Dear Colleague.. Two main differences besides the Plant (Soya) Vs Animal (Milk) origin proteins. 1- Cost comparison per Carton of 150 sachets: (Plumpynuts= 54.7$, Supplementary Plumpy= 46.7$) 2- Suggested Dosage: a- Plumpy nuts: 200Kcal/Kg/Day, hence fulfilling major portion of caloric requirements as well. b- Supplementary Plumpy: 1 sachet/day delivering 75Kcal/Kg/Kg, only fulfilling the supplementary needs. Also, supplementary Plumpy is a Ready to use supplementary feed for moderate malnourished <5yr and PLW, for appropriate for situations where there is lack of access to resources for ensuring hygienic preparation of UNIMIX/ FBF (e.g. clean drinking water and utensils). Further, Plumpy nuts have been recommended for MAM cases in emergency situation e.g. flood affected areas of punjab-Pakistan due to non- availability of FBF & Supplementary, so a temporary measure, agreed by Nutrition cluster members. Plumpynuts would do no harm, except cost effectiveness issues... best wishes ijaz

Dear Dr Ijaz, Thank you very much for your reply. Still i am not convinced. From what you said, i do have further questions: 1.If there is no difference in nutritional composition, can we use supplementary plumy for the treatment of SAM after adjusting the dose meaning supplementary plumy of 200Kcal/Kg/Day? 2.If the difference is only cost (no difference in nutritional composition), what is the point ordering plumy nut as it is very expensive?

Severe malnutrition includes kwashiorkor. Outcomes from kwashiorkor are better when milk protein is used compared to soy. Take a look at the 'published ahead of print' section of Journal of Nutrition. Our group shows that even treating children with SAM in Malawi with 10% milk RUTF is inferior to 25% milk RUTF. The essential elements of milk that promote recovery from kwashiorkor are not really understood, some researchers believe they are related to growth hormones in the milk. Because of kwashiorkor it is not recommend to use a milk-free product.

Dear Mark, Thanks for your reply. This means, thers is no need to purchase only plumpy nut (animal product) as it is costy. so, to minimize the cost of the programme/project, it is good for gencies to purchase more plumpy nut (soy/cheakpea) or supplementary plumy and some plumy nut (milk product) only for oedema cases (based on prevalence). Thanks

Dear Anonymous 81, One should be very careful when comparing nutritional products based only on their nutritional composition. Ingredients are important for determining outcome as well. And all ingredients are not the same. For instance, there are many soy products (hulled, de-hulled, roasted, extrusion cooked, protein concentrates, protein isolates etc.) and many kinds of protein sources of different quality and with different antinutrients, many different vegetable oils, many different added minerals and so on. You should not take for granted that different products will give the same outcome because they have a similar nutritional concentration on their packet. As regard supplementary plumpy, I understand it is now prepared with soy protein isolates (to be checked) but I am not aware it has been formally tested in SAM children. The study Mark refers to from Malawi is rather reassuring for non oedematous children. However, it should not be readily extrapolated to other areas where you have more extreme forms of marasmus or different background of micronutrient deficiencies. FYI, there is a previous study from Malawi (available freely on the web at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1717098/pdf/v076p00242.pdf . See abstract below) giving the same message: diets not including milk give poorer results for kwashiorkor than those including milk even when nutritional composition is similar. Children in this study received mineral and vitamin supplements including Zn, K, Mg. Brewster DR, Manary MJ, Menzies IS, Henry RL, O'Loughlin EV. Comparison of milk and maize based diets in kwashiorkor. Arch Dis Child. 1997 Mar;76(3):242-8. Abstract The dual sugar test of intestinal permeability is a reliable non-invasive way of assessing the response of the small intestinal mucosa to nutritional rehabilitation. AIM: To compare a local mix of maize-soya-egg to the standard milk diet in the treatment of kwashiorkor. DESIGN: The diets were alternated three monthly in the sequence milk-maize-milk. There were a total of 533 kwashiorkor admissions of at least five days during the study who received either milk or maize. Intestinal permeability was assessed at weekly intervals by the lactulose-rhamnose test in 100 kwashiorkor cases, including 55 on milk and 45 on the maize diet. RESULTS: Permeability ratios (95% confidence interval) on the milk diet improved by a mean of 6.4 (1.7 to 11.1) compared with -6.8 (-16.8 to 5.0) in the maize group. The improved permeability on milk occurred despite more diarrhoea, which constituted 34.8% of hospital days (29.8 to 39.8) compared with 24.3% (17.8 to 30.8) in the maize group. Case fatality rates for all 533 kwashiorkor admissions were 13.6% v 20.9%, respectively, giving a relative risk of death in the maize group of 1.54 (1.04 to 2.28). The maize group also had more clinical sepsis (60% v 31%) and less weight gain (2.9 v 4.4 g/kg/day) than the milk group. IMPLICATIONS: Milk is superior to a local maize based diet in the treatment of kwashiorkor in terms of mortality, weight gain, clinical sepsis, and improvement in intestinal permeability.

