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The Science Behind Project Peanut Butter

In 2000, with a few simple, inexpensive ingredients, Mark Manary, M.D., a pediatrician at St. Louis Children's Hospital and a professor of pediatric medicine at Washington University School of Medicine, revolutionized the feeding protocol for young children who are ill from severe malnutrition.

Dr. Manary chose to work in the country of Malawi, a peaceful, land-locked country with a high rate of poverty and a 70% rate of pediatric malnutrition. His treatment protocol included providing a high protein, lipid-dense paste, rich in nutrients, for an in-home, multi-week feeding therapy that resulted in an up to 95% recovery rate for participating children. This community-based treatment stood in stark contrast to the previously offered formulas provided in germ-infested, over-crowded Nutritional Rehabilitation Units (NRUs) that children were traditionally taken to when ill from malnutrtion. These offered dismal recovery rates, and required mothers to remain at facilities with their ill children, often for weeks, leaving their crops untended and their other children vulnerable.

Dr. Manary experimented with a mixture of ground, roasted peanuts, vegetable oil, powdered milk, vitamins, minerals and sugar, now known as Ready-to-Use Therapeutic Food (RUTF). It can be stored, unrefrigerated, for months without spoiling, requires no cooking and is transported by truck to rural villages for the home-based therapy. Teams of medical personnel measure malnourished children for height, weight and arm circumference, and provide a two week ration of RUTF for children who need treatment. Thereafter, medical teams return to the village every two weeks to reassess enrolled children and provide the next two week ration if necessary. Most often, children are fully recovered in six to eight weeks’ time, achieving normal height, weight and arm circumference for their age group.   

Study Results

In the 2000-2001 hungry season, about 400 children were treated according to the new home therapy using imported peanut butter food. In this study 80% of the children receiving a full diet of RUTF for a period between 2 and 12 weeks reached their 100% weight for height goal. This included a 95% recovery rate for HIV negative children. Crowding in the hospitals decreased significantly, so that the most severely ill children were able to receive more attention during inpatient treatment.  

During the 2001-2002 hungry season, 300 children were treated with locally prepared peanut butter food. Eighty percent of these children reached their 100% weight for height growth goals. In the 2002-2003 hungry season approximately 2,000 children were treated. Encouraging results were again achieved, on a much larger scale and at a wide variety of field sites. At that point in the project, seven operating sites including mission, rural, and district NRUs participated, transferring inpatients directly to the RUTF program for phase two home-based treatment. Eighty percent of these children recovered, with an average time in the program of 6 weeks. Mothers were once again free to attend to the daily rigors of crop tending and child rearing, and children who were allowed to recover at home were able to do so without the additional risks associated with exposure to the infectious agents so prevalent at the NRUs. International relief agencies began taking notice of this great forward leqap in the science of treating malnutrtion, and caqme calling.  Dr. Manary knew he must produce RUTF on a larger scale, and began plans to develop a production facility that could produce enough RUTF to accommodate other NGOs.

Project Peanut Butter continued helping malnourished children in Malawi during 2004 and 2005, honing and field testing the formula to continued, record improvement in child recovery rates.  As of May 2005, Project Peanut Butter served twelve fully operating sites, and witnessed recovery rates of  89.9% overall. At the site at Misolmali, for example, in the month of April 2005 alone, 96 of 101 children (95%) fully recovered. It was time to expand operations, accommodate other partners and add more sites.

In July 2005, Project Peanut Butter extended its production and distribution to 15 sites. The project continues to rehabilitate wasted children back to meet the normal growth curves for height and weight. The future goals of the program are aimed towards looking at ways to formulate RUTF with less milk in order to better treat infants between the ages of 6 and 18 months. Research has shown that it is within this critical age range that malnutrition has the greatest  negative impact on growth. Project Peanut Butter seeks both to treat malnourished children and to test strategies on prevention. Toward that end our medical teams train local health service assistants to recognize the signs of early malnutrtion, allowing earlier intervention. Moreover, we are committed to developing and testing supplementary foods to prevent malnutrition in the developing world.

Ready-to-Use Therapeutic Food

To produce RUTF, peanuts are shelled, roasted and ground. Vegetable oil is added to the peanuts,  and the two ingredients are creamed together in a stainless steel mixerat 105 rpm until homogenous. A z-shaped kneader blade minimizes the amount of air impregnated into the mixture, and special care is given to avoid any moisture getting into the mix . Bacteria require moisture to grow and multiply; denying them this crucial moisture ensures the safety of RUTF at ambient conditions. Powdered milk,  vitamin and mineral mix and powdered sugar are combined in a dedicated plastic drum, and then emptied into the electric mixing bowl. The RUTF should be mixed at 105rpm for 6 minutes, 210rpm for 6 minutes, and 323rpm for 6 minutes. The mixing time ensures homogeneity and prevents separation during storage. All implements are washed thoroughly after each production day, but not during the production, to prevent accidental addition of water to the product. RUTF can be stored in large plastic drums, and hand-packed into 275g plastic bottles with screw tops for distribution.

Powdered milk comprises 25% of ingredients, yet 67% of current costs. It is also the most difficult ingredient to obtain in many parts of the world in which food insecuriities exist and malnourishment is rampant. In spring 2008, clinical trials will commence that will test the efficacy of substitute ingredients for a portion of the milk ingredient. If Dr. Manary’s hypothesis holds true and the new formula is as effective as the present formula, the cost of production will be lower and Project Peanut Butter and all relief agencies that purchase our RUTF at cost will benefit.

The average child remains in the program for 6 weeks, or 4 follow up visits, and consumes about 11 kg of RUTF. In today’s dollars the total cost of the food ingredients to save the life of one child is only $15.

RUTF Production and Safety Measures

Local production of RUTF requires a reliable peanut paste processor in country, with adequate aflatoxin screening safety measures. This was not a problem in Malawi, where peanuts are regularly roasted and sold either salted and packaged, or as paste. An independent food technologist determined that the peanut butter-based Ready-to-Use Therapeutic Food produced locally in this manner harbored no significant microbial contamination and aflatoxin levels below the most stringent safety standards (<2ppb), even after contamination with a child's dirty hands. In the second year of locally made RUTF in Malawi, a local company was identified to undertake the production of RUTF according to specifications. In this instance, the recipe was modified to use crystalline rather than powdered sugar. Roasted peanuts were mixed directly to the oil and dry ingredients, and the RUTF was extruded as paste. Again, this mixture was satisfactorily tested for safety.

A Malawian mother holds her severely malnourished child.

it is not always evident that a child is malnourished, because edema, characterized by excess fluid in the tissues, can mask the weight loss.

Below, a nurse presses the flesh of a toddler's foot to check for edema.

malawi has a 70% rate of pediatric malnutrition.

In today’s dollars, the total cost of the food ingredients to save the life of one child is only $15.

with your help, project peanut butter's factory in malawi can produce enough rutf to feed all the severely malnourished children in the country.