Quality of Relief Diets: New Products Dr. Buddhima Lokuge Doctors Without Borders

Appropriate Complementary Foods Updated by Brown & Dewey, Food Nutr Bull 2003 WHO: Brown, Allen & Dewey, 1998

Insufficient Health Services & Unhealthy Environment undernutrition Disease Inadequate Dietary Intake Inadequate Care for Mothers and Children Inadequate Education Resources & Control Human, Economic & Organizational Potential Resources Political and Ideological Superstructure Economic Structure Underlying Causes Immediate Causes Basic Causes Manifestation Multilateral Institutions Development Banks  IMF Bilateral Institutions Private Sector Inadequate Access to Food

International Conference on Nutrition, Rome, 1992 “ Among refugees and displaced populations, high rates of malnutrition and micronutrient deficiencies associated with high rates of mortality continue to occur. Donor countries and involved organizations must therefore ensure that the nutrient content of food used for emergency food aid meets nutritional requirements”.

SC-UK, ENN study of Supplementary Feeding programs Conclusions Efficacy: Out of 67 SFPs, less than 40 % have a recovery rate above 75 % Defaulter rate appears to be the main determinant of recovery rate. –programme design and management ? –population’s opportunity costs ?

Maradi, Niger Wasting 11.6% (18.5%) Stunting 62.2% (52.0%) U5MR 231/1000 (374/1000) DHS 2006 (1998) Maradi Region

39,158 admissions (94% SEVERE) 60% of admissions in 13 weeks 95% < 85 cm height 91.4% cure, 3.2% death, 4.7% default, 29 day length of stay 64.5% direct into outpatient care Maradi 2005

nutriment type I deficiency disease nutriment type II growth failure & wasting systemic effects Malnutrition Golden hypothesis iron, copper, selenium, calcium, iodine, vitamins A, B, D, E, K nitrogen, essential amino acids sodium, potassium, chloride, phosphorus, sulfur, zinc, magnesium

Dense in nutrients (F-100 formula) Dense in energy (5x F-100) Ready to eat, no water needed Difficult to contaminate Individual & adaptable packaging Better capacity & coverage Simplified outpatient treatment Multiple, decentralized sites Better quality Early diagnosis (recruitment) Improved intensive care Ready to Use Therapeutic Food (RUTF) Ready-to-use foods New therapeutic products & strategies

Seasonality severe malnutrition

Targeted Distribution RUSF Guidan Roumdji, 2007

Dr Mike Golden, Oct 2007

% WFP FOOD FORTIFIED 100%+ MICRONUTRIENT NEEDS MET FORTIFICATION COMPLEMENTARY FOODS SPRINKLES Corn Soy Blend General Food Basket Cereals, Pulses, Legumes, Vegetable Oil, Salt, CSB Nutrition Strategy WFP: FEEDING BETTER FOOD… DSM is playing a critical strategic role in enabling WFP to launch the strategy at the global level. + micronutrients

Going beyond current paradigms and practice Malnutrition: a neglected disease

2000 Further extension of treatment to outpatients by Collins and Concern 2004 Spearheaded by Valid International - use of outpatient management by many NGOs particularly Concern + SCF. Data presented to show dramatic increase in coverage and low mortality 2006 extension of treatment to moderately malnourished by MSF 2007: lipid based spreads used to prevent malnutrition at population level in Niger (MSF)

1994 First use of F100 in Rwanda after genocide. Results revolutionary! Extensive use of F100 and F75 by most NGOs (Grellety) 1995: refusal of patients in North Uganda to come for treatment (Lord’s Resistance Army kidnapping children) – need for ready-to-use food recognised by Grellety 1996: ACF scientific committee discussed options and developed the idea of a paste based on premixes seen in Liberia (Golden, Grellety, Briend) 1997: successful use of local fortified foods for treatment of SAM by ICDDRB (Kituri and Halva)

Local diets Briend has shown by linear programming that it is not possible to get the same nutrient concentrations from local diets without fortification with some minerals and vitamins. The best diets contain a large variety of local foods mixed together However, addition of mineral and vitamin mix to mixtures of local foods can indeed result in a diet that emulates F100 and derivative diets There remains the problems of anti-nutrients and the necessity to test new diets against the gold standard (F100/RUTF).