By Peter Rohloff | Medical Director
Dear Friends, I recently wrote a piece on "New Nutrition Supplements for Children" for an online global health clearinghouse website. Since one of those "New Nutrition Supplements" is Plumpy'doz, the distribution of which you have been supporting in Guatemala with your contributions to this Globalgiving Project, I thought you might like to read some excerpts (see below!). Also, check out the pictures I am uploading here of Plumpy'doz distributions and the links below to some videos of the same. As always thanks for your support!
Lipid based nutrient supplements (LNS) are perhaps one of the most exciting, and potentially transformative emerging technologies for the treatment of chronic malnutrition. LNS preparations are called ‘lipid-based’ because, unlike older nutritional formulations, they derive a much larger percentage of their calories from fats (typically from peanuts, milk, and vegetable oils). They also generally contain a full complement of vitamins and micronutrients. Because they are fat-based, these micronutrients may be more easily absorbed by the body (they are not bound up by plant phytates which are abundant in grain-based nutritional supplements). They also provide essential fatty acids, whose importance for promoting healthy growth and brain development is more and more appreciated today.
Most people have heard of at least one type of LNS product, Plumpydoz®, which has revolutionized the treatment of severe acute malnutrition in many countries throughout the world. Plumpydoz® is classified as a therapeutic food, meaning that it is extremely dense in calories and is essentially meant to be used in a situation where aggressive ‘refeeding’ is necessary. Since the product has a long shelf life, does not require mixing or cooking, and is tasty, it has produced a paradigm shift in the treatment of severe malnutrition. Previously, most cases of severe malnutrition needed to be hospitalized, often simply because the mixing and preparation of refeeding solutions was complex and required special tools and training. Plumpydoz® uncomplicates this process, which means that refeeding can happen in the home and in rural communities.
What many people do not know, however, is that new research has led to the development of a range of other LNS products, which are lower in calories while still providing a full complement of micronutrients. These products include some which provide a medium amount of calories (Plumpydoz® is one example) and some that provide a small amount of calories (Nutributter® is an example). These are very welcome developments, because they could potentially be used in development settings where chronic malnutrition, rather than acute malnutrition, is the norm. Chronic malnutrition, is generally a smoldering illness which affects a child over months to years and, until now, we haven’t really had any very effective tools for dealing with it. Using Plumpynut® for treating chronic malnutrition would be sort of like using a fire hose to put out a candle.
This isn’t to say that the ‘candle’ of chronic malnutrition is something to sniff at. There are many more children in the world with chronic malnutrition than with acute malnutrition. Whereas acute malnutrition puts a child at immediate and obvious risk of death, chronic malnutrition consumes their biological and social potential in a slow, insidious way. Chronically malnourished children are shorter than their peers. They have more frequent episodes of diarrhea and respiratory illness. They have slower intellectual development and lower IQs. They are less likely to complete school. As adults, and are more likely to be unemployed or to have low paying jobs. Perhaps most horrifying of all, chronic malnutrition as a child greatly increases the risk of obesity, hypertension, and diabetes in adulthood – directly contributing to the rising epidemic of these disease in the developing world.
Exactly how to combat chronic malnutrition with LNS formulations is not entirely worked out yet. There are some positive studies; for example, this study showed that the rates of severe chronic malnutrition could be reduced by supplementation with a Nutributter® like product in children in Malawi. However, the factors which influence and maintain chronic stunting vary significantly from environment to environment. For example, in Malawi chronic malnutrition is greatly influenced by seasonal food insecurity and cyclical droughts; in this type of setting, it is common for there also to be a lot of acute malnutrition. On the other hand, in Guatemala (which has the highest rates of chronic malnutrition in the Western hemisphere), there is no seasonality to malnutrition patterns; here, malnutrition is clearly related more to endemic racism and lack of access to basic medical care and only more obliquely to food production patterns and food insecurity. In short, what might work in one context to treat (or prevent) chronic malnutrition might not work somewhere else.
Clearly, there is exciting and important work to be done. In Guatemala, we have been working at Wuqu’ Kawoq with both medium calorie and low calorie LNS products. For example, we have been using Plumpydoz® in 5 different communities for about 12 months now. In these communities, the Plumpydoz® seems generally well accepted with decent uptake and utilization. In the cohort of the most severely stunted children, height recovery also seems to be progressing nicely. Most mothers also report reductions in rates of acute illness in their children. We are conducting a prospective analysis of the growth data in these communities over the next several years, which we hope will bear out these observations. Potentially the great advantage of a medium calorie preparation is that it could provide some nutritional boost to children who are already malnourished at the start of a program, and this is the hypothesis we are exploring – that Plumpydoz®, or another product like it, can provide both prevention of malnutrition onset in the youngest children but also some recuperation in older, already-malnourished children.
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