Treatment of SAM in older people through outpatient

Hi Pascale, By my calculations I found that for an adult weighing 60kg, that formula would result in a ration size of about 12 sachets, or more than 1 kg of RUTF per day. This is quite a lot of RUTF to expect someone to eat. I don't think it was every written up or published, but many years ago I spoke with a researcher from Valid who had done some work on RUTF use among HIV-infected adults in Malawi, and found that on average, adults would eat about 300g per day of the peanut-based RUTF (may be a taste thing though - it's possible that other, less sweet formulations would be more palatable). I have seen national protocols that call for a flat dosage of roughly 500g/day for an adult with SAM (2700-3000kcal/day). Keep in mind that even when enrolled in a therapeutic feeding program, adults are not likely to eat only the RUTF ration - they will also be eating their usual family meals. You don't want to give people more RUTF than they can reasonably eat, because the RUTF will just end up on the market.

The metabolic rate of a child of 6 to 24 months is about 100kcal/kg/d (with 10% allowance for malabsorption and 10% allowance for spillage) so that this is the maintenance amount we prescribe in the acute phase - and it is increased in the transition to 130kcal and in recovery to about 170kcal, which if it is all taken by the child would result in an average weight gain of 6 and 14g/kd/d respectively). The metabolic rate of a normal elderly person is from 30 to 35kcal/kg/d and the gain of weight should be 1gm/kg for each 5kcal/kg that is ingested above this maintenance amount. 100kal per day is way in excess of what then need, what they could ingest and if they did ingest that amount they would be in grave danger of developing the refeeding syndrome. In the generic protocol (version 6) that Yvonne Grellety and I have written we give amounts and of diet and drugs to give for all ages of malnourished patients up to 60kg! ( If they are over 60kg they are not malnourished!) - you can access the protocol on the CMAM forum at http://www.cmamforum.org/Pool/Resources/Example-of-IMAM-protocol-West-Africa-Golden-Grellety-2012-eng.pdf (english version - 2.9mb) and the French version at http://www.cmamforum.org/Pool/Resources/Exemplaire-protocole-PCIMA-l%27Afrique-l%27ouest-Golden-Grellety-2012-fr.pdf (3.2 mb). When we do evaluations we normally visit the adult wards (medical, surgical and O&G) of local hospitals - and take muac measurements on the patients - the results are shocking! over half of the patients we find are severely malnourished and nobody is doing anything about this! The same applies to adolescents and juveniles - in Ethiopia we even found adolescents with MUAC of less than 110mm languishing with no treatment - and quite a lot of the adults had kwash as well. It is quite wrong to restrict treatment to young children alone for anyone who has taken a Hippocratic oath. There is not much published about these patients in poorer countries - but quite a lot in the anorexia nervosa literature and the care of the elderly in western countries - but they do not use the sorts of protocols we have developed for SAM and MAM. I wish you all the best and hope that you will share your experiences. Cheers Mike

