1. Alternative Recipes for RUTF Height board Impovements
Supply Update
Alternative Recipes for RUTF
Height board Impovements
Jan Debyser & Alison Fleet
UNICEF Supply Division
UNICEF and USAID/FFP partnership meeting
Nairobi – 28 Sep 2018

2. Before we dive into the engaging topic of alternative ingredients, I would like to join you in Africa. We have been talking to many country to offices in the last few months, to see if we can work more closely with programmatic nutrition goals. After gathering and synthesizing the information, there was a few common themes globally. This can be conveyed in a story that I hope resonates with your experience

3. Meet Amina
She lives in an East African village where there is no more maize or sorghum to eat due to drought

4. the health minister in Amina’s country.
Now meet Mateo,
the health minister in Amina’s country.
Mateo is trying to convince his counterpart in the department of finance a SAM program in Aamina’s province from the national budget.
On Mateo’s right, the agricultural minister is eager to hear Mateo’s plan to use local legumes and cereal products for locally made RUTF
The Agricultural minister supports Mateo’s proposal and together they convince the finance minister to allocate the budget needed

5. Meet the farmers that would benefit from the government purchase of the RUTF that includes local legumes, seeds and cereals
This farmer has a big grin on her face because she and her fellow farm workers are excited that the local RUTF factory have accepted their produce for the RUTF. They know the factory well as they have been working closely with them to get the right quality raw materials. They also know that their produce is at a price the factory is willing to buy on an ongoing basis, so there is some economic security. The RUTF factory people have helped the farmers build skills in agricultural practices and this has increased the yields that meet the quality standards, which means more produce to sell

6. Potential benefits of RUTF with alternative ingredients
Potential price reduction
Increased acceptance of a product using local ingredients
Increased adoption by governments
Increased access to treatment of SAM
Economic benefits to local economy
So in the example just shown there are three potential benefits that UNICEF aims to impact by opening up our tender to include recipes of RUTF with alternative ingredients. 1st, there a potential for a price reduction 2ndly the ingredients in may be more acceptable to the local population, as we have seen in the work done with Cph university in Cambodia. 3rdly the use of local agricultural products provides an important incentive to governments to spend their national budget on RUTF because it contains local ingredients and thus supports their economy.

7. Consultations Ongoing Consultations Suppliers
Regional Supply and Nutrition colleagues
Partners such as WFP, MSF, USAID…
Suppliers
World Health Organization
Consultations
Questionnaires to regional and Country offices :
Has your country office (CO) programmed an RUTF that is not based on peanuts?
Would your CO be interested in an alternative version of RUTF?
What kind of evidence would be required prior to scale up in your country/region?
Would your country be interested in trialing
a new version of RUTF ?
Questionnaires to Suppliers:
Has your company formulated an RUTF that is not based on peanuts?
What are the key ingredients ?
What is the estimated cost difference compared to the peanut version of RUTF?

8. Supplier offerings for alternative ingredients:
Overview of RFI responses on Alternative Recipes
Total suppliers contacted
Total suppliers replied
No. of suppliers having an alternative recipe 9
Suppliers having 1 alternative recipe 3
Suppliers having more than 1 alternative recipe 6
Total number of alternative formulae 30
Estimated cost savings compared to peanut 3-5%
UNICEF will be releasing a tender in the coming months that will include alternative recipes for RUTF

9. Survey of Regions : snapshot of key points
Most countries reported that RUTF is too expensive and want a more affordable product
Around half said a pilot trial / acceptability trial was needed to demonstrate acceptability of the new product would be needed. Some countries said efficacy trials were needed
Around half of the countries that responded would be interested in using a different version of RUTF

10. Joint statement: Compositional Guideline
At least half of the protein should come from milk

11. RUTF Cost components for materials* *2013 data
Producers from Africa, India, USA all have similar ingredient cost drivers. Dairy is the highest, followed by peanuts, oils, sugar, packaging and then vitamin and mineral pre-mix. This data is from 2013 – but the cost drivers in RUTF remain the same.

