How environmental protection is making aid quality and standards evolve: the case of RUTF and Nutriset

Malnutrition is one of the consequences of the failure of the food system. During emergency responses to severe malnutrition, humanitarian actors use ready-to-use therapeutic foods (RUTFs), such as PlumpyNut®, which can help to save children’s lives when all else has failed. These products meet strict specifications that evolve in response to new research and proofs of concept to improve the treatment. These specifications refer to the product itself, but also to packaging and quality control. They aim to guarantee that the product is as effective as possible for children, and that it respects their rights and saves their lives.

However, at a time when there is increasing focus on the issues of climate change, waste management and the ‘One Health’ approach, environmental parameters are not yet being sufficiently taken into account in RUTF guidelines.

The first treatments

The Nutriset Group has been fighting malnutrition for 35 years. In close collaboration with NGOs like MSF and research centres like IRD, the Lescanne family (from Normandy) developed products that aimed to effectively treat acute malnutrition. With the initial therapeutic milks (F-75 and F-100) developed by Nutriset, specialised centres linked to hospitals (therapeutic nutrition centres) were at last able to treat malnourished children. However, this represented a major investment for families (distance from the hospital, one or more people accompanying the child, treatment that lasted several weeks, often the mother away from home, loss of income, etc.), and did not guarantee that the child would survive after getting out of hospital. What is more, these preparations required access to clean drinking water, which often was not available.

In 2005, during the famine in Niger, a nutritional solution that Nutriset had been studying for a number of years – PlumpyNut® – was used on a large scale outside health centres. Thanks to this formula, which no one had previously been capable of developing, or had taken the trouble to develop, the child was able to go home when their condition was stabilised. They would continue their treatment there for several days/weeks and would only have to go to hospital once a week. With these new programmes (Community-based Therapeutic Care/Community-based Management of Acute Malnutrition), the percentage of malnourished children who received treatment rose from 10-15 % to more than 50 % (the current minimum according to international standards).

Development of the local network

The Nutriset Group is convinced of the importance that each country should have the capacity (know-how and facilities) to meet its own population’s needs. Since 2005, it has been supporting a network of independent partners, known as the PlumpyField® network, made up principally of small and medium-sized local businesses and NGOs so that production takes place as close as possible to where the needs are. Following a request from UNICEF to encourage local production, significant support was also provided so that quality products in keeping with international recommendations for RUTFs could be produced locally and would be available, even in fragile contexts (e.g. Nigeria, Sudan and Ethiopia). Thanks to technical support from the Nutriset Group, particularly in terms of industrial development, quality assurance and R&D, agri-food and phytosanitary standards are respected. Thus, countries with industrial production units within their territories can move a step closer to nutritional autonomy. Today, there are Plumpyfield® network producers in the majority of countries where there is malnutrition: Haiti, Guinea, Burkina Faso, Niger, Nigeria, Sudan, Ethiopia, Madagascar, India, etc.

In Africa and Haiti, to limit imports as much as possible, the Nutriset Group, its partners, and sometimes certain donors have contributed to structuring and developing local agricultural sectors in order to increase the proportion of locally sourced ingredients. This is the case, for example, for peanuts, which are usually sourced locally. As a result, the peanut sector has gradually become more solid:

• The deployment of Aflasafe®, a biological solution to protect peanuts from a mycotoxin (aflatoxin)¹;
• The establishment of peanut roasting factories so that they can be used in nutritional solutions in Niger, Ethiopia, Sudan, Burkina Faso and Haiti.

Thousands of local peanut producers are now able to cultivate and sell their produce, which is then processed (sorting, shelling and roasting), before being used to make nutritional solutions. This locally sourced produce has several advantages as it gives local producers work and limits the number of ingredients that are imported internationally.

The revision of RUTF specifications

These products, which contain relatively simple ingredients (vegetable oil, peanuts, sugar, milk derivatives and micronutrients) are only available under medical supervision and are sometimes included in the list of essential medicines in the recipient countries. Yet, they are not produced by the pharmaceutical industry, but by the agri-food sector. Since 2015, the Codex Alimentarius – under the auspices of FAO and WHO – has been drawing up guidelines for ready-to-use therapeutic foods used to treat acute malnutrition among children over 6 months of age. These guidelines were officially adopted in November 2022² and are already included in the specifications that UNICEF and other bodies who buy RUTFs use, and have therefore been integrated by RUTF producers.

The guidelines and UNICEF’s specifications mainly focus on the nutritional composition of the product: the list of authorised ingredients, the quality of proteins (essential amino acids), fatty acids (omega 3 and omega 6), and to a lesser extent, the adaptation of the levels of certain micronutrients. All this will help to guarantee what is best for the child’s development, provide guidance for the development of innovative formulas, and help states to regulate the local production of RUTFs which is being put in place to meet soaring demand. Until now, the focus was the child’s physical growth, but their cognitive development is now being taken into consideration. These new specifications will align all actors in terms of the enhanced nutritional quality of products, provide a rigorous basis for developing alternative formulas (more adapted to available ingredients, to the geographical area, to dietary habits…) and will allow governments to supervise these new local formulas.