From Geoff Douglas, HETN: Dear Doctor Briend I am delighted that you hold the view that 'One should be very careful when comparing nutritional products based only on their nutritional composition' and 'You should not take for granted that different products will give the same outcome because they have a similar nutritional concentration on their packet'. Nowhere is this more true than in the area of micronutrients. With the possible exceptions of folate and iodine, attempts to address Hidden Hunger by the fortification of foods with micronutrients in the form of chemical isolates have failed. This should be no surprise. In the 1930s, the Nobel Prize winning discoverer of Vitamin C, Szent-Györgyi , found that the pure ascorbic acid he had isolated had little effect - unless it was combined with the bioflavonoids and plant carrier proteins from which it was isolated. We have known for years that ionised minerals have low bio-efficacy and high toxicity compared to food forms and amino acid chelates. This is particularly true for iron, zinc and selenium. The man in the street may eat white bread, but he knows that whole grain food is more nutritious, despite EFSA's argument that this has not be proven in a randomised clinical trial! We do not need an RCT to show that the milling and refining process removes most of the micronutrients from the flour. And, never forget that it was the polishing of rice that caused Beri Beri. Dr Briend, do please look carefully at the vitamin and mineral cocktail in Plumpy'Nut. And, as you rightly say, do not be fooled by the label claim. Bio-efficacy is the only thing that matters. Geoff Douglas CEO - HETN www.hetn.org

Dear Dr Douglas, When I said one should not only look at the label of therapeutic foods, I meant one should also look at efficacy and effectiveness data. Supplementary plumpy, as far as I know, has not been formally tested in SAM children. One should be careful before using is widely for SAM children (although it may work in many cases), even if its nutritional compositoin is quite similar to RUTF. RUTF have been used on millions of children and its track record in terms of efficacy and effectiveness is rather good. Nevertheless, we are not sure its mineral and vitamin cocktail is optimal. Your suggestion to have another look at it and to improve it is welcome, but this should be based on hard data (trials showing improved efficacy of alternative formulations compared with current formulation), not on general statements. The discussion is about therapeutic foods for SAM children. Micronutrient fortification is a different topic. Your statement that: "attempts to address Hidden Hunger by the fortification of foods with micronutrients in the form of chemical isolates have failed" is not relevant to the current discussion. It is also rather surprising. I am not sure many mainstream nutritionists would endorse it. Your statement about ionised minerals having low efficacy and high toxicity is also surprising, especially for Zn. Again, I am not sure this would be supported by mainstream nutritionists. Zn salts were added to therapeutic foods after clinical trials showed it improved weight gain presumably by increasing the percentage of lean tissue deposition. Zn is also given as supplement (inorganic salts) to children with diarrhoea, again after clinical trials showed its efficacy. I am not aware that superior results have been obtained to treat SAM children or children with diarrhoea by using other sources of Zn. All these issues should be discussed with efficacy data, not by throwing general statements.

