Plumping-up the starving with peanut butter

Death rates among severely malnourished women and children can be halved if the high-calorie peanut-butter based food called Plumpy'nut is administered. Picture / Reuters

When an Antonov An-12 airlift took off from Marseilles, heading for a famished region of Niger, it carried several tonnes of oil and sugar, supplies you would expect to be used to feed starving people.

But it also carried several tonnes of a 92g, 500-calorie foil sachet that is a household name in hungry countries and almost unknown in well-fed ones.

The sachets are packed with Plumpy'nut - known to millions of hungry and formerly hungry children as Plumpy - a peanut-butter food for the acutely malnourished which is transforming the way hungry people are treated. The French newspaper Liberation called it "this magic potion".

But Isabelle Sauguet, the sales and development manager at Nutriset, the French humanitarian foods company that invented Plumpy'nut, says that description is excessive. "I don't think magic potions exist outside Asterix. But it has been revolutionary."

The ingredients are simple - peanut paste, vegetable oil, milk powder, vitamins and minerals. This combination comes in a a foil pouch with red lettering and an apostrophe that is shaped like a peanut.

Cut the corner of the pouch, feed to a severely malnourished child two to three times a day for about 40 days, and the child will usually be up and about. Normally, 25 per cent of severely malnourished children do not survive, even in clinical conditions. But with Plumpy'nut, death rates can be cut by half.

"This isn't a small step," says Mark Manary, an American paediatrician who uses peanut paste to feed the malnourished children of Malawi. "It is a quantum leap."

And it is needed. Every five seconds a child dies because of hunger. Starvation kills more people than Aids, Tb and malaria combined. Severe malnourishment - starvation complicated by disease - is a condition as easy to get as it is tricky to treat.

The World Food Programme usually treats malnourished adults with one-and-a-half cups of rice or flour, a tablespoon of beans or lentils, and a spoonful of oil and salt. But the more vulnerable severely malnourished - women and children - need high-energy milk formulas called F100 and F75 that took years of research to develop.

Ideally, a malnourished child stays in a therapeutic feeding centre, or TFC, for as long as four weeks, being fed every two hours with milk formulas carefully diluted and measured according to the child's weight. If all goes well, the child should recover in about a month.

The treatment is labour-intensive, requiring careful clinical supervision, but there is no doubt it works.

Caroline Wilkinson, a nutritionist with Action Against Hunger, says: "We were asking ourselves whether mothers should stay for such a long time in a TFC, because it has consequences on life at home."

Every child in a TFC must be accompanied by a carer, usually the mother. This takes the mother away from other children and from her fields.

Steve Collins, of Valid International, a non-governmental organisation (NGO) says that feeding a child at a centre "has a negative impact on food security. It's a nasty cycle."

Malnutrition damages the immune system, so putting sick children among sick children is a perfect breeding ground for infection. The impetus came in 1998. "There were tens of thousands of starving Sudanese kids crowding centres that only had space for hundreds. We had to find another way."

Some believed the solution was to treat the child at home. But with what? The milks had to be carefully diluted with clean water. When the mother is illiterate, and the water is dirty, it is not going to work.

Even leaving the milk standing can contaminate it. Anything else had to be non-water-based, easy to store, easy to feed and easy to eat. It had to be a ready-to-use therapeutic food (RUTF) that did not require clinical supervision.

Then Andre Briend, a child nutrition expert, saw a jar of Nutella.

For a while he had been looking for a viable alternative to high-energy milk. He realised paste was it and contacted Michel Lascanne, the chief executive of Nutriset.

Lascanne had developed a chocolate bar during his time at a French dairy company, but the taste was poor and in high temperatures the chocolate melted.

Lascanne and Briend realised that a paste made of peanut butter would store easily and it was rich in protein and energy.

By 1999 the recipe was ready. It just needed a name. "We started with pump, then plump, then Plumpy'nut," Sauguet says. "We wanted something that encapsulated joie de vivre. A little bit of happiness."

And a lot of business. Now, the Nutriset staff of 40 make a product in their factory near Rouen in France that saves the lives of hundreds of thousands of children.

"We're not replacing NGOs," Sauguet says. "We just hope we have taken on the cooking that they were having to do to prepare the milk. If the humanitarian network is a restaurant, we're in the kitchen, out of sight."

Since January this year, Nutriset has produced 1300 tonnes of Plumpy'nut, which sells for about 25c a sachet. It is not much cheaper than the milks, but the sachets take up less transport space, and cut the cost of hospital treatment.

"Plumpy'nut is complete and it's clean," Sauguet says. "A child can feed himself, but he will self-regulate." It even tastes good, thanks to the 28 per cent sugar content.

But why did something so simple take so long to be invent? After all, the nutritional properties of peanut butter have been known since the 19th century when a freed slave, agronomist George Carver Washington, invented a way to use surplus peanuts.

"It is partly because the milks were so good," Collins says. "But it is also because the treatment of severe malnutrition has been over-medicalised. Doctors see a severely malnourished child and they say, 'There are metabolic complications, you have to put them in hospital'. That's not always true."

Collins is the best-known advocate of community-based therapeutic care (CTC), in which children are treated at home after an initial triage and treatment phase.

"If every time someone is malnourished you put them in hospital, you're giving the message that the family can't deal with it," Collins says. Mothers can treat even a severely malnourished child if the right food is available.

In Malawi, Manary researched ready-to-use-foods, then used them. With a mixture of traditional foods added, 75 per cent of children recovered. On an entirely RUTF diet, recovery was 95 per cent.

He began thinking about how to deliver the food cheaply and appropriately, and in 2003 Project Peanut Butter began. They used local food - peanut butter, chickpeas or soya - and added the milk, oil and vitamins.

They tested recipes on the two children of the local Medecins Sans Frontieres director, and found one that worked.

"It has everything it needs in it," Manary says. "Nobody has to cook it, which was one of the barriers. The kid just has to stick his finger in the jar. There is no water, so bacteria can't grow. And it is not like any other food people eat - we tell them it is 'special medicine food' - so there is less problem with sharing with siblings."

A Nutriset food scientist helped to set up the Project Peanut Butter factory, and a Malawian production manager did a two-week internship in France.

Sauguet says: "Our philosophy is to feed children. As long as it's for a specifically humanitarian aim, and the quality control is acceptable, that's fine."

It is less fine if the rival is a commercial company. Nutriset's Lascanne says profits, which have doubled, are put back into research and development, and the company doesn't countenance using its technology to sell purely commercial products, such as high-energy bars for athletes.

For now, Plumpy'nut's only real competition is BP100, an RUTF biscuit produced by the Norwegian company, Compact.

Patent issues do not concern children such as Milika. When she arrived in Manary's malnutrition ward she was 18 months old and weighed 5kg.

Her grandmother lived on the streets and her young mother had gone back to school.

Milika's grandmother fed her the peanut butter, and came back for more when she was supposed to. Milika thrived and survived.

HIV-positive children show similar results.

In November, the World Health Organisation, the conservative arbiter of the world's health standards, will consider recommending CTC and ready-to-use therapeutic foods. If it is not a revolution, then it is a highly satisfactory evolution.

"Successful treatment of severe malnutrition was possible before," Wilkinson says. "It will continue to be so without RUTF.

"But it is a revolution in that it offers a chance to do treatment at home that is safe. It opens a lot of doors that weren't open before."

- INDEPENDENT