Access pdf of February 2011 editorial here
Access pdf of February 2011 commentary here
Access pdf of February 2011 correspondence here
Access pdf of March 2011 correspondence here

Sir, This letter follows the coverage and correspondence on ready to use therapeutic food (RUTF) that appeared in the February and March 2011 issues of World Nutrition. We are writing to express our deep concern over the pressure on countries by international organisations like UN bodies and donors, to work collaboratively with problematic companies, to use RUTF in the management and even the prevention of malnutrition. We also propose some solutions to manage severe forms of malnutrition.

In his 26 December 2011 Report to the UN General Assembly (1), the Special Rapporteur on the Right to Food states that 'When ecosystems are able to support sustainable diets, nutrition programmes, policies and interventions supporting the use of supplements, RUTF [ready-to-use therapeutic foods], fortificants and infant formulas, are inappropriate and can lead to malnutrition, and ... the marketing of these food substitutes and related products can contribute to major public health problems'. We agree.

The term 'ready to use therapeutic food' refers to several varieties of ready to eat foods, ranging from those prepared from locally available foods by village women in their own self-help groups for the malnourished children in their village, to those prepared according to specific formulas in factories to be shipped all over the world. The term now almost always refers to the latter, and specifically a peanut and milk- powder based spread with specified amounts of micronutrients, providing energy equivalent to 520-550Kcal/100g, produced by companies such as Valid Nutrition (Malawi), Nutriset (France) and Insta EPZ (Kenya). Even 'local' production, when mentioned these days, refers to centralised production with technical oversight, usually at the national or sub-national level, something which cannot be replicated at the village level. For example, Insta EPZ has an annual RUTF production capacity of 4,500 tonnes (2).

An increasing number of large and medium sized companies are now entering the malnutrition market. Besides the seven global corporations and an equal number of national corporations selling RUTF to UNICEF (3), other corporations are supplying their products across the world though USAID and other donor organisations. There is even talk of giving incentives to food companies to develop RUTF (4). Valid Nutrition describes itself as 'a business in that it aims to earn revenue and profit although these profits are re-invested in the business in pursuit of its social mission' (5).

Why is the commercial sector willing to invest in setting up manufacturing units that may be closed after say one decade if, as we all hope, severe forms of child malnutrition are then eliminated? There is already evidence that programmes using RUTF do not decrease its prevalence (6). Nevertheless the market is growing. UNICEF's forecast for purchase of RUTF for 2012 is 28,000 tonnes, up from 23,000 tonnes in 2009-10 (7).

Trade-driven policies and interventions based on a product are market-centred and not people-centred. People-centred strategies, that empower people to eliminate malnutrition, are those that address the social determinants of malnutrition – such as rising food prices; loss of livelihoods; privatisation of or reduced access to community resources of land, water, seeds, and forests; feminisation of labour, particularly in the unorganised sector where there is little or no maternity protection; increased costs of health care; climate change; and deregulation of trade and commerce.

The UN's framework for child malnutrition dating from 1990, which identified these determinants, seems to have been lost in the push for RUTF. Chronic malnutrition is a symbol of the denial of the human right to adequate food. This is defined by the UN Special Rapporteur on the Right to Food in 2002 as being 'inherent in all people, to have regular, permanent and unrestricted access, either directly or by means of financial purchases, to quantitatively and qualitatively adequate and sufficient food corresponding to the cultural traditions of people to which the consumer belongs, and which ensures a physical and mental, individual and collective fulfilling and dignified life free of fear'.

Strategies to address malnutrition should protect people's livelihoods; provide equitable and 100 per cent coverage and access to adequate food, to safe water and sanitation to primary health care, to full support of optimal breastfeeding and of growth monitoring.

Malnutrition, especially chronic malnutrition, is the result of a complex set of factors resulting in a lack of access to adequate food and a loss of nutrients from preventable diseases. Therefore the sustainable management of malnutrition also requires a comprehensive set of responses primarily geared to ensure this access. The RUTF approach fails to address these factors. This is obvious.

We therefore respectfully suggest

• Strategies to manage all forms of malnutrition, including severe acute malnutrition, should be food-based, not single supplement product-based.
• Reduction in the prevalence of severe malnutrition, particularly in children, over a specified period of time, should be the first indicator of the success of strategies to manage malnutrition.
• Communities that are stable, and where poverty and inability to access food is the primary cause of malnutrition, should be declared no-go-zones for commercial RUTF.
• Commercially packed unbranded RUTF should be used in emergency situations where people are displaced, such as in conflict zones or disaster areas following floods, earthquakes, fires, tsunamis. Such use should be time-bound, and RUTF should be replaced by fresh cooked foods at the earliest possible time.
• Energy-dense foods produced or manufactured by local people and groups using local food ingredients, in as close a form to the food regularly eaten by the community as possible, should be used for community management of severe forms of malnutrition. Micronutrients can be added separately to the food as required. There should be strong emphasis on supervised feeding to ensure that optimal feeding practices are followed.

Chronic malnutrition in children, in the numbers seen today, is glaring evidence of glaring inequities in access to food, both globally and nationally. Ready to use therapeutic food does not address these inequities. It should be used in emergencies, but it is not the solution to malnutrition.

Please cite as: A, Schuftan C, Valente F, Rundall P, Holla R. Ready to use therapeutic food is not the solution to malnutrition. [Letter] World Nutrition, April 2012,3, 3: 168-171. Obtainable at www.wphna.org

References

1. Report submitted by the Special Rapporteur on the Right to Food, Olivier De Schutter, December 26, 2011.Obtainable at http://www2.ohchr.org/english/bodies/hrcouncil/docs/19session/A.HRC.19.59_English.pdf
2. USAID. Saving Lives One Packet at a Time - Increasing Regional Food, 16 September 2011. Obtainable at http://eastafrica.usaid.gov/en/USAID/ Article/2858/Saving_Lives_One_Packet_at_a Time
3. Komrska J. Overview of UNICEF's RUTF Procurement in 2010 and past years. Presentation made at consultation with RUTF suppliers, Copenhagen, 18 October 2010. Obtainable at: http://www.unicef.org/supply/files/Overview of_UNICEF_RUTF_Procurement_in_2010.pdf
4. The global game plan of Big Snack. [Editorial] World Nutrition, February 2011, 2, 2: 55- 61. Obtainable at www.wphna.org
5. Jeremy Shoham (2010). Valid Nutrition. Field Exchange 39, September 2010. Obtainable at http://fex.ennonline.net/39/agencyprofile.aspx
6. http://www.unicef.org/nutrition/index_51688.html
7. 2011-2012 Tender Overview. Consultation with RUTF Suppliers. Copenhagen, 18 October 2010. Chief, Medicines and Nutrition Centre, UNICEF Supply Division. Obtainable at http://www.unicef.org/supply/files/2011-2012_Tender_Overview.pdf