The table shows the amount for the higher weight (rounded) in the weight range 40-60kg and was first designed for inpatient management. It might be useful to cover some of the theory. In the malnourished state there are two main competing considerations. First, there is reductive adaptation whereby the metabolic processes are reduced (by about one third) and activity curtailed meaning they can survive on much less intake per kilo at the cost of compromising function. The second is that they lose disproportionately more fat and muscle - low energy consuming tissues than brain, heart etc. This change in body composition means that each kilo of body has a higher proportion of high-energy-requiring tissue and if the tissues did not have reductive adaptation the energy requirement would be much higher than normal to maintain body weight; often these two factors almost balance out. But during treatment we expect the reversal of the physiological changes to take place long before muscle and fat are repleted. So for the first week or so after the start of treatment there is an increase in maintenance requirement. Now malnourished elderly have a BMR of around 25kcal/kg/d or even less (which is lower than normal elderly of about 30kcal) - and this increases to about 35kcal/kg/d during refeeding. (note in the “normal” elderly there is usually a reduction in physical activity - saving energy - balanced by a reduction in fat and muscle tissue - making each kilo need more energy - so that healthy elderly’s energy requirement does not change much from that of a younger adult.) Incidentally, it is the change in body composition that accounts for nearly all the higher requirement of children - each of their kilos has a relatively huge proportion of brain and other high-energy requiring tissues - the consumption of each gram of the different tissue types is virtually the same in children, adults and the elderly (and in different animal species) and in humans the increment in energy required for normal growth is relatively small (circa 5kcal/kg/d). Other considerations that contribute to the individual variability/uncertainty are the amount of physical activity that is taken (much more at home than as an inpatient), the amount of malabsorption, fever/infection and such things as thyroid function (iodine deficiency) etc. At any rate let us take 35kcal/kg as the maintenance requirement. If we multiply this by 1.7 (the same increment as we use in children) we end up with 60 kcal/kg/d - which should lead to a weight gain of about 5g/kg/d if it is all taken. This would mean that a 40kg person would need about 2400 and a 60kg about 3600kcal.kg.d to achieve this rate of weight gain (the factor of 5kcal above maintenance to give one g weight gain is derived from experiments on children - and depends upon whether they are making fat or lean tissue predominantly - it should be the same for adults). In Jamaica we studied some adults with SAM; they gained weight as in-patients at about the same rate as the children (14g/kg/d) on the same diet if they took what was prescribed exclusively, with the same energy cost of tissue deposition, and a maintenance energy requirement of about 35kcal/kg. So much for theory - not that helpful from a programmatic point of view I agree. So let us try and be more practical. Nearly all adults really do not like to take RUTF exclusively for prolonged periods (even for a few days) and demand normal food even as in-patients - this will be even more problematic as outpatients. Even with young children in OTP there is usually extensive sharing and other foods being taken (if 170kcal/kg/d is all taken the rate of weight gain would be 14g/kg/d - with 200kcal/kg/d it would be 20g/kg/d - this is never achieved - and from these calculations we can determine the amount of energy that is being taken - at rwg of 5g/kg/d this will be about 125kcal/kg/d - of which some will be normal food and some from the RUTF). There are several problems with mixing the diets: first, if “normal” food which is nutritionally inadequate for rehabilitation is taken with the RUTF the resulting mixture is unbalanced in terms of the nutrition required for rapid physiological recovery; second there may remain uncorrected essential nutrient deficiencies; third, the anti-nutrients in the normal food inhibit the absorption of some of the essential nutrients in the RUTF. For this reason the RUTF should be taken BETWEEN meals and not used as a sauce with the staple (as some suggest). There is a real need for a more bland, less sweet, acceptable adult-RUTF (and maybe OPT-RUTF) that is re-formulated to account for it being taken along with, but at a different time from, normal food – happy to discuss this with those interested in testing such modifications. At any rate, you are correct in thinking “what is the point in giving large amounts of (expensive) RUTF to adults when they are not going to take much of it”. This opens a whole new discussion on the several reasons and necessity for patients to share the RUTF – happy to post my thoughts about this if readers are interested. At any rate, there is very little experience with feeding older malnourished patients in the context of humanitarian assistance – we have a “starting point” from the limited data and theoretical considerations – now, I would love to be able to refine the recommendations based upon real data and evidence. I urge you to document your program, analyze the data and write it up for ENN or elsewhere. Mike

Hi Pascale, We are currently also facing malnutrition in over 5 & especially elderly in the refugee camps in South Sudan. As you said, people are not able to eat more than 3 to 4 RUTF sachets per day. See below, the protocol we use for ATFC. We provide 2000 Kcal/ day, considering that they will get the remaining through family food (We propose eventually to mix different RUTF to improve acceptability). Phase 2 - Teenagers: minimum 100 kcal/kg/day, up to 3000 kcal/day - Adults: minimum 80 kcal/kg/day, up to 3000 kcal/day - Elderly: minimum 70 kcal/kg/day, up to 3000 kcal/day 5.2 Dietary protocol - Ambulatory As soon as the patient recovered from medical conditions and has good appetite, he/she can be send home and continue his/her treatment in ATFC. He/she should therefore receive: MUAC >170 and <185 mm: 3 PPN/day or 2 PPN + 2 BP5* or BP100: 5 bars/ day or 3 bars + 2 BP5 MUAC = 170 mm: 4 PPN/day or 3 PPN + 2 BP5 or BP100 7 bars/day or 5 bars + 2 BP5 Family ration: BP5: 6 boxes/week * to improve compliance We started only few weeks ago, so I don't have much data yet to evaluate the results. Hope this help

Hi Pascale, Reading through the great responses and discussions here, this points again to the need to develop a 'adult acceptable RUTF' and protocols based on that, rather than the scale up of paediatric treatments. In the meantime (and unfortunately not tested by valid research) care of older adults with undernutrition could be based around a few days of loading treatment with RUTF and then encouragement of 3 normal meals with snacks of RUTF to at least ensure weight gain and that the adults continue to adhere to treatment. This has worked well in a few HIV nutritional support programmes I have worked on. The other important issue is that of the micronutritients and it might be interesting to add use of a sprinkles type product to meals daily in order to start addressing this side of their nutritional deficits. Claire

We tell them to eat this between the family meals, they are supposed to eat also 750 to 1000 kcal through family meal.