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Peanut butter treatment nourishes starving children

Mark Manary, a WUSM pediatrician at St. Louis Children's Hospital, is saving the lives of children in Malawi with peanut butter. His revolutionary new method for treating starving children in malnourished regions could become a worldwide standard of care.

Tina Hesman tells the story of Manary's work in the following St. Louis Post-Dispatch article.

WU doctor uses peanut butter to treat starving children in Malawi

(Republished with permission from the St. Louis Post-Dispatch. This article originally ran on Sunday, August 8, 2004)

By Tina Hesman

Dr. Mark J. Manary may have found the solution to world hunger in a common pantry item - peanut butter.

Mothers at Montfort Health Centre in Nchalo, Malawi give their malnourished children a trial feeding of peanut butter food as part of Project Peanut Butter, a program developed by Dr. Mark Manary of Washington University.

Mothers at Montfort Health Centre in Nchalo, Malawi give their malnourished children a trial feeding of peanut butter food as part of Project Peanut Butter, a program developed by Dr. Mark Manary of Washington University.

Manary, a Washington University pediatrician, is a leader in a revolutionary new way to treat starving children. He sends them home with rations of fortified peanut butter. The technique is gaining acceptance among humanitarian aid groups and could become a new standard of care endorsed by the World Health Organization within two years.

The southern African country of Malawi, where Manary works, could soon become the first nation to switch to feeding malnourished children at home with spoil-proof foods.

When Manary first traveled to Malawi a decade ago, he was eager to make a difference.

Everyone told him to stay away from the nutrition wards in the large hospital where he worked. It will depress you, they told him.

"So I went to this area of the hospital," Manary said. "It was appalling. It was fascinating. And it captivated me."

"The hungry season"

Rains come to Malawi only once a year, between November and March. It's the same time that subsistence farmers are running out of the crop they harvested in April or May. It's the period when children become malnourished. It's called "the hungry season."

The hungry season in Malawi this year will be longer than usual because of an extended dry spell and late rains. The World Food Program's Crop and Food Supply Assessment Mission estimates that 1.3 million people, about 11 percent of the population, will suffer from food shortages between now and April, when the next harvest comes in.

An average of 20,000 starving children each year enter the so-called Nutritional Rehabilitation Units in hospitals throughout Malawi. There in the overcrowded wards, the children sip small meals of milk. Mothers, the primary providers for Malawian families, stay for weeks to care for their children, leaving other family members at home. Since women are the main farmers in Malawi, their absence during planting season may put families in future danger of starvation. In the packed hospital, sick children pass infections to each other, further weakening their fragile bodies.

Only a quarter of the children in the wards recover fully. Of the rest, 10 percent die, and 20 percent relapse and return to the hospital. The remainder suffer from chronic malnutrition at home. At least half of Malawi's children are malnourished, and 13 percent of children die of starvation before they reach their fifth birthday.

Manary knew there must be a way to improve those numbers, yet the workers were already giving the children the care considered the gold standard. The now-traditional technique of feeding malnourished children small quantities of milk up to eight times a day in a hospital has saved countless children from starvation. The World Health Organization, emergency relief agencies and other nongovernmental aid organizations endorse the practice.

Manary considered other options. He wondered what would happen if the villagers were provided with ample supplies of corn and soy. It soon became evident that plan would not work. Children would have to eat staggering amounts of the foods to recover from their severe hunger. And mothers would never have the time to cook so much food. It wouldn't keep either.

He needed something with a long shelf life, easily portable, and energy- and nutrient-rich that didn't have to be cooked.

About that time, French research scientist Andre Briend began testing a fortified peanut butter mixture in Chad. The mixture contained peanut paste, dried skimmed milk, sugar, oil, vitamins and minerals.

Mark Manary

Mark Manary

"The idea of developing this product came to me when I realized that the chocolate spread used by my kids to put on their bread during breakfast (Nutella) had a protein lipid energy composition very similar to the liquid milk-based food recommended by WHO to treat severe malnutrition," Briend said in an e-mail. He worked with Nutriset, a company that specializes in making foods for emergency relief, to develop a peanut-based version of the product.

"The advantage of the new product is that bacteria do not grow in it and it is safer to use than the milk-based diet" used by the World Health Organization, Briend said.

He first tried the peanut butter product on starving children in one hospital in Blantyre, Malawi - and 95 percent recovered fully.

"Bang! That's powerful. That's something really meaningful," Manary said.