From Geoff Douglas: Dear Dr Briend, Thank you for your comments. The discussion is actually about Plumpy'Nut vis-à-vis Supplementary Plumpy in the prevention and treatment of moderate acute malnutrition (MAM), and it is bio-efficacy to which I am referring. The micronutrient fortification of such foods is germane to this discussion - indeed it is the key. My statement that 'attempts to address Hidden Hunger by the fortification of foods with micronutrients in the form of chemical isolates have failed' is hugely relevant to the issue of moderate acute malnutrition. Nor am I just 'throwing a general statement'. In South Africa, there is widespread deficiency of calcium, iron, zinc, selenium, vitamin A, vitamin D, vitamin C, vitamin E, riboflavin, niacin, folic acid and vitamin B6. With the exception of folic acid, attempts to correct these deficiencies by a national programme of maize and wheat flour fortification, using chemical isolates, has been a failure. This is confirmed by the National Food Consumption Survey - Fortification Baseline (NFCS-FB-I) South Africa, 2005. You state, 'RUTF has been used on millions of children and its track record in terms of efficacy and effectiveness is rather good'. I appreciate your further comment, 'we are not sure its mineral and vitamin cocktail is optimal'. I certainly agree that any change should be based on trials showing improved efficacy of alternative formulations compared with the current formulation. The problem I have is that I can find no scientific data demonstrating that the current formula improves micronutrient status. I would be grateful if you could quote any references. My literature search to date suggests that 'efficacy and effectiveness' is defined as increase in BMI. There is a plethora of scientific evidence concerning the bio-efficacy and toxicity of different forms of micronutrients, but space does not permit me to include them all here. Iron has been studied the most. Hurrell et al [1] concluded that iron absorption is higher from cereal foods fortified with NaFeEDTA than from those fortified with ferrous sulphate or ferrous fumarate. Andang'o et al [2] showed that consumption of whole maize flour fortified with NaFeEDTA caused modest, dose-dependent improvements in children's iron status, whereas fortification with electrolytic iron did not improve iron status. On the other hand, Van Stuijvenberg et al [3] demonstrated that ferrous bisglycinate as the iron fortificant in brown bread performed better than electrolytic iron in a group of iron-deficient school children over a period of 7.5 months. Their later study [4] further concluded that electrolytic iron at the level currently used in South Africa is not effective in improving iron or haemoglobin status. Likewise, studies have shown that chelated zinc has greater bio-efficacy than zinc salts. Zinc status did not improve in the South African fortification programme where a zinc salt was used for fortification. In the case of selenium, inorganic salts are toxic and lack efficacy, whereas selenium-rich yeast is non-toxic and has high bio-efficacy. I will not labour the issue, but I agree with you that we need to base all our claims on scientific data, particularly in the case of a product like Plumpy'Nut that is promoted as a 'miracle food'. HETN is currently involved with the University of the Witwatersrand (WITS) in South Africa, studying the effect on the nutritional status of impoverished crèche children of a whole grain, precooked food supplement - fortified with chelated minerals. We should have good data by the year end. Thereafter, we would welcome the opportunity to trial this product against Plumpy'Nut. Would you be up for this? Geoffrey Douglas CEO - HETN 1. Hurrell et al. An evaluation of EDTA compounds for iron fortification of cereal-based foods: British Journal of Nutrition (2000); 84: 903-910 2. Andang'o et al. Efficacy of iron-fortified whole maize flour on iron status of schoolchildren in Kenya: a randomised controlled trial: Lancet (2007); 369: 1799-806 3. van Stuijvenberg et al. The efficacy of ferrous bisglycinate and electrolytic iron as fortificants in bread in iron-deficient school children: Br J Nutr (2006); 95(3): 532-8 4. van Stuijvenberg et al. Fortifying Brown Bread with Sodium Iron EDTA, Ferrous Fumarate, or Electrolytic Iron Does Not Affect Iron Status in South African Schoolchildren: American Society for Nutrition J. Nutr. (2008); 138: 782-786

