KATHMANDU, Nepal — Each year roughly 3 million children die of undernutrition, which accounts for approximately 45 percent of deaths of children under 5 globally. South Asia and sub-Saharan Africa bear the largest burden.
While malnutrition is a multifaceted problem which requires multisectoral solutions, these deaths are not because of a lack of viable treatment options.
Ready-to-use therapeutic food — or RUTF — a paste made of peanuts and milk powder, is widely accepted to be a safe and effective way to treat children with severe acute malnutrition — or SAM — while keeping them inside their own communities. But the average full course of treatment for a child costs between $41 and $51, according to UNICEF data, putting it out of reach of most health programs. Today, only 1 in 4 children with SAM are currently treated with RUTF.
Now, health practitioners are looking at local solutions in the hopes of tapping widely available staples to meet the needs of gravely malnourished children.
Dolores Rio, nutrition specialist at United Nations Children's Fund’s headquarters in New York, told Devex that 90 percent of the cost of RUTF comes from ingredients and packaging.
The Gates Foundation led the latest round of investment for Evolve, a privately held microbiome company, because of the connection they see between the microbiome and severe acute malnutrition.
Rio said that almost two dozen of UNICEF’s RUTF suppliers have already come up with local formulas, many of which substitute peanuts and milk powder with cheaper alternatives. However, so far only one alternative formula has passed clinical efficacy trials.
Last year, Valid Nutrition, a social enterprise that develops and produces RUTF, was the first company to publish clinical efficacy trials of its alternative RUTF formula, which was undertaken in Malawi in 2016. Its alternative recipe was found to be as efficacious as the standard recipe in terms of recovery and mortality in infants and children from 5-59 months.
Soya, maize, and sorghum are its primary ingredients — 25 percent less expensive than the standard peanut and milk-based formula.
Paul Murphy, chief executive officer of Valid Nutrition in Ireland, told Devex this price drop alone could enable hundreds of thousands of additional children with SAM to be treated within the current budget.
“It’s no longer a dream, it’s a reality. We have an alternative recipe and we have hard, clinical data to demonstrate that it’s as good as the peanut and milk recipe and actually has a number of other advantages,” Murphy said.
In addition to the lower cost, the new recipe has other advantages: It could be used for children with lactose or nut intolerance; it contains 10 percent less sugar; and it has a lower carbon footprint than RUTF which isn’t produced locally.
And Valid Nutrition isn’t the only one working on developing cheaper formulas to treat SAM.
The International Centre for Diarrhoeal Disease Research, Bangladesh, one of the world's leading global health research institutes, is also developing a recipe to produce RUTF using locally available ingredients such as chickpeas and rice.
Dr. Tahmeed Ahmed, a leading scientist behind the project at the center, said he expects the cost for the chickpea and rice-based RUTF to be around a quarter of the price of commercially available products, if produced locally in large quantities.
The product passed acceptability trials last December and clinical efficacy trials are currently on their way.
"It's not rocket science. By processing locally available ingredients centrally and getting rid of intellectual property, you'll be able to reduce the price and also maintain the quality,” said Ahmed.
Prevention is key
The research conducted by the disease research center and Valid Nutrition is part of an ongoing global effort to make RUTF more affordable and more suitable for different environments, using anything from fish powder to pulses.
Across the developing world, undernutrition has lifelong cognitive and economic impacts, and remains a leading cause of death for young children. Could fish be the solution?
“There’s a good momentum, it’s not fast enough and good enough, but we’re getting there,” UNICEF’s Rio said. Although she wants local formulas rolled out by the end of the year, realistically she said it might take up to three years until they’re actually used in the field.
“We’re not there yet. And even if we have these new recipes, all those new recipes need to be validated. We’re reviewing the guidance, we have to have new guidances and new normative standards that are more flexible to us and can accommodate the variation we’d like to have in terms of local recipes,” Rio said.
She added that governments around the world with a high burden of malnutrition prefer local formulas for a range of reasons.
“Asia was more interested [in it] because it’s local and more acceptable, while in Africa they were much more interested because it will drive the cost down. But really, the majority of countries have expressed an interest to have local recipes,” she added.
Murphy said the primary advantage of local formulas is that by reducing cost you can treat more children with a restrained budget.
“The other key advantage is, that by actually having a recipe that can be manufactured from ingredients sourced locally, you increase the relative competitiveness of local manufacturers, which will then further stimulate their ability to take more market share, which from a developmental perspective, we believe is highly relevant,” he told Devex.
But, as Rio pointed out, more affordable RUTF won’t fix or prevent malnutrition. Instead, it may make room to the shift the focus more on understanding the local factors of malnutrition, and on finding innovative solutions for prevention.
“The product isn’t the only part of the solution of SAM. It’s an important fact, but we have to put it into the bigger picture when it comes to how we can prevent children from falling into the trap of SAM in the first place,” Rio said.
While Murphy agrees that the ultimate goal should be prevention, he hopes for a fast roll-out of clinically tested alternative formulas.
“Prevention is, of course, ultimately the best course of action, but in the meantime, the problem is that you’ve got a huge number of children who need treatment,” Murphy said.
Looking ahead, experts acknowledge the huge resources that are required to overcome malnutrition in all its forms.
While locally produced RUTF is not a panacea to ending hunger, it could play a critical role in the fight against SAM and in doing so, save hundreds of thousands of lives.