The new e'Pap site is now up and running, so for a full run down on what e'Pap is, how it works and lots more please have a look at this link.
The e'Pap effect
Hidden Hunger affects more than two
billion people. Even when a person consumes adequate calories and protein, if
they lack one single micronutrient - or a combination of vitamins and minerals
- their immune system is compromised, and infections take hold.
World
Hunger Series 2007 - Hunger and Health
World Food Programme
Geoffrey Douglas, a physician and occupational medicine specialist, with 30 years of work experience in Africa and CEO of Health Empowerment Through Nutrition (HETN) has written a fascinating and edifying article following the recent pilot study conducted in 2013 in Tanguiéta, Benin. The aim of the study was to assess the
effectiveness of e’Pap as a nutritional supplement in improving the nutritional
status of children aged 6 to 59 months.
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| Child K at his first visit |
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| Child K after 2 weeks |
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| Child K after 8 weeks |
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| Child M first visit |
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| Child M after 8 weeks |
An Appeal to Reason
A
pilot study was conducted in 2013 in Tanguiéta, Benin, to assess the
effectiveness of e’Pap as a nutritional supplement in improving the nutritional
status of children aged 6 to 59 months.
E’Pap,
a fortified supplementary food, was chosen for the study because it is whole
grain, unlike many supplementary foods that are based on refined cereal flours,
which lose much of their nutrients during processing. E’Pap is fortified with chelates
and food state nutrients, unlike many supplementary foods that use vitamins and
minerals as chemical isolates. And e’Pap is pre-cooked, unlike many
supplementary foods that require cooking, and cooking can destroy vitamins.
The
unpublished results demonstrate that e’Pap is an efficient way to improve
nutritional status. On admission to the study, 87% of the children had
nutritional problems, 32% of which were severe. After a mere eight weeks, this
pattern had been reversed, with 88% of children being nutritionally normal, and
no child displaying severe acute malnutrition. Anthropometric measurements rose
steadily, and haemoglobin levels improved significantly from 6.8 to 8.9g/dl.
This
pilot confirms what was found when the impact of e’Pap on the health and
well-being of crèche children and adult TB patients was assessed in Alexandra
Township, South Africa. Like the Benin study, this one was carried out with
significant resource limitations, making it impossible to control all
confounding variables, but, despite this, the results allowed statistical
analysis which showed significant change over time.
Improved
general well-being among the adults, accompanied by fewer reports of low
energy, was in stark contrast to a study in Malawi, which used Corn Soya Blend
(CSB) and Plumpy’Nut. The observed increase
in Body Mass Index (BMI) without change in waist / hip ratios among adult
participants suggested that BMI increases were due to muscle gain rather than
fat gain. This was similar to the results in the children, where improvements
were observed in lean body mass. Hand-grip
strength improved in both adults and children, supporting the view that the
increases in BMI were likely to be secondary to improvements in lean muscle
mass.
This
study population's subsistence diet relied heavily on pap (refined maize
porridge) and bread, which are fortified with vitamin A, zinc, iron, folic acid
and other vitamins according to South African Government guidelines. However,
despite dependence on these fortified foods, the data showed high levels of
micronutrient deficiency at baseline, suggesting that fortification of these
staples with chemical isolates does not result in nutrient repleteness. In
particular, the improvement in iron levels over
one month is notable, as similar improvements had not been achieved after more
than five years of iron fortification of wheat and maize flour in South Africa.
It
would be easy to criticise these pilots, but the results strongly suggest that
it is indeed possible to reverse malnutrition quickly with a product that does
not fill children’s bellies with refined starch, nor with fat and sugar, and
which costs considerably less than Plumpy’Nut.
Before I get too excited, many readers perhaps believe that we
already understand the causes of the global nutrition crisis, and that science
has the solution, but they would be wrong.
The German scientist, Baron Justus von Liebig (1803-1873)
certainly has a lot to answer for. In his 1840 monograph, Chemistry in Its Application to Agriculture,
he proclaimed that only three soil nutrients were required for plant growth.
These were nitrogen (N), phosphorus (P) and potassium (K). The ‘NPK mentality’
was born and survives to this day.
Monoculture has replaced mixed farming,
crop rotation and effective animal husbandry. Plants have always
concentrated their roots in, and obtained most of their nutrients from topsoil,
which has the highest concentration of organic matter and microorganisms, and
where most biological activity occurs. But farmers could now ignore this and
deep-plough. NPK was all that was needed.
Liebig’s other great proclamation was that human growth depended
solely on the correct balance of protein, carbohydrate and fat. The ‘balanced
diet mentality’ was born and, once again, survives to this day. Suffice it to say
that, when he made this assertion, vitamins and other essential micronutrients
had yet to be discovered.
Both of Liebig’s claims
are examples of the tyranny of scientific reductionism, which
determines what is effective only when it has been tested through the rigour of
a randomised controlled trial, which, by definition, ignores valuable
contributions to science through qualitative studies. Tragically
for us, the death of sustainable agriculture and the death of good nutrition
can both be laid at the Baron’s door, and his pioneering work on the
development of the Oxo cube hardly justifies any reprieve.
