What is RUTF?
Ready-to-use therapeutic food (Plumpy’nut) was
invented in the late 1990s by research scientist André Briend and Nutriset, a
private company making nutritional products for humanitarian relief. RUTF is
high in energy and protein, with added electrolytes, mineral and vitamins,
specifically designed to treat SAM in the rehabilitation phase. It is
equivalent to F100 in terms of nutrients/100kcal. It does not have to be mixed
with water and so is microbiologically safe and enables treatment in the
community.
What is the advantage of using RUTF?
RUTF has significant advantages over liquid based
diets. The paste is oil-based with low water activity and, as such, can be
stored at home with little risk of microbial contamination. It is easily used
at home by mothers and caregivers, and is digestible and popular among sick and
malnourished children and adults. RUTF is effective in promoting rapid weight
gain in malnourished children.
What is the composition of RUTF?
The most widely used at present is Plumpy’nut.
The ingredients are peanut paste, milk powder, vegetable oil, sugar, potassium,
magnesium, vitamins, and minerals. Each 92g pack provides 500kcal.
Can RUTF be produced locally?
The high cost of the imported RUTF is a
significant barrier to the wide-scale implementation of CTC. To overcome this
barrier, the CTC program currently promotes local production of RUTF.
Local production of RUTF has been successful in
Malawi. The cost of the local version is about half that of the imported
version. The locally produced RUTF follows the same recipe as original
Plumpynut and is packed in 250g plastic jars with a shelf life of up to six
months. Comparison efficacy studies demonstrate that the locally produced RUTF
is nutritionally equivalent to the imported version.
What makes RUTF different from family foods and other feeds fed to severely malnourished children?
·
RUTFs do not need cooking and do not need to be mixed with
water.
·
The high fat content and low moisture prevents bacterial
growth, which means that they are microbiologically safer than feeds prepared
with water. RUTF will keep for several months in simple packaging.
·
Electrolytes and micronutrients are added during production,
whereas these need to be provided as supplements when using family foods.
·
RUTFs are usually more expensive than high-energy mixtures
of family foods.
There are four
basic ingredients in RUTF: Sugar, Dried Skimmed Milk, Oil, Vitamin and Mineral
Supplement (CMV) In addition, up to 25% of a product’s weight can come from
oil-seeds, groundnuts or cereals like oats.As well as containing the necessary
proteins, energy and micronutrients, RUTF should also have the following
attributes:
1)Taste and texture suitable for young children; and 2)No need for
cooking before consumption
Resistant to contamination by micro-organisms and long shelf-life without sophisticated packaging. Product should be oil-based
Resistant to contamination by micro-organisms and long shelf-life without sophisticated packaging. Product should be oil-based
Ready-to-Use
Therapeutic Food
High energy,
fortified ready to eat food suitable for treatment of severely malnourished
children. This food should be soft or crushable, palatable and easy for
children to eat without any preparation. At least half of the proteins
contained in the product should come from milk products.
Nutritional composition
|
|
Moisture content
|
2.5% maximum
|
Energy
|
520-550 Kcal/100g
|
Proteins
|
10 to 12 % total energy
|
Lipids
|
45 to 60 % total energy
|
Sodium
|
290 mg/100g maximum
|
Potassium
|
1100 to 1400 mg/100g
|
Calcium
|
300 to 600 mg/100g
|
Phosphorus (excluding phytate)
|
300 to 600 mg/100g
|
Magnesium
|
80 to 140 mg/100g
|
Iron
|
10 to 14 mg/100g
|
Zinc
|
11 to 14 mg/100g
|
Copper
|
1.4 to 1.8 mg/100g
|
Selenium
|
20 to 40 µg
|
Iodine
|
70 to 140 µg/100g
|
Vitamin A
|
0.8 to 1.1 mg/100g
|
Vitamin D
|
15 to 20 µg/100g
|
Vitamin E
|
20 mg/100g minimum
|
Vitamin K
|
15 to 30 µg/100g
|
Vitamin B1
|
0.5 mg/100g minimum
|
Vitamin B2
|
1.6 mg/100g minimum
|
Vitamin C
|
50 mg/100g minimum
|
Vitamin B6
|
0.6 mg/100g minimum
|
Vitamin B12
|
1.6 µg/100g minimum
|
Folic acid
|
200 µg/100g minimum
|
Niacin
|
5 mg/100g minimum
|
Pantothenic acid
|
3 mg/100g minimum
|
Biotin
|
60 µg/100g minimum
|
n-6 fatty acids
|
3% to 10% of total energy
|
n-3 fatty acids
|
0.3 to 2.5% of total energy
|
Commercial Pre-packed
Plumpy'Nut
Plumpy’Nut is a ready-to-use therapeutic spread produced by Nutriset and
presented in individual sachets. It is a paste of groundnut composed of
vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin,
sugar, mineral and vitamin complex.
