treat or prevent vitamin A deficiency and not showing how to make better use of local foods, is disempowering.

Those who advocate treating local nutrition problems with capsules, or specially formulated foods brought in from the outside, are sometimes criticised for taking a medical approach to the problems. This may be inaccurate, since doctors generally talk with their patients. But often interventions actually take more of a 'veterinary' approach, with the people not consulted at all, as if they were livestock in a feedlot. Local people should be fully involved in formulating the solutions to their own problems, especially when it involves outside intervention.

Treatments provided by outsiders, including specially formulated foods, should be regarded as temporary, something provided while people gain increasing capacity to provide for themselves. Medical treatments may sometimes be necessary, but whenever possible they should be accompanied by programmes designed to phase out the need for them.

George Kent
Honolulu, Hawai'i, USA
Email: Kent@hawaii.edu

References

1. Latham MC, Jonsson U, Sterken E, Kent G. RUTF stuff. Can the children be saved with fortified peanut paste? [Commentary] World Nutrition, February 2011, 2, 2: 62-85. Obtainable at www.wphna.org
2. Serventi M. RUTF is not the answer in Darfur.[Letter] World Nutrition, February 2011, 2, 2: 98-100. Obtainable at www.wphna.org

Please cite as: Kent G. Limits to medicine [Letter] World Nutrition, March 2011, 2, 2: 152-153. Obtainable at www.wphna.org