Modern
farming methods have conspired to maximise yields at the expense of nutrient
content. Deep ploughing, NPK fertilisers, pesticides, fungicides, monoculture,
early harvesting, transport over long distances and artificial ripening all
play a part. Agri-business has become
big business, with a drive for profit at the expense of quality.
Today,
our food contains a fraction of the essential micronutrients it contained one
hundred years ago, and the food industry has compounded the problem by milling,
refining, processing and the extensive use of additives, sugar, corn syrup and
hydrogenated oils (trans fat).
The
result is a global pandemic of Hidden
Hunger (Type B Malnutrition), which afflicts the hungry and the obese. Even
in the West, where people live longer, half have health problems that require
prescription drugs on a regular basis.
Hidden Hunger affects more than two
billion people. Even when a person consumes adequate calories and protein, if
they lack one single micronutrient - or a combination of vitamins and minerals
- their immune system is compromised, and infections take hold.
World
Hunger Series 2007 - Hunger and HealthWorld
Food Programme
Multiple
micronutrient deficiencies are manifest in an explosion in the prevalence of
chronic degenerative disease, including obesity and diabetes, high blood
pressure and heart disease, mental illness and dementia, and conditions related
to impaired immunity, such as cancer, tuberculosis, asthma and arthritis.
In
many third world countries, today, the staples are refined maize meal or other
cereal, bread (mostly refined), white sugar, traditional margarine (trans fat)
and cooking oil. These are all ‘empty’ calories. Is it any wonder that chronic
degenerative diseases are escalating and that immunity is impaired? Is it any
wonder that this Hidden Hunger interacts
with repeated bouts of infectious disease, causing some three and a half million
preventable maternal and child deaths annually?
So
what are we doing about it? It has long been known that the 1000 days between
conception and a child’s second birthday are critical to that child’s future
development. Evidence shows that the right nutrition at this time can save more
than one million lives each year, significantly reduce the human and economic
burden of diseases such as TB, malaria and HIV/AIDS, reduce the risk of
developing various chronic diseases later in life, improve a person’s
educational achievement and earning potential, and increase a country’s GDP by
over two percent annually.
As
a result, leading scientists, economists and health experts all agree that
improving nutrition during this 1000 day window is one of the best investments
we can make to achieve lasting progress in global health and development.
It
is argued that the methods, which are readily available, affordable and
cost-effective, should include ensuring that mothers and young children get the
vitamins and minerals they need, promoting good nutritional practices -
including breastfeeding and appropriate, healthy foods for infants - and
treating malnourished children with special, therapeutic foods.
Sadly,
much of this global effort involves fortifying refined staples with chemical
isolates, and distributing Corn Soya Blend (CSB++), Plumpy’Nut and Sprinkles. Unfortunately,
in the words of Albert Einstein, ‘We can't solve problems by using the same
kind of thinking we used when we created them.’
Let’s
first look at an example of fortification. To address micronutrient
deficiencies, especially in the most vulnerable, and on the advice of the
Global Alliance on Improved Nutrition (GAIN), South Africa began a food
fortification programme in 2004, adding iron, zinc, vitamin A, folic acid and
other B vitamins to all maize and wheat flour. But five years on, the project
was judged a resounding failure. Apart from a modest improvement in folic acid
status, the prevalence of vitamin A, zinc and iron deficiencies in children had
all increased.
This
is hardly surprising, when a review that evaluated programmes fortifying wheat
flour with iron alone in seventy eight countries concluded that most were
likely to be ineffective. The major reason for this is that chemical isolates
have a significantly lower bioefficacy than whole foods. Despite this, fortifying
or supplementing a defective diet with micronutrients in the form of chemical
isolates is now commonplace, despite a plethora of scientific evidence that
they are poorly absorbed, rarely act in the body in the way intended and, in
some cases, may even be toxic.
It
has been known for over fifty years that phytic acid, found in grain, combines
with important minerals such as iron and zinc to form insoluble phytates,
which cannot be absorbed by the intestines. Phytic acid also chelates vitamin
B3, a deficiency of which causes pellagra. For these reasons, phytic acid
is known as an antinutrient, which makes it futile to attempt the mineral
fortification of maize and wheat flour with inorganic minerals.
What
about CSB++? Operating in nearly one hundred countries around the world, World
Vision is a Christian humanitarian organisation, dedicated to helping children,
families, and their communities reach their full potential by tackling the
causes of poverty and injustice. World Vision is on the frontline of
the fight against hunger. It is the largest organisation assisting orphans
and vulnerable children, and it places some eighty five percent of the food aid
provided by the World Food Programme (WFP). WFP ships refined surplus grain,
from which most of the valuable nutrients have been removed and sold on as
animal feed. Their special nutritional product, Corn Soya Blend (CSB, CSB+
and CSB++) is based on refined maize and soya, with added vitamins and minerals
in the form of chemical isolates. The product needs to be cooked. So, once
again, most of the good stuff has been removed, and what has been put back
would either be destroyed by phytic acid or by cooking.