Plumpy’Nut is specifically designed to
treat acute malnutrition without complications and has the following
characteristics:
·
It is
nutritionally equivalent to F-100 (therapeutic milk used for in-patient care in
Phase 2)
·
One sachet has an
energy value of 500Kcal
·
One sachet has a
weight of 92 g
·
Each carton of
Plumpy'Nut contains 150 sachets (around 15.1 kg)
Benefits and
composition of Plumpy'Nut
·
The quantity
distributed to each child is easy to calculate based on the weight
·
One simply needs
to open the sachet by cutting one corner and eat the paste
·
No preparation or
cooking is necessary
·
Does not need to
be diluted with water. This eliminates risk of contamination
·
Can be used at
home with supervision from the health centre
·
Reduces length of
stay in hospital or Therapeutic Feeding Centre
·
Reduces number of
staff necessary for preparation and distribution of therapeutic food
·
Has a faster
recovery rate and higher acceptability than F100
·
Can be stored at
room temperature for long periods of time
·
Has a long shelf
life, even without refrigeration (24 months)
Quality Control
Choice if
ingredients: Whichever the scale of production is used, quality control is
achieved by safe storage of the ingredients, adequate training and supervision
of the production personal, and product testing for composition and
contaminants. Throughout the world, authorities set standards for food production
companies; those organizations involved in RUTF production should adhere to
these standards. Key issues in quality control are listed as follows.
Aflatoxin contamination: This toxin is produced by an
aspergillus species of fungus, which contaminates the peanuts after they have
been harvested, but before they have been ground into peanut butter. The fungus
is ubiquitous, fungal growth can be curtailed by storing the peanuts in a cool,
dry environment, and can also be controlled using chemical fungicides. Methods
to prevent aflatoxin contamination have been described in detail elsewhere.
Peanuts should be purchased from a supplier that can ensure that steps to
prevent contamination have been implemented during harvest and storage.
Aflatoxin contamination is more likely to be seen in peanuts with black
discoloration, and among nuts that have a shriveled, irregular appearance.
Consumption of aflatoxin can result in hepatic oxidative stress, and predispose
the individual to hepatic cancers. RUTF should conform to international
standards for maximum aflatoxin content, 10-20 ppb. Very high doses of
aflatoxin can produce acute intoxications. Moderate doses may depress child
growth.
Bacterial contamination: The inherent microbiological
safety of RUTF allows it to be packaged under clean and dry, but not sterile,
conditions. Care must be taken to prevent the introduction of water into RUTF
during production. Increasing the water content of RUTF allows bacteria and
mold to grow within the food, promoting product degradation and exposing the
malnourished child to potential pathogens. Water is most likely to be
introduced from residue left on the mixing bowls and containers after they have
been washed. Therefore, it is better to limit the number of times the
implements of production are cleaned with soap and water, and to simply dry
wipe them clean instead. Typically implements need to be cleaned with soap and
water only once a week. If the containers in which the RUTF is to be dispensed
are first washed, care should be taken to see that they are completely dry. Enteric
bacterial contamination is most likely to occur from fecal contamination of
stored ingredients or during the mixing process. Care should be taken to store
in ingredients in areas which are free of rodents. Workers should wash and
thoroughly dry their hands before manipulating the RUTF, wear clean plastic
gloves, hair coverings and protective coats during RUTF production. Milk and
RUTF should be periodically checked for salmonella contamination by standard
microbiological methods in reliable laboratories.