12. 2013 - Ingredients and Total Cost Estimates
Input
Grams per sachet
Average Proportion of cost
Milk powder
20-30%
18.5g-27.5g
25%
Sugar
20-28%
18.5g-26 g 6%
Peanuts
25-35%
23-32 g
15%
Soy or canola Oil
15-20%
14g-18.5g 4%
Palm oil 2% 2g
8 %
Vitamins and minerals
2.5%
2.3 g
Emulsifier (mono/diglycerides)
1-1.3% g
2 %
Production
26%
Packaging materials
Testing
This is a very rough cost calculator demonstrating the estimated percentage of raw material costs in the peanut formula. We can see here that on average, dairy ingredients are around 25% of the total cost, followed by peanuts.

13. Strategies for reducing cost of RUTF
Options to reduce the cost of RUTF by adjusting the formula/spec
1. Milk proteins sources from whey permeate, whey powder can be cheaper than
skim milk or whole milk (depending on dairy market)
2. Fat from soy or canola oil could be increased slightly (5%) up to 60% of calories, and this may lower the cost – matrix integrity is a limiting factor
Different legumes, cereals and seeds instead of peanuts (e.g. lentils, chickpeas, rice, corn, sorghum, soy, seasame, sunflower seeds)
Issues:
limit to added sugar to not more than<20% total free sugar
Suppliers encouraged to use sustainable sources of palm oil
may lead to an increase in cost in COGs ?

14. Trials on Lipid Nutritional Supplement (LNS) alternatives to date
Published trials have been done in at least 6 African countries using local formulations. The acceptability trials in Ethiopia and South Sudan used a RUSF based on chick peas; in Zambia a soy-sorghum and maize RUTF product was used. Another acceptability trial was performed in four countries, including Ethiopia, (in addition to Ghana, Pakistan and India) using almond, lower inputs of peanuts, lentils and soy.
Zambia, Ghana, Ethiopia, Egypt, South Sudan
Pakistan, India, Sri Lanka Bangladesh, Cambodia, Vietnam

15. Innovative Novel Renovation egg Insect fish
Added amino acid to meet protein requirements;
increased micronutrients
legumes
cereals
1. Products that include non-vegetable proteins other than milk (eg fish, egg, insects)
2. Products that use added amino acids or supplemental proteins (eg valid formula with added amino acids) Paluku Bahwere,etal. Soya, maize, and sorghum–based ready-to-use therapeutic food with amino acid is as efficacious as the standard milk and peanut paste–based formulation for the treatment of severe acute malnutrition in children: A noninferiority individually randomized controlled efficacy clinical trial in Malawi. AJCN;
3. Products that use legumes and or cereals (eg chick peas, soy, maize, lentils, oats, sorghum, millet, sesame)

16. Regulatory Pathway of Products that do not meet the “Joint statement” composition:
Novel RUTF products that do not meet the compositional requirements contained within the Joint statement, such as the products that include amino acids, additional iron, zinc and no dairy need to be assessed by an expert group
How can a product in the ‘Novel category” be approved?: An assessment of this product (and its evidence) through a transparent process, such as the WHO guideline review process is needed to initiate a guideline amendment which includes this formulation.
What are the next steps?
In order to leverage the work done both by suppliers and partners in this emerging area, resources are needed to enable operational evidence to be generated, and for a WHO guideline review process to be undertaken.
Novel category:Products that have had a major change of composition from the Joint statement guidance need to demonstrate equivalence of efficacy to products that do follow the Joint statement through an appropriately designed clinical trial. A recent trial in Malawi used a product with added amino acids, increased zinc and iron and no dairy, reporting equivalence to the current peanut and milk-based formula.
Next steps: National governments and partners require reassurance that new products will still be accepted and consumed as well as the current peanut-milk product, and that the risks have been identified and addressed prior to scale up.

17. Alternative recipes/ingredients - approach
Considerations for the gradual introduction of alternative recipes/ingredients :
with programmes receptive to carry out acceptability and program the product
already familiar with the alternative recipe e.g. chickpea version of RUSF (e.g. Pakistan)
with local manufacturers of alternative recipes
where trials have already been conducted successfully
with regulatory pathway that is easy to navigate
If trials are needed, decide on a case by case basis who can fund: donor, government, partner, supplier …

18. A short update to share the new height board that UNICEF is about to do some operational trials on. We have identified an imporved board thru a competitive innovation tender process that will hopefully result in significantly reducing human error in the data inputs for height and length measurements. This board is around double the cost of the current board (at present). It runs on rechargeable batteries.

19. Thank you