Hi there, This is very exciting research. My colleagues and I have also been working on developing a food supplement at the local level, but our research is based more on the biochemical aspects of ensuring the supplement meets specific nutrient requirements - In terms of cost-effectiveness, the idea is for the foods to be produced locally by farmers or home-growers. Can I ask you: where will the foods be sourced? what specific foods are you targeting? how will the efficacy of the supplement be assessed? (anthropometric, biochemical data) Please do get in touch - I'm really looking forward to hearing more about your work, and maybe the possibility of collaborating in the future. Regards Keiron Audain www.keironaudain.com

Hi Keiron, Many thanks for your interest. The idea is to source the foods locally in Cibotoke province of Burundi. It is very much at the early stages - the idea is a supplement based on a mixture of perhaps soya, maize, millet and perhaps and peanut mixture to be grinded in a local mill, which we intend to set up also. Avocados will then provide lipids in the diet. However, peanut mixture is risky given the risk of aflatoxin contamination as well as potential peanut allergies. There is also the question of quality control and required standards as in the case of Plumpynut and other such foods. As regards efficacy assessment I honestly do not know how we will do that. I know that I will have technical support from a nutritionalist in country though. Although I have been look at alternative RUTF foods that do not need peanuts. See http://fex.ennonline.net/21/malnutrition.aspx for Development of alternative RUTF formulations (Jeya Henry) section. Thats the only information I could find on alternative RUTF formulas. My own backround is anthropology and development. My main focus then is the socio-economic factors such as product affordability, local food tastes and division of resources in the household with technical support then from a nutritionist in country. What kind of supplement are you working on with your colleagues?

Hello John, This will be interesting research, as many of us would like to produce RUTFs etc at local level! I have a couple of issues to take into consideration for you, related to your reply to Keiron. 1. Promotion of avocado trees, to provide lipids to the diet. If avocados are not part of the normal diet - and thus people would not know it - it will be very hard to convince the people to grow avocados, and actually eat them will be even more difficult. It might be worth checking which local possibilities there are, and promote these (even if the people are not used to eat tehm, at least they know the food). Next to that it takes a very long time before avocado trees produce fruit, and growing them requires very specific conditions (see at Wikipedia if you type 'avocado' under cultivation). you also have tot ake into accuont the seasonality of the fruit, and how you plan to store them so they can provide lipids throughout the year. 2. Peanut allergy. I have looked into this just a few weeks ago as I got questions on peanut allergy as well. As far as I know there never has been any reported case of peanut allergy in a child using plumpynut (I never heard of it while working with it). One possible reason is the fact that in nearly all countries in Africa and Asia peanuts are part of the normal diet. When asking around none of my colleagues ever heard of any case of peanut allergy, and several confirmed that this is because the children are used to eat peanuts from a very young age. Via the Valid international website (http://www.validinternational.org/demo/ruf/about.php) I got a link to the CBS show '60 minutes' where they talked about Plumpynut in Niger, and the MSF doctor in charge very clearly stated that children do not show allergic reactions to Plumpynut, and that this is possible due the fact that peanuts are part of the diet. (video of this CBS show: http://www.cbsnews.com/video/watch/?id=3389659n) 3. Quality control and storage. These might be the main problems you will find when trying to develop a locally produced supplement. You have to consider shelve life, and the longer you want to be able to store the item, the more important the quality control, hygiene rules etc during the production process need to be, as contamination can be a serious problem. 4 Socio-economic issues. If your main interest are the socio-economic issues such as affordability, you might be interested in the Cost of Diet method from Save the Children UK, a tool that looks into the affordability and availability of local foods that can provide all nutrient requirements of a household and of individuals in the household. For an overview of this method see Field Exchange 34 page 21 for an overview of the method (http://fex.ennonline.net/34/cost.aspx). Abit longer reply than planned, but I hope this helps you in your research! Esther

Dear John and Keiron, The development of a low cost RUTF/RUSF based on local ingredients indeed would be a major advance. You may wonder why there is no much work about this published since the ENN paper you refer to based on a presentation made in 2003 in Dublin. One reason may be that attempts so far have proved unsuccessful. All ingredients are not equivalents to prepare a supplementary food for young children, and one has to take into accounts many factors beyond its nutritional content such as the antinutrient and dietary fiber content of the food to make it work. I heard that some promising attempts actually failed because the developed supplement was poorly tolerated children. It is important to work in collaboration with a nutritionist for this development work. But this will not be enough, as some factors which are key in making a food more or less successful are not so easy to assess even by a skilled nutritionist. So it will be important you assess the efficacy of the food you develop (in terms of lean body mass or at least height gain) before promoting its use. Good luck,

From Samuel Oluka: John, your idea is Novel. In the event that you need to still use Pea nuts, I suggest you have an outreach component and outsource to farmers who can follow appropriate processing to minimize the Aflatoxin levels. You will als need to conduct analyses and where possible fix the maximum acceptable aflatoxin level that the outsourcing agent could adhere to. Otherwise, I seem to notice peanuts are indeed one locally produced food with guaranteed availability. Kind regards and the best of luck. Samuel

Hi John, You idea is timely and pertinent; the thinking for some time now has been how to produce local products equivalent to plumpy nut et al. What I read from above responses suggest that you have to do a thorough literature review to understand what has been done, challenges and successes. Many successful products build on tried and tested ideas. I would suggest you seek advice from Ethiopia and Malawi- they have already piloted locally made products. Secondly, consider seeking advice from Universities/ Technical institutes who are normally involved in research of new products using appropriate technology. e.g. University of Nairobi Nutrition/ Food tech department. It was once funded/partnered by/with Swiss, and my thinking is that they would have the capability and know how to fast track you ideas. In fact you might be lucky to get some bright students seeking projects for their graduate studies and with the right partnership with their professors, you might be able to fast tract the whole process. UON successfully developed supplementary foods for a Major UN agency in the 90s. Just consider them in you literature review. Best Luck. Mordecai

Hello John, You're thinking along the right lines, and as many others stated, there are a variety of cultural, technical, and nutritional challenges to overcome. I would enjoy talking with you about our vision and plans for production of RUTF and other locally-sourced fortified foods to combat severe and moderate acute malnutrition in Rwanda. We have a robust, highly capable partnership of people, organizations, and companies working on this, and I think there could be some great synergies. We'd love to learn more about your work in Burundi to see how we might support your efforts. Please email me at bret@mananutrition.org, and we'll arrange a time to talk.