Home-grown peanuts

Encouraged by the success, Manary's group started producing its own home-grown version of the commercial peanut butter. Malawi already produces peanuts and most of the other ingredients. Only the vitamin and mineral mixture is imported.

The Nutriset product is called Plumpy-Nut. Manary's group calls its version Ready-to-Use Therapeutic Food, or RUTF. Malawians call it a name that translates roughly to "mashed-up peanut medicine."

Washington University medical student Heidi Sandige showed up in Malawi in June 2002 to work with Manary. When she arrived, Project Peanut Butter didn't have quite enough money to pay its nurses for the next month. Manary wasn't worried. He ran the project on $5 to $50 donations collected by his two children back in St. Louis, she said.

"Mark does this. He just says, 'It will all be OK. It will work out,'" Sandige said.

It costs between $12 and $14 to feed a child back to health at home with the peanut butter mixture, Sandige said. The liquid milk therapy costs at least twice that much and is administered in hospitals and feeding centers, each with their own associated costs.

Manary and Sandige expanded the program to eight sites around Malawi. Manary has turned the program over to local hospitals this year, and Sandige will travel back to Malawi in the fall to help establish more distribution centers.

The program has an overall success rate of about 82 percent. Otherwise healthy malnourished children recovery fully about 95 percent of the time. The overall success rate is lower due to the prevalence of HIV infection in Malawi, estimated to be as high as 30 percent. Children who are infected with HIV don't fare as well, recovering about 60 percent of the time on the peanut butter diet.

But that success rate is far greater than other approaches to solving malnutrition in HIV-infected people, nutrition experts say.

"The effectiveness, I think, is proven," said Eunyong Chung, a nutrition adviser in the Office of Health, Infectious Disease and Nutrition at the U.S. Agency for International Development.

HIV complications

The promising results Manary and others have achieved with peanut butter are getting more attention because of the HIV/AIDS epidemic in Africa and elsewhere, Chung said. People who are infected with HIV often develop a wasting syndrome and are at higher risk for severe malnutrition. About 5 percent to 10 percent of children under 5 years old develop severe malnutrition in southern Africa, Chung said. That number is expected to double as the HIV infection rate climbs and children are orphaned by the disease, she said.

The U.S. Agency for International Development is working with the World Health Organization to revise guidelines for treating severe malnutrition. The new standards will include home-based treatments, such as the peanut butter therapy, Chung said.

"We're moving in the right direction, but we still face restraints - mostly financial," Chung said.

The agency would like to drop the cost of therapeutic foods even further, Chung said. The U.S. Agency for International Development is sponsoring work to find cheaper replacements for expensive milk powder. Other researchers are reformulating the food by replacing peanuts with chick peas or sesame seeds. The new formula could be used in places where peanuts are not normally produced or in rare cases of peanut allergy, Chung said.

Peanut allergies are the most common food allergy in the United States. But only about one in 5,000 children in Africa has an allergy to peanuts, Manary said.

Humanitarian relief agencies are also slowly adopting home-based therapies.

"So far we are still really, really cautious," said Sophie Simon of Action Against Hunger.

Last year the group did its own field study of ready-to-use therapeutic peanut butter in Sierra Leone. Action Against Hunger is using peanut butter in Uganda, Afghanistan and Sudan now, and hopes to bring the therapy to Congo soon, Simon said.

Extra food won't hurt

But the group is still committed to operating feeding centers, Simon said. Severely malnourished children are fragile and need stabilizing treatment to recover from starvation, dehydration and illness, she said. Parents often are unable to provide that care at home.

In the early stages of treating malnutrition, people can't digest protein and high-energy foods well, Simon said. It could be dangerous to give the most fragile children such a rich food early in their treatment without close medical supervision, she said.

Now that Manary has found an effective treatment for starvation, he's setting his sights on developing dietary supplements to help young children transition from breast milk to an adult diet without falling into the malnutrition trap.

Last year, Manary tested eight different energy-dense recipes on about 150 6-month-old babies. He selected two for further testing. One mixture contains soy, peanuts, oil and sugar. The other is composed of sesame, oil, sugar and chickpeas. He will compare the growth rates of children who eat those two diets with growth rates of children raised on a traditional corn mush diet.

Manary cautions that he doesn't know if the supplements will spare children from starvation, but he's sure that the extra food won't hurt them either. He continues to support and run the peanut butter project and says he's optimistic about its future as a therapy for malnutrition.

"I think we're in the middle of a transition, and it's going to be good for kids everywhere," Manary said.

Copyright 2004 St. Louis Post-Dispatch, Inc.

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