Prevention of oxidation: Oxidation of the fatty acids
contained in the RUTF and of some vitamins, mainly vitamin A and C, is the main
factor limiting the storage life of RUTF. During the production, some preventive
measures should be taken to avoid initiating the oxidation process. While it is
helpful to heat the oils during the mixing process to achieve a homogenous
mixture, heating to temperatures over 45ºC accelerates the oxidation of the
lipids, which reduces the period of time that the product is stable after
production (shelf life). To prevent oxidation, it is also better to use
airtight containers and containers filled as much as possible so that the
quantity of oxygen within the container is minimized. The shelf life of locally
produced RUTF without airtight packaging is 3-4 months. When RUTF is packaged
in airtight foil envelopes under a nitrogen atmosphere (devoid of oxygen), the
shelf life can be extended to 24 months.
Composition of RUTF: Errors may be made during the
mixing process, which result in RUTF that has a substantially different
nutrient content. These are best avoided by careful training of workers mixing the
food, use of convenient measures of ingredients for batches of RUTF and
periodic compositional testing of RUTF. Measuring a single mineral, such as
potassium, by atomic absorption is an inexpensive, reliable way to monitor the
vitamin/ mineral content, since the minerals are added as a premix product. If an
atomic absorption spectrophotometer is not available, a colorimetric assay for
Vitamin C can be substituted. Measuring fat and protein content assure that the
other ingredients are being added in appropriate amounts.
Quality control
is achieved by adopting operating procedures that are internationally accepted
as
standards for
food production, the Codex Alimentarius and the Hazard Analysis and Critical
Control Point Program (HACCP). These procedures prescribe raw material
procurement, storage of ingredients, mixing of ingredients and storage of
finished product. In addition to international standards, every nation of the
world has a Bureau of Standards which regulates the production of food. These Bureaus
also prescribe operating standards, conduct inspections of factories and issue
licenses to produce food. Product testing is used to verify the quality of the
production process, and should be done with every large batch of finished
product, certainly every week. In Malawi, finished product is tested weekly for
contaminating microbes (salmonella, staphylococcus, total flora of aerobic
mesophilic bacteria, coliforms, E. Coli, yeast, mold), aflatoxin and product
composition (fat, protein and potassium). Testing is best done locally so that
it can be used to identify lapses in production quality in a timely manner.
Batches of RUTF
should not be sent to consumers without verification of product quality. Almost
every nation of the world has a laboratory associated with their Bureau of
Standards that can conduct the independent testing.
Real Time vs. Accelerated Shelf Life
Studies There are two
basic methods for performing shelf life studies: Real Time and Accelerated.
Real time studies store the product under the normal conditions of the product
for a period of time greater than the expected shelf life. The product is
checked at regular intervals to determine the point of product deterioration. Accelerated
shelf life studies attempt to predict the shelf life of a product without
running a full length storage trial. This type of study is usually used for
product with a longer shelf life. Acceleration factors such as temperature are
applied to the product to attempt to increase the rate of deterioration. The
data can be used in predictive mathematical models to project spoilage rates
and bacterial growth. Accelerated studies should be used with caution, you must
know a good deal about your specific product formulation and properties to
interpret the data optimally.
It is always
recommended that when an Accelerated study is selected that a dual, real-time
study is also run concurrently to validate the projected data.
7 Steps to Determine Shelf Life
- Identify what may cause the food to spoil
- Product: raw materials, formulation, water activity, pH, oxygen availability, preservatives
- Process: Processing activities, packaging, storage conditions
- Decide which tests to use
- Sensory: odor, appearance, flavor texture
- Microbiological: spoilage and pathogenic organisms
- Chemical: pH, free fatty acids, headspace analysis, etc.
- Physical: product abuse storage and handling
- Plan the shelf-life requirements
- What tests need to be done
- How long will the studies be run
- How many samples for each test
- How many samples for the entire study
- What are the storage conditions
- When will the study be run
- Run the Shelf Life study
- At time intervals established in step 3.
- Run the appropriate tests in step 2
- Determine the shelf life
- Eventually a point is reached when the product no longer meets requirements for quality or safety, which is the shelf life
- Usually a pre determined point is established to end the study if quality and safety are not affected
- Establish working shelf life
- Working shelf life will be less than actual shelf life due to real world factors such as storage conditions and potential product abuse
- Once product is released to the market -> Monitor Shelf Life
- Investigate any customer complaints or failures
- Evaluate samples from production and distribution to validate study results.