The impacts of these new specifications

The new specifications are forcing RUTF producers to revise certain practices and approaches in order to rapidly change their formulas. Though the nutritional values are precisely specified, producers are free to establish their own ‘recipe’ to achieve these. Each producer chooses the ingredients, and their proportions, in order to meet these new demands. This can involve new ingredients (soya, for example) or more suitable peanut varieties, supplied locally or internationally, or increasing the milk content in the RUTF.

The peanuts produced in Africa and Haiti by the partners involved in the PlumpyField® network do not meet the specifications regarding Omega 6 and Omega 3. This means that local producers have to find other ingredients with a different nutritional profile, but which may not be available locally. The soya varieties produced in the United States, or the peanuts produced in Argentina have a nutritional profile that is more adapted to the new specifications. But these varieties are not cultivated in Africa and Haiti. RUTF producers in these countries will therefore have to import them, which will disrupt the local sectors and increase transport-related greenhouse gas emissions.

Establishing a new agricultural sector that meets a specific need take years. New varieties need to be identified and selected. They need to be tested to ensure that they can be developed in a specific region of the world, and to ensure that farmers adopt them, cultivate them and are able to sell them. And you need to ensure that they are integrated into processing and commercialisation systems. As such, new sectors are difficult to develop, organise and consolidate. But they are essential so that the food system can be transformed in the future, with more local development and a reduced carbon footprint.

Though the specifications take into account the cognitive development of the child, they do not take into account the ingredients used and the localisation of producers, even though Nutriset raised this issue several times. The nutritional value of RUTFs is standardised in order to provide what is best for children’s development, regardless of the geographical area where the malnourished child lives, regardless of the quality and availability of the agricultural products cultivated nearby. There are numerous production centres and though some producers can find all the ingredients locally (in the USA and in India, everything is available locally), this is not the case everywhere, and certain ingredients have to be imported. The varieties of peanuts cultivated in Africa and Haiti do not have the right essential fatty acid profile, and milk ingredients such as milk powders are not available there either. Therefore, the continuous efforts by a number of local producers (including the members of the PlumpyField® network) to use local ingredients, to reduce their carbon footprint and to contribute to economic and social development, are not systematically taken into account by UN agencies (UNICEF/WFP) and NGOs in their purchasing processes.

The thorny issue of packaging

The new specifications also concern the product’s packaging and confirm the minimal durability date (DDM), which is two years. Without a cold chain, the product should maintain all its nutritional properties, its consistency should be stable, and the packets should remain sealed for two years. Given the climatic conditions in which they are used (often very hot or very humid), and the oily consistency of the product, extremely hard-wearing packaging was developed which is difficult to recycle. And, unfortunately, countries affected by malnutrition rarely have facilities where waste can be efficiently recycled or destroyed. What is more, mothers take the packets with them, sometimes to remote villages, and collecting them is complicated for the health centres or NGOs who manage the nutritional centres and distribute the RUTFs.

Though the nutritional quality of the products should of course be preserved, is a DDM of two years really essential? Given that these are emergency products that are only ordered when funds for a specific emergency have been secured, they should be used relatively quickly.

The Nutriset Group looked into the idea of reducing packaging at the source (modifying the composition of the packets, redesigning the packaging of boxes in order to use less plastic film, and recycling pallets). Though a lot of proposals were not taken up (transforming packaging into tatami mats, furniture, bricks, insulating fibre drapes, cool boxes, mobile incineration units), one was a success: the Eat&Play Box. It consists of reusing a pre-cut part of the boxes as toys for the children who receive food aid. It is another tool that health officers can use to stimulate children’s cognitive development and reinforce the impact of nutritional interventions. Though the nutritional content of each meal counts in the development of the brain which forms hundreds of connections each second, 15 minutes of play is enough to trigger thousands of brain connections. In the field, stimulating the child, particularly through play, complements the nutritional treatment and helps the child to recover and reduce developmental delays. It was such a good idea that it is going to be taken up by UNICEF for all its suppliers.

The Nutriset Group’s Packaging teams are currently working on a packet that respects the constraints and can be recycled. But questions remain about how the packets will be collected and whether it will be possible to recycle them locally.

Conclusion

Though commitments are made by donors and international organisations, and charters are published to promote good practice in terms of environmental impact, the purchasing policies of humanitarian actors are not in keeping with these major commitments. When children are treated for acute malnutrition, apart from the specifications that provide a strict framework, humanitarian buyers and donors rarely have to comply with strict demands for green or more environmentally friendly products, and they are rarely prepared to pay more for these. Indeed, paying more to protect the environment would mean not being able to procure as much treatment and therefore treating fewer children.

Despite these different issues, it should also be noted that the ‘One Health’ approach is beginning to make inroads. The objective is no longer simply to reduce our waste or our carbon footprint, but to understand the interdependence of lifeforms, the fragile balance that needs to be preserved so that the planet, human beings and animals live in harmony and in good health: the health of one depends on the health of the others. It is an approach that will no doubt help more and more people to realise that practices need to change.

Claire Fehrenbach is Advocacy Lead of Groupe Nutriset.

1. Aflatoxin is a common fungal toxin in agricultural products and food. It is associated with acute and chronic toxicity in animals and humans. Aflasafe is the biological control product that significantly reduces aflatoxin in crops.
2. https://www.unicef.org/supply/stories/new-codex-guidelines-pave-way-innovation-ready-use-therapeutic-food-rutf