Hi everyone, This is a very informative discussion. In response to your question John, our supplement will be more disease-specific, e.g. identifying the nutritional deficiencies associated with a particular disease and meeting those requirements with a locally produced supplement. At the moment, the main emphasis is efficacy, as in will the supplement actually be of clinical benefit. I am also very keen in finding out how the logistics of such a project would pan out, so please let's all keep in touch and continue to share information, as in my opinion, there is very little research more important than this! Regards

thanks all for a wonderful discussion .i share with you a similar one pager developed for Sudan on utilisation of abundant wild foods to sustainably treat acute malnutrition through the STOMS initiative.Read below and thanks SUSTAINABLE TREATMENT OF ACUTE MALNUTRITION IN SUDAN -STOMS Going really with the management of acute malnutrition Feasibility Trials into the Production of community therapeutic food using peanut (ground nuts) and naturally occurring oil seed (Lulu) in South Sudan: In south Sudan, Malnutrition remains rampant and continues to kill children unnecessarily with donor attention quickly shifting to provision of services long known to be longer routes of reducing malnutrition: most of which though very necessary take decades to achieve any impact . Essential nutrition actions that are shorter routes to alleviating child malnutrition unfortunately are not receiving as much attention. In the mean time few lucky vulnerable communities continue to receive one off feeding programmes that utilize expensive pea nut paste imported a cost of more than USD 4,500 per metric tonne.During the peak hunger times, access to some of these few programmes are further compounded by heavy remains making most households with malnourished children to be cut out of the centers. Even with efforts to decentralize as much as possible through approaches like CTC, coverage still remains low in south Sudan and sustainability of the programmes especially on the supply of Plumpy nut continues to be a big issue that needs to be addressed. Local production of Plumpy nut has been trialed in a number of countries through franchise arrangements but ultimately these needs some NGO etc buying the product for final free distribution to the beneficiaries. But what happens if the NGO doesn't buy the commodity or runs short of donor funding and the MOH budget can't manage to ensure a consistent flow of Plumpy nut as is the case currently in most counties faced with massive malnutrition problems? And what about the poor who cant afford the product even if it were to be socially marketed? In order to treat malnutrition sustainably during non famine situations, efforts to tackle the problem should therefore be focused at the household level through the utilization of local and in some cases naturally occurring uncultivated foods that are familiar to the affected communities. The use of these easily available resources stimulates indigenous knowledge and practices and empowers communities to address some of the route causes of malnutrition. So many combinations exist that are useful in the production of therapeutic foods .the big problem that hinders uptake remains the amount of ingredients that need to come out of the production area and the eventual access of these products to the poor who practically are the ones who are more affected with the problem of malnutrition. For the production of the valuable product to go really local, the use of peanuts and oil from the Lulu tree (very common in lakes state and parts of warrab state) to produce some of the ready to eat food for correcting acute malnutrition is one such avenue that is worth pursuing and replicating. This indigenous knowledge already exists and will only need initial resources for training the community on food hygiene, preparation, storage, quality control and administration among other things. It's hoped that such a venture targeting households will give enough health benefits and returns to households through the treatment of their malnourished children and consequently raise the potential for increased production. This in the long term goes along way to increasing the human productivity in south Sudan through reduced child mortality and morbidity. However as is with any product development, it's vital to conduct a feasibility study to lay a ground work and provide an initial information framework for the promotion of the home making of therapeutic food in south Sudan.

Hi John, Please do get in contact to report on the developments in your research. I can be reached on info@keironaudain.com Much success

Dear all I have been involved in setting up sustainable equitable social enterprise associated with payment for ecosystem projects in central Africa. Our projects facilitate and promote the production of nutritional supplements that are locally grown and produced in country to address malnutrition and the need for off farm alternate livelihoods and revenue. I just saw this exchange back in 2010 and wondered how your research turned out (particular in Burundi). Please call me, John Kendall, at 1 778 378 9119 or by email at johns day one@yahoo.com Murakoze

I believe Plumynut is a brand of RUTF and I just want to alarm everyone in the discussion not to equate it as RUTF. I appreciate the question raised here regarding local options for RUTF...as it is also being presented as magic bullet in India also. Plumynut was brought in Madhya Pradesh by an UN organisation even without consulting Government of Indian and State Government. There has been significant efforts for commercialisation of Pumpynut and Other RUTF brands. Most of the international organisations are not interested in getting into the discussion of Local options. We have examples (Jan Swasthya Sahyog, Bilaspur, Chattisgarh State of India), where Different kinds of Cereals, Jaggary, Pulses, edible oil and Eggs are being used in Creche program for children; definitely it took 6 to 8 months and more in some cases, but it worked. This organisation did make some arrangements for micro-nutrient supplementation as medicine separately. JSS has also proved that strong availability of primary health services and secondary health services are most essential for addressing chronic malnutrition and SAM. Is it necessary to follow golden formula of RUTF work by word, point by point......./ If you are looking for a local option, you will have to take a different line from Plumpynut!! Sachin Jain India sachin.vikassamvad@gmail.com