Dear Dr Douglas, Apparently, you switched the discussion to from supplementary plumpy vs RUTF to the issue of staple food fortification. This is a rather different topic. Indeed, staple food fortification does not solve all problems. In particular it is well known that it is virtually useless to correct deficiencies in children. just because they don't eat much of the staple food and their requirements are very high. But the discussion here focuses on foods for infant and young children. A quite different subject. Fortification of infant foods targeted to infants / young children does work to prevent deficiencies. Iron deficiency anemia in children for instance dropped drastically in developed countries after introduction of iron fortified infant foods (with iron salts). It was a major public health issue up to the 70-80's. Ask any old paediatrician. Or also see for instance: Yip R, Walsh KM, Goldfarb MG, Binkin NJ. Declining prevalence of anemia in childhood in a middle-class setting: a pediatric success story? Pediatrics. 1987 Sep;80(3):330-4. Apparently, you mix up the issue of metallic iron (a non ionised for of iron) with inorganic iron. It is well known indeed that metallic iron (or other metallic forms of other minerals) is very little absorbed. These metallic forms are not used in RUTF and similar foods. RUTF is fortified with salts. EDTA has been known for years indeed to be better absorbed than other forms of iron, but until recently, its introduction in infant foods faced regulatory problems and was not possible. I understand the situation is changing, however. Please note that SAM children usually have an excess of iron at the beginning of treatment. I am well aware of work done on amino acid iron chelates. However, these compounds are more expensive than other mineral forms. Also, ferrous bisglycinate, the best absorbed form of iron chelates, promotes oxidation in foods and cannot be used in high fat foods so easily. See a discussion in the WHO document on food fortification p 103: http://www.who.int/nutrition/publications/guide_food_fortification_micronutrients.pdf So these compounds may not be the miracle option for RUTF. Apparently, you failed to notice that RUTF is derived from previously recommended WHO F-100 diet and in particular has the same fortification formula. Although the formula as a whole has never been tested indeed, many of its key components have been added based on clinical research which has being going on since the 60's on SAM children. As you mention Zn in a previous mail, please note for instance that addition of Zn salts was tested and shown effective in several clinical trials. See: Golden MH, Golden BE. Effect of zinc supplementation on the dietary intake, rate of weight gain, and energy cost of tissue deposition in children recovering from severe malnutrition. Am J Clin Nutr. 1981 May;34(5):900-8. Khanum S, Alam AN, Anwar I, Akbar Ali M, Mujibur Rahaman M. Effect of zinc supplementation on the dietary intake and weight gain of Bangladeshi children recovering from protein-energy malnutrition. Eur J Clin Nutr. 1988 Aug;42(8):709-14. Hemalatha P, Bhaskaram P, Khan MM. Role of zinc supplementation in the rehabilitation of severely malnourished children. Eur J Clin Nutr. 1993 Jun;47(6):395-9. A trial also showed the potential risk of too high dose of Zn: Doherty CP, Sarkar MA, Shakur MS, Ling SC, Elton RA, Cutting WA. Zinc and rehabilitation from severe protein-energy malnutrition: higher-dose regimens are associated with increased mortality. Am J Clin Nutr. 1998 Sep;68(3):742-8. All these studies were taken into account when determining the Zn level to add to F-100 and which form to use. RUTF was not not formulated in a vacuum. Again, we don't know whether RUTF fortification formula is optimal, suggestions for improvement are welcome, and if they make sense, they should be tested in clinical trials, but mass fortification of cereals or preparation of fortified bread are quite different from designing RUTF for SAM children and the two issues should not be mixed up. A final remark. RUTF was designed for treatment of SAM children to promote rapid weight gain and restore body composition and key body functions, not for feeding children in a crèche. I don't see the point of testing RUTF in this group of children for which it is presumably useless. You could test the supplement you designed with other foods currently used for the same purpose, such as WFP CSB. Or with specially designed LNS, or sprinkles, which are other options, and maybe better adapted.

To summarise the response to this question: There is evidence that outcomes for kwashiorkor are better when milk protein is used compared to soy, hence the preference for Plumpy'nut over Supplementary Plumpy. Supplementary Plumpy may not have been formally tested in children suffering from severe acute malnutrition (SAM) since it was designed for treatment of moderate acute malnutrition, whereas Plumpy'nut and other RUTFs have been used extensively for the treatment of SAM children with positive results in efficacy and effectiveness. We have asked Nutriset to comment on this question about their products and provide any further clarification.