Volume 27 · Number 2 · Winter 2010
Tiny Packets of Hope
UC Davis leads efforts against malnutrition with a $16 million Gates Foundation grant.
(Steve Vosti/UC Davis)
Images of mud huts, lush jungle growth and rust-colored soil flash across Steve Vosti’s computer screen as the UC Davis economist scans photos of some of his research sites. Interspersed are snapshots of young children with shy smiles — the hope and future of Africa and, Vosti says, among “the very poorest kids on the globe.”
If not born malnourished, many will be severely lacking in essential nutrients by the time they are 6-12 months old. Without intervention before age 2, their health, stature and thinking abilities may be forever damaged. Vulnerable to infectious diseases, they could be among the 5 million children around the world who will die each year of malnutrition.
But Vosti and a team of international researchers, led by UC Davis nutrition professor Kathryn Dewey, may have found something that can help in a soft, squeezable package about the size of a fast-food catsup packet.
The unlikely, but potent, remedy is a peanut butter-like nutritional supplement, rich in vitamins, minerals and essential fatty acids. French pediatric nutritionist André Briend, who until recently worked with the World Health Organization, developed the first version of a similar ready-to-eat paste more than a decade ago to treat severely malnourished children in Africa. In 2000, the Normandy-based firm Nutriset began producing the supplement under the commercial name Plumpy’nut.
Since then, it has been sold to and distributed by humanitarian aid organizations working in more than 50 developing countries. In 2004 alone, it was credited with saving the lives of more than 30,000 malnourished children in the Darfur region of Sudan.
The UC Davis researchers worked with Nutriset in 2003 to develop a more concentrated type of lipid-based nutrient supplement called Nutributter. It has the same food ingredients as Plumpy’nut but also includes all of the essential vitamins and minerals in a much smaller, 20-gram daily dose, equal to 4 teaspoons and containing about 110 calories. This is about one-tenth of the daily ration for treatment of severely malnourished children.
Nutributter, designed to prevent rather than treat severe malnutrition, is to be given starting at 6 months of age to enrich, not replace, local foods fed to infants and young children. It is full of calories and nutrients, doesn’t require refrigeration or clean drinking water, and can be made primarily from locally produced ingredients. Furthermore, kids love its flavor.
The first randomized trial using Nutributter was conducted by the UC Davis team in Ghana in 2004–2006, with promising results. It reduced anemia and eliminated faltering growth in children between 6 and 12 months of age and doubled the percentage of infants who were able to walk independently by 12 months. Another research team, working in Malawi with a similar type of supplement, found a large reduction in the number of children who became severely stunted in growth.
However, these lipid- or fat-based supplements still need to be refined into the most nutritious, effective and affordable formulations.
That’s the goal of the UC Davis team and its network of international research partners, whose vision last year captured the endorsement of the Bill and Melinda Gates Foundation in the form of a five-year, $16 million research grant. The funds will support one of the most comprehensive international nutrition research projects ever mounted.
Dubbed the “iLiNS” or International Lipid-Based Nutrient Supplements Project, the effort includes public and private institutions in Burkina Faso, Finland, France, Ghana, Malawi and the United States. Their task is to identify the most nutritious and cost-effective formulations of the supplements for children under age two and for pregnant and lactating women, and the best methods for distributing them.
To do this, the researchers will need the participation of nearly 7,000 African women and young children in Ghana and Burkina Faso in West Africa and Malawi in southeast Africa. Much of the project’s first year has been spent in planning and preparing to recruit participants, house-to-house and village-to-village.
Briend, the pioneer of the lipid-based supplements, is optimistic about the huge study.
“I wish the iLiNS team success in its project,” he said. “For prevention of malnutrition, we need to go back to the drawing board and formulate a supplement that provides, at minimal cost, just the nutrients that are missing in the local diet.
“This is a totally different problem than was addressed previously with either liquid diets or the existing paste-like supplements, and it requires extensive research and field testing in different settings,” Briend said. “I am glad to see these issues addressed by a large international consortium with a broad range of expertise in many different areas. Hundreds of millions of children who live in poor countries and do not receive a diet providing all of the nutrients that they need for their development may benefit from the outcome of the iLiNS research.”
Out of Davis, Into Africa
The project’s UC Davis team includes administrative, nutritional and economic components. Dewey, the project director and an authority on maternal and child nutrition, began working on nutrition intervention studies in Ghana in the mid-1990s. Her task is to keep all of the wheels of the mammoth research project spinning.
“The safety and security of our research teams always concerns me, as does the safety of our participants,” she said. “We have systems in place to safeguard participants’ health, but anytime you give someone something and ask them to eat it, you really want to make sure it is safe.”
She noted that the research team tries to be sensitive to the cultures in which they are working, and obtains approval from the tribal chief or other local authorities before recruiting participants. They also have found that in Africa it is critical to obtain the consent of the father, as well as the mother, before enrolling a child in a study.
In addition to Dewey, the project’s nutrition team at UC Davis includes Kenneth Brown and Lindsay Allen, both experts in international nutrition. Brown, also a pediatrician by training, is leading field studies with children in Burkina Faso to determine the optimal amount of zinc to include in the supplement. Zinc, a micronutrient, is critical to the proper growth and development of young children.
Allen, who directs the U.S. Department of Agriculture’s Western Human Nutrition Research Center at UC Davis, also studies micronutrient deficiencies and will be visiting the field sites in Malawi. Her center helped design the micronutrient composition of the supplement and will perform many of the biochemical assays of serum and breast milk samples from Africa in order to monitor the micronutrient status of the study participants.
