e'Pap newsflash April '14

A new look!

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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.

Posted below is the full article, but the photographs from the study are mind boggling and a huge testimony to the effect e'Pap has.  The period covered from the first to last photographs is just eight weeks. 

Child K at his first visit

Child K after 2 weeks

Child K after 8 weeks

Child M first visit

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The unpublished results demonstrate that e’Pap is an efficient way to improve nutritional status.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