Pediatrician Mark Manary sees more widespread uses for his pioneering peanut butter supplement that treats severe malnutrition in children.
Some moms joke that their toddlers live on peanut butter. But for thousands of malnourished children in sub-Saharan Africa, the traditional sandwich spread has literally been a lifesaver—thanks in part to Dr. Mark Manary, a professor of pediatrics at Washington University in St. Louis and founder of Project Peanut Butter (PPB).
PPB, a nonprofit that operates in Malawi and Sierra Leone and is expanding into Ghana, works to advance treatment of severe acute malnutrition (SAM) using locally produced ready-to-use therapeutic foods (RUTFs). High-energy RUTF pastes typically are made from peanuts, oil, sugar and milk powder, along with vitamin and mineral supplements. During the past decade they have emerged as a safe, spoilage-resistant, cost-effective option that makes it possible to treat children at home, saving hundreds of thousands of children’s lives since the early 2000s, mainly in Africa.
For decades malnutrition was viewed as a hopeless condition … But these supplements work, and we should make them as widely available as possible.”
— Mark Manary
Manary remembers a child named Milika who weighed only 11 pounds when she was 18 months old, despite being treated for severe malnutrition several times. “Milika’s mother had abandoned her with her grandmother, and the grandmother was homeless, with genuine mental illness, unfit to care for a child,” says Manary. “A six-week course of RUTF doubled her weight to 22 pounds… Her village pitched in to assist with her rearing, PPB provided a roof for a new house, and when Milika was 6 years old she started school.
“For decades malnutrition was viewed as a hopeless condition, not as an illness that could be treated. It was marginalized in the health and medical community,” Manary adds. “But these supplements work, and we should make them as widely available as possible.” PPB alone has treated approximately 600,000 children, and Manary has set a goal of saving 2 million children by 2015.
Better treatments for more people
About 20 million children worldwide, mainly in Asia and sub-Saharan Africa, have SAM, and roughly 1 million children die from it every year. Until recently the standard treatment for SAM was to hospitalize patients and rehabilitate them with fortified milk formulas. But this approach had limited impact in developing countries because many rural families could not travel to hospitals. Formulas required access to clean drinking water, and many areas where hunger is prevalent did not have trained medical staffers to manage inpatient treatment.
Manary established Project Peanut Butter in Malawi in 2004, and today he is researching ways to improve and broaden community-based therapies for malnutrition and to adapt RUTFs for other vulnerable populations. Last year he and his research team published results in the New England Journal of Medicine from a clinical trial in Malawi, which found that adding antibiotics to PPB’s supplement made the treatment even more effective, cutting death rates to less than 5 percent. Children with SAM have reduced resistance to infection, so the antibiotics helped them fend off bacterial infections while they gained strength from the peanut supplement.
With a team at the University of Georgia’s Peanut and Mycotoxin Innovation Lab, Manary is also studying the use of RUTFs to treat pregnant women in Malawi who have moderate malnutrition, in order to reduce stunting among infants. “This is a ground-breaking study that should have been done 30 years ago,” Manary says. “We’re using a fairly standard peanut-based supplement, formulated differently from the one for children—it includes dairy protein, whey and more micronutrients.” The supplement was developed at a General Mills pilot plant in Minneapolis under a collaboration between PPB and Partners in Food Solutions, a nonprofit founded by General Mills that links volunteer employees from General Mills, Cargill, Royal DSM and Buhler to small and growing food processors and millers in the developing world.
Home from the hospital
Manary zeroed in on malnutrition after practicing medicine for a decade, including stints in Tanzania and on a Native American reservation in South Dakota. In 1994 he traveled to Malawi as a Fulbright scholar and took charge of the pediatric malnutrition ward at a large hospital. Doctors were treating patients according to World Health Organization (WHO) guidelines, but only 25 to 40 percent of the youngsters were recovering.
“We cleaned things up and standardized procedures, but the recovery rate didn’t improve because the kids were passing germs to each other,” Manary recounts. “I wanted to move treatment out of the hospital, but we needed to find a way to make home-based therapy work.”
He connected with Dr. Andre Briend, a French physician who also was interested in community-based therapy. Working as a consultant for Nutriset, a French manufacturer of nutritional products, Briend had already co-developed a peanut-based RUTF called Plumpy’Nut in 1996. Together Manary and Briend developed a similar peanut-based RUTF, and in 2001 Manary started running trials in Malawi. He found that recovery rates soared as high as 95 percent for young SAM patients who were treated at home with peanut-based supplements.
Although the idea of a nutritious nut-based spread wasn’t new, “food technology allowed us to produce an appropriate supplement,” says Manary, by managing key quality control issues such as detecting aflatoxin contamination in peanuts, packaging the supplement without introducing water (which would promote growth of bacteria), and preventing fatty acids and vitamins in the peanut paste from oxidizing during production.
Manary and his colleagues published their results in peer-reviewed medical and nutritional journals between 2004 and 2007. As evidence from Manary and others accumulated showing that community-based therapy worked, the WHO, World Food Programme and UNICEF issued a joint statement in 2007 endorsing community-based therapy with RUTFs as a preferred approach for treating SAM in children under age 5. In a 2013 position paper, UNICEF stated that RUTFs “have revolutionized the treatment of uncomplicated forms of severe acute malnutrition among children.”
Spreading the wealth
In addition to running its own production facilities in Malawi and Sierra Leone and constructing a new factory in Ghana, PPB has helped other nonprofits develop and make their own RUTFs on a small scale in the Philippines, Somalia and Kenya.
Producing the peanut supplement locally multiplies its benefits, says Manary. The factories use mainly local ingredients, generate jobs and support local economies. Making supplements where they are needed instead of importing them avoids shipping costs and customs fees. And communities take pride in running the factories and caring directly for their own children.
Despite their success in Africa, however, RUTFs are less widely accepted in Asia, where some activists and government agencies reject them as foreign food. “Their argument is that food is natural and should be prepared at home and grown in your garden, not manufactured by foreigners,” Manary says with some exasperation.
To offer other options, Manary and Washington University doctoral student Kelsey Ryan are developing a global food ingredient database and a spreadsheet of methods for formulating them into RUTFs that meet international specifications. The project is being supported by the London-based Children’s Investment Fund Foundation.
“We want to reduce the cost of RUTFs by making them available locally, which will make it easier to treat more children,” says Manary.