She is particularly interested in determining the best time to give the supplement to young children and mothers.
“Is it best to give the supplement to women during pregnancy to improve development and micronutrient status of the fetus or would it be better to give it to the mothers during lactation so that the breast milk that their young infants consume has more micronutrients?” she said. “Or do you give it directly to older infants and young children? Or, perhaps, for the best results, should you provide it during all three of these time periods?”
And then there is the economic branch of the study, directed by economist Vosti of UC Davis’ Department of Agricultural and Resource Economics. As social scientists, his team will have multiple tasks in each of the three countries.
“We need to know what factors determine what people eat and why,” he said. “For example, if there are no perceived benefits associated with consuming a lipid-based nutrient supplement product — if people are not willing to pay for the supplement — we are lost. Then, you’ve got another potential miracle that just sits on the shelf.”
The Bottom Line
To do this, the researchers will use a set of economic tools, including “economic experiments.”
“We’ll bring the participants together and give them each, say, $5 if they will listen to us talk about this new nutritional supplement,” Vosti said. “Afterward, they will be free to spend their $5 on anything they want, including the supplement. But of course they will also start thinking about how they could spend it on goats and shoes and eyeglasses.”
Once the optimal nutritional content for the supplement is determined, the economists will put the product on the market in Africa and see what sells and at what price.
“The research project will be incomplete if you only find out what supplement works nutritionally,” Vosti said. “We need to help the policymakers understand what types of policy changes are needed to make sure this nutritionally effective product gets into the mouths of the children and women who need it.”
The researchers hope to develop supplements that can be sold for as little as 5 cents per packet but realize that for some of the people, many living on just $1 per day, even that minimal cost might be too much.
“Some people will never be able to afford the supplement, regardless of how inexpensive we make it,” Vosti said. “So for those people, we’ll tell the policymakers, ‘Hey, give it away — this is your investment in the future. Punto finale!’”
Eye on Prevention
Lipid-based nutrient supplements have mostly been used in treating malnutrition but the iLiNS researchers want to take them to the next level and prevent malnutrition in women and children.
Steve Vostis/UC Davis)
“Some people think of such supplements as a temporary fix until families have enough money to be able to feed their children the foods that they need,” Dewey said. “But this may not be just a temporary solution. Fortified products for children between 6 and 24 months of age probably need to be a permanent part of the food system.”
She noted that many of us have a skewed view of our nutritional history and don’t realize that our hunter-gatherer ancestors consumed a very nutrient-rich diet and were taller and healthier than most modern-day populations in developing countries.
“Their diets were much higher in vitamin and nutrient content than what we eat today — and more than eight times higher in iron than what people in developing countries eat,” Dewey said. “That’s why iron deficiency is so common in children around the world.”
Furthermore, hunter-gatherers ate almost no cereal grains, which now contribute at least 50 percent of the calories consumed by children in developing countries, she said.
“Between the ages of 6 and 12 months, you see a dramatic faltering in growth of children in developing countries,” Dewey noted. “The main problem is usually not insufficient calories but that the available foods don’t provide all of the nutrients that infants require for rapid growth and development.
“They need a high-quality diet that includes all of the necessary micronutrients such as zinc and iron,” she added. “And since infants don’t eat very much, they need very nutrient-dense foods to complement what they obtain from breast milk.”
The researchers hope to stave off malnutrition in both moms and their babies by providing the lipid-based nutrient supplements to pregnant women, as well as children. And as the infants are introduced to complementary solid foods — usually just a watery, grain-based porridge containing only a fraction of the necessary nutrients — the supplement will make up for the lacking nutrients.
“Their Skin Shines Brighter”
In Africa, study participants are being recruited through door-to-door visits and at health clinics. So far, the local residents have been pleased with the supplements that will be evaluated, Dewey said.
“We’re not the first ones to show up with new ideas, so there is some skepticism,” Vosti said. “It’s tricky because it’s not as if we’re delivering fertilizer that will generate obvious benefits in a few months. Many of the benefits of the nutrient supplements will be long-term, and many of those benefits will be societal rather than private benefits.”
Dewey says that mothers are mostly motivated by having healthier children, and they are remarkably willing to do whatever they think will make that happen, if they can afford it.
“The mothers may not notice that a child’s growth is improving, but they say things like ‘their skin shines brighter’ or that they look healthier.”
The Vision
As the iLiNS team enters the second year of the massive project, the researchers find themselves caught between the urgent and the enduring aspects of their work. Ensuring adequate nutrition for women and children is truly a matter of life and death in developing countries and it is a long-term investment in Africa’s future.
Team members also are touched by both the scientific and the humanitarian potential of the project.
“As researchers, our main goal is to get results that we have confidence in and to publish those results. We report what we find,” Dewey said. “In addition, we have other objectives such as training graduate students and distributing technical information.
“But then there is the grandiose dream,” she said. “In the long run, if the results are positive, I’d like to see lipid-based nutrient supplements become widely accessible and affordable, and to be coupled with educational information on optimal feeding of infants and young children and on the need for ensuring adequate nutrition during pregnancy and lactation.”
There is a very real sense that the researchers are in this for the long haul — far beyond the initial 5-year scope of the project.
“My guess is that we will be following these children for the rest of their lives,” Vosti said with a smile. “It’s really rare to have the opportunity to isolate and track the effects of an intervention over the long term.
“We’ll be old and grey, but our students will be tracking the effects of these supplements on the lives of the children for years to come.”