Plumpy’Nut
is promoted and marketed across Africa as a major breakthrough in the fight
against malnutrition. Manufactured by the French company, Nutriset, it was
designed by Dr André Briend to be used for a maximum of two to three weeks in
cases of severe acute malnutrition. This is appropriate, but it is not the
reality on the ground, where Plumpy’Nut is hailed as a miracle food and as the
solution to moderate malnutrition, particularly in Africa. This is complete
nonsense, but it goes unchallenged as a claim.
Plumpy'Nut
is a combination of powdered milk (30%), sugar (28%), peanut butter (25%),
cotton-seed oil (15%) and vitamins and minerals as chemical isolates. It has
the consistency of a paste. The dangers of high levels of refined sugar and fat
for young children are now so well understood that the UK Government recently
banned all advertising to young children of such products. This ban would
include Plumpy’Nut.
There
is scientific evidence that Plumpy’Nut increases BMI and Mid Upper Arm
Circumference (MUAC). This is useful when rescuing a dying child, but increases
in BMI or MUAC in the moderately malnourished tell us nothing about nutritional
status, unless we believe that fatter children are healthier children. Where is
the evidence that Plumpy’Nut makes children nutrient replete, or that it
improves nutritional status? As far as the micronutrients are concerned,
Plumpy’Nut also uses a mix of chemical isolates that have low bioefficacy and
will have little impact addressing the nutritional needs of the malnourished. A
final gripe is that the high cost of its components makes it unaffordable, and
therefore unsustainable, in a resource-poor context without donor funding.
One
of the largest ever nutrition interventions has just begun. The project
protocol, entitled ‘Formative research to develop culturally-appropriate,
supplementary feeding programs for children 6‐23 months in rural
Mozambique and Malawi’, states, inter alia, that ‘it will identify potential
barriers and facilitating factors to appropriate complementary feeding,
and that these findings will be
used to develop culturally-appropriate message and communication
strategies based on local food concepts and behaviour to successfully
promote age-appropriate, energy‐dense foods, including but not
limited to Nutributter (a variant of Plumpy’Nut), which will yield appropriate
and sustained usage among children 6-23 months.’
It
should be horrendous to all that ‘developing culturally‐appropriate,
supplementary feeding programmes for children’ is a euphemism for weaning
them on to daily high fat, high sugar ‘treats’. In Davos in 2013, Marc Van
Ameringen, Executive Director of GAIN, highlighted the links between
under-nutrition and obesity, and how many emerging countries suffer from what
is now referred to as a double-burden of malnutrition.
If fortification,
CSB++ and Plumpy’Nut have little, if any, beneficial effect on nutritional
status, and do not appear to be ‘promoting good nutritional practices and
appropriate, healthy foods for infants’, what about Sprinkles?
Sprinkles
are claimed to be an innovation in home fortification. They are sachets
containing a blend of micronutrients in powder form, which can easily be
sprinkled onto foods prepared in the home. The idea looks attractive but, once
again, the micronutrients are chemical isolates. A recent large and
authoritative study in Pakistan, within the one thousand days arena, used
micronutrient powders for an extended period. The results, which were published
in The Lancet, indicated a
failure of effective nutritional gain. Haemoglobin
improved in the treated groups, but they all remained anaemic. There was
improved growth in one group, but it was limited. Serum zinc and vitamin A
showed little change. Side effects, including diarrhoea - which zinc is
supposed to reduce - were serious and militated against any benefit. This is
not an intervention that anyone should be recommending, and it comes as no
surprise to those who understand the importance of nutrient form.
If
we are serious about the plight of the malnourished, it is high time that we
conduct robust comparative studies, in order to demonstrate the best way
forward. These studies need to look objectively at nutrient form. We need to define
those markers that accurately assess nutrient status, but it is even more
important is to define the markers that determine nutrient repleteness. It is
regrettable that in this ‘evidence-based’ era, we are still a long way from
‘best-practice’.
It
is not acceptable for UNICEF, GAIN or World Vision to argue that they do not
need evidence for the benefit of what they are doing because it is ‘accepted
practice’. Nor is it acceptable for World Vision, which claims to be an ethical
organisation, with the highest regard for good stewardship, to argue that they
are not expert in this area, but act on good advice. Anyone who is doing
something, however well-intentioned, to our children must know absolutely that
what they are doing is the best that is possible.
Now
we have two e’Pap pilot studies that not only offer hope, but support the
anecdotal evidence of all those involved in these studies. It is satisfying to
discover, in accordance with Einstein’s premise, that we can do more
(nutritional repleteness) by doing less (whole grain and biomimicry in
fortification). In the words of Rita Mae Brown, ‘Insanity is doing the same
thing over and over again, but expecting different results.’
Dr
Geoffrey Douglas
MSc
MA FRCP MFOM
CEO
– Health Empowerment Through Nutrition
