Your opinion sought on draft guidance to regulate marketing of Ready to Use Supplemental Foods

I do agree with the statement: RUFT should be used for a short period, in case of an exceptional event. What you write is all correct.I say so after experience of many years working in African and Asian countries. RUFT risk to become 'dangerous' like the BMS, true. I'd add a third 'trojan horse' that I've been witnessing in recent years: the introduction in a poor country of new drugs, new molecules, often expensive, sometimes obsolete in Europe, not strictly necessary for the majority of treatments in children. Not only antibiotics, but also antidiarrhoeic like actapulgite,smecta, loperamide,yeast.... liberally prescribed: their introduction make the use of ORS out of fashion, not anymore prescribed by doctors and rejected by the mothers. Cough syrups,anticholic 'waters',antiemetic drugs...all not necessary, but prescribed and bought by mothers. Who are poor and should buy food instead of drugs! The fatc is that pharmaceutical companies (from Europe,but not only) are on the way to penetrate the market in African countries.They do not find much impediments to do so.... as it happened for the producers of formula milk. Suffice to get in an ordinary pharmacy (they are many!!) of a town in Africa to see tins of powder milk on the shelves, attractive wallpapers promoting new drugs and remedies that provide 'health and relief'. I underline the fact that: whenever a new drug is accepted in a country it will be prescribed, soon or later: it is a matter of time. Therefore the barrier should be established at the level of importation.

Dear Dr. Briend, the good quality of RUFT, the effectiveness of RUFT are not in question:they represent the best way to treat or even to prevent SAM, your data suffice. The question is: are RUFTs a sustainable, durable, culturally accepted way of treating/preventing SAM? 1) Sustainable? surely not, can we sustain the treatment of 8 million indian children with plumpynut? plus the extra mllions from Africa? how many containers? for how many years? 2) Durable? surely not, what will happen to the child that has been 'rescued' from SAM with RUFT? he will go back to the same family , with the same problems of poverty,lack of food or lack of enough nutritional knowledge. 3) Culturally accepted? certainly not, RUFT are manufactured in France to feed African children. Were African nutritionists involved in the process of 'inventing' such miracle food? How do the mothers perceive RUFT? something like a drug? coming from 'rich and fat' whitemen? did we ask them what they think of RUFT? I have no data...but let me question: the child has become malnourished after a long period of lack of adequate nutrition. Something wrong happened to him, to his family, maybe he has been weaned too early, or left with his granmother or....well, the question is: was the mother informed early enough that her child was on the way to become malnourished? was the mother able to see on the growth card that the curve of her child's growth was deflecting? In my opinion, SAM should be prevented and all money available should go there...not on manufacturing and shipping containers of RUFT. Parents, african, indian parents, whatever poor they are, should be made responsible for the nutrition of their children, under any circumstance, escept of course in case of severe famine,war or catastrophe. The only way to inform the mother that SAM is starting to affect her child is to put him on a scale and show to her his position on the card curve. If the body weight is 'bad' she should receive adequate nutrition orientation and requested to come back after 15 days.....to re-check the body weight...and again. The community , the village leaders should be informed that in their amidst there are children with SAM.....most of time they do not know. Growth monitoring, on monthly basis, for the first 2 years of life. Local food, that is available, culturally accepted. Community involvement. Breast feeding for 2 years, a must! Thanks. Massimo from Bangui

Dear Massimo, I was wondering if you clarify your comments by separating RUSF and RUTF. It seems to me that things are mixed. The discussion is about RUSF (Ready-to-use food) which is totally different from RUTF in terms of purpose. Or are you against both products, RUTF and RUSF? With regard to growth monitoring, according to the publication of lancet series (Lancet 2008: 371: 510-26), stand-alone growth monitoring has not been proven to have a direct effect on udernutrition. Thanks

Dear Kiross, I confess to ignore the difference between RUSF and RUFT. Trying to guess....I would agree to use F75 and F100 (how do you call them?) in case of a child affected by severe SAM who is hospitalized. Let's offer to him the last chance to revert a process that has reached the final step, it is ethical. In the past we were used to make DISCO, a mix of dry skimmed milk,oil and sugar, kind of F75/F100 but certainly less balanced. Plumpynut(PN),energetic buiscuits (how do you call them?)...are my 'enemies'. I fear that the use of them is becoming too liberal, without control, this being an ' expected event' in the reality of Africa, people are poor, food, any food is welcome,please give one PN for my other child at home.... I do not argue the quality and effectiveness of plumpynut : I'm against its (easy) distribution, that will possibly lead to confusion,dependency and delay in the fight against malnutrition. I'd like to have the opinion of an African nutritionist. I remember well : 30 years ago in Tanzania we were used to have children affected by SAM. Local nutritionists (Prof. Malentlema of TFNC) were strict: no imported food was allowed to treat these children. Emphasis was on MCH/Growth Monitoring, systematically done, every month, in all the 3000 dispensaries/health centres distributed in the country. Affluence to clinics was good and still is. Situation improved (other factors contributed certainly) : today severe SAM is rare in Tanzania. I know the articles you mentioned on Growth Monitoring(GM). I personally conducted sessions of GM and I challenge anybody to deny that they reperesent the best, non medical way to have a contact/interaction with the mothers. No drugs are involved...but a simple measurement of a parameter. Yet mothers are eager to see the growth of their children, oh yes, very much. Do it in a correct way, praise those mothers with 'fat' children, separate those with children 'at risk', talk to them, do not blame, encourage breast feeding and local nutritious food, ask to come back after 15 days,mention the importance of mosquito net, talk about a child with dirty eyes..... this is the real PHC in action. Before leaving the village talk to the leaders, tell them that this and that family has a child with poor nutrition, they will involve the father, they will create awareness. Malnutrition is a community problem and needs a community answer....said many years ago but still valid today. Mind you : you'll be surprised to hear from them that their children are not malnourished but sick, so they'll ask you more drugs. They may have nutritious food but for some reasons they do not use for children. Would you call this GM as 'stand alone'? deprived of any additional advantage for the mother? if it so why then Tanzanian mothers do come and want to see the growth of their children? Mothers are the same in Africa as in Europe, they want to see their children eat and grow. The health sector has the duty to show the real fact: children are maigre, weak and inappetent because they lack food and not because they are sick. Give plumpynut and mothers will interpret it as a sort of drug, a special 'buiscuit' of the white man (as mothers in Darfur call PN). Give PN and they will understand that their local food is not good for their children. PN is unethical. Its liberal, unruled distribution deprives the parents of the Responsibility and Right of feeding their children. Food is not a drug, food is life, food is culture. Respect please.

Guidance like this would be useful for locations distributing / using RUSF regardless of the context (emergency or not) if nothing else it would help reduce confusion amongst health care workers at all levels. Although RUSF at present is still directed towards children and PLW, are there any plans to include some guidance for use amongst Adults with more moderate undernutrition or stable undernutrition?

I am grateful to ENN for facilitating and am pleased to see this discussion getting started. So far there are many excellent comments. To begin with, I recognize that there are many products that could be included in such guidelines, including commercial complementary foods, fortified blended foods, and a growing array of ready to eat foods that may eventually expand beyond any definition we choose to include in such marketing guidelines. The present ones were intentionally designed only to cover only RUSFs and cover RUTFs only when they are used OUTSIDE the context of treating SAM. (I greatly doubt that treatment of SAM is something anyone would advertise products for, at least to the general public.) Here I will respond to the comments from my friend Andre Briend. He makes excellent points. First, we are indeed uncertain whether some way can be found to provide a few of the more difficult to obtain nutrients at lower cost than from the natural foods they contain. However, it is an even more complex question whether doing so will always provide the same health effects as the natural foods themselves do--for example so far we cannot find any way to provide the cancer-lower effects of vegetables in the diet by supplementing with certain nutrients or other substances in them. Many of us are struck by the impact of milk on infant growth, for example. I doubt we'll find a way to match that with non-milk or at least plant food diets, no matter what nutrients they are fortified with (except perhaps soy formula--which is too expensive). That said, I certainly think that some, such as the fatty acids DHA and EPA, deserve a good deal more research. Some groups may well benefit from supplementation, even in rich countries. (The same is likely true for vitamin D, though perhaps not so much in most low-income populations who get a lot of sun.) Second, I agree that our language about water should be changed. IF mothers provided cooked foods soon after cooking, they would be safe. But the main point is that RUSFs are being inappropriately promoted as a way to reduce the risks of water-born disease and that is probably, on the whole, not among their benefits. Our main point is that while RUSFs do not spoil or get risk dangerous levels of bacterial contamination like most other foods, that is not the same as saying their use will reduce the child's risk of getting sick from bacterial contamination in his/her environment, as many may assume. (And I agree that Andre, Nutriset and others have not used this as an argument.) While Andre is correct that food is a much better medium for bacterial growth than plain water, the sad fact is that the more nutritious that food, the more rapid and dangerous is said bacterial growth. Plain gruel with no milk or other animal foods added, the main type of food given to infants, does not become dangerous for quite some time, especially if stored with a lid on, not such a difficult behavior to achieve. These thin gruels are NOT good complementary food for infants. But if replaced by RUSF, the water gruels contain will have to be replaced by drinking water, itself often unsafe, especially for infants. Thus I do not on the whole think that our point about water is misleading. I personally tend to agree with Andre's point about using RUSFs for preventing malnutrition, but that opinion is not shared by others in the group that produced the guidelines. More importantly, while Andre agrees that these products must be safely used and not harm breastfeeding, he does not address the other issues that the guidelines are intended to address. Will open commercial sales of RUSFs (as opposed to controlled use by NGOs and other organizations), accompanied by advertising and promotion be beneficial? We know from past experience with other products (including drugs, as Massimo mentions) that the free market will exploit the good will toward these products generated through their use in responsible ways by the development community. At the very least, this can lead to poor people spending too much on them. Trying to find a way to reduce the risks attendant to commercial promotion of these products to the public in low-income countries is the main purpose of the guidelines. The debatable points rightly raised by Andre can, if necessary, simply be left out of any future marketing guidelines without reducing their importance or effectiveness. If harmful marketing is simply allowed to happen; if nothing is done to prevent this, then it is only a matter of time until someone documents resulting harm. A polarized situation will result, just as in the case of infant formula companies. Then manufacturers and organizations associated with these products may end up being called the "bad guys" in simplistic media reports. This would be unfortunate and harmful to all concerned. Thus I would be interested in hearing Nutriset's response to the guidelines (which should be considered separately from the cover letter that ENN published separately). I sent the guidelines for comment to another RUTF manufacturer and they wrote back to me that they found the guidelines to be constructive, well-worded and easy to follow. Their only warning was that not too much information can fit on labels of products that may be sold in quite small amounts. (Other solutions can be found of course.)