RUF Magazine Issue 1/2009

Locally Produced Ready-to-Use

Food (RUF)
Piloting in Mild and Moderately Wasted Children,
Nias Island, Indonesia
Veronika Scherbaum1,2, Olga Shapiro1, Ratna C. Purwestri1,2,
Dyah A. Inayati2, Diana Novianty1,3, Wolfgang Stütz1, Yusran
Yusran3, Torsten Müller3, Nia N. Wirawan4, Julia Suryantan5,
Maurice A. Bloem5, Michael Koeniger5, Rosnani V. Pangaribuan6,
Matin Qaim7, Tilman Grune1, Volker Hoffmann2,
Anne C. Bellows2, Hans K. Biesalski1

1Institute of Biological Chemistry and Nutrition (140a+d), University of Hohenheim, Stuttgart, Germany;
2Institute for Social Sciences in Agriculture (430a+b), University of Hohenheim, Stuttgart, Germany;
3Institute of Plant Nutrition (330c), University of Hohenheim, Stuttgart, Germany; 4Faculty of Medicine,
Study Program Nutrition, University Brawijaya, Malang, Indonesia; 5Church World Service,
Indonesia/New York; 6SEAMEO-TROPMED Regional Center for Community Nutrition, University of
Indonesia, Jakarta, Indonesia; 7Department of Agricultural Economics and Rural Development, University
of Goettingen, Germany

Correspondence: Veronika Scherbaum, Institute for Social Sciences in Agriculture, Food and Gender,
University of Hohenheim, Schloss, Museumsflügel, 70593 Stuttgart, Germany
Email: [email protected]

Introduction United Nations Children’s Fund (UNICEF) found a

high prevalence (12.8%) of wasting (defined as < -2
Nias Island in Indonesia was severely affected by the Weight-for-Height Z-score, or WHZ) among children
2004 Indian Ocean tsunami and a consequent earth- aged below five years in South Nias, which is also one
quake some months later. A 2005 survey led by the of the poorest sub-districts in Indonesia.1

About two years later, Church World Service

Indonesia (CWS) reported as many as 11.9% of chil-
dren were still wasted in its intervention area on Nias
Island,2 and began piloting a newly developed Ready-
to-Use Food (RUF) to reduce the prevalence of wast-
ing.

The nutritional products used in this study, such as

cereal/nut/legume-based RUTF-Nias biscuits and
peanut/milk paste (PMP-Nias), were originally
designed for severely wasted children but were
nonetheless used in the interests of a conservative
approach in moderately wasted children. This article
reports some of the preliminary findings from a larger,
ongoing research project entitled ‘Effectiveness of
Malnourished child with mother on Nias Island Locally Produced Ready-to-Use Foods (Part I) and
Home-Based Foods (HBF) Fortified with Micro-

SIGHT AND LIFE Magazine 2009;1:29–37 29

SIGHT AND LIFE RUF

nutrient Powder (Part II) for tent of the biscuit similar (but not skimmed milk powder instead of
Wasted Children in Nias, Indo- identical) to that of Plumpy’nutTM. whole milk powder, explaining the
nesia.’ A vitamin and mineral premix importance of peanuts) were there-
which would enable this was final- fore made. However, caretakers
Objectives ly produced by DSM Nutritional continued to complain about per-
Products, Singapore, for use in the ceived consequences for their chil-
The objectives of the study were to: production of RUF biscuits on Nias dren (such as diarrhea and consti-
Island. pation) when consuming PMP-
• Develop new recipes of cereal- Nias.
based RUF, in the form of bis- In Nias, data on the constant avail-
cuits, for local production and ability of ingredients to produce the Based on this experience, a new
consumption by wasted children biscuits were collected through a intervention area was established in
aged 6 to 60 months. market survey and in-depth inter- another district, where caretakers
• Compose a new vitamin and min- views with key CWS staff. Based did not participate in the local pro-
eral premix that would make the on this information, four of the duction of PMP-Nias during the
micronutrient specifications of RUF recipes were used to produce first month. Later, after the product
the RUF-Nias biscuits compara- biscuits that were field-tested in had been accepted and the caretak-
ble (but not identical) to that of seven feeding centers. The biscuits ers observed the benefits for their
Plumpy’nut™ and reference data were examined for appearance, children (increased appetite and
of WHO, WFP, UN-SCN, weight gain), they even started to
UNICEF.3 voluntarily assist in the production
• Explore baking time and temper- of the PMP-Nias. In contrast to the
ature yielding the lowest loss of original problems with PMP-Nias,
micronutrients; compare the RUF-Nias biscuits were readily
micronutrient content of the accepted and liked by the children
baked biscuits with the calculated and their caretakers.
ones; and study the stability of the
micronutrient content of the bis- Micronutrient stability test
cuits after 3–4 weeks of storage at
room temperature. Laboratory examination was per-
• Calculate the number of RUF- formed to analyze the nutrient com-
Nias biscuits needed to meet position of the biscuits using High
approximately 50–60% of the Child participating in feeding Performance Liquid Chromato-
daily energy requirements of chil- program graphy (HPLC) for vitamins A, E,
dren aged 6 to 60 months. C, and B1, and Atomic Absorption
• Compare the costs of locally pro- color, texture, consistency, smell Spectrophotometry (AAS) for iron
duced PMP-Nias and cere- and taste under given local climate and zinc.
al/nut/legume-based RUF-Nias conditions. This organoleptic eval-
biscuits. uation was repeated after two to The composition of micronutrients
three weeks to fulfil the demands of before baking and their deteriora-
Methodology weekly RUF distribution programs. tion during baking and storage
The two recipes for biscuits most were examined. Baking times and
Product development and favoured by wasted children and temperatures were investigated
evaluation their caretakers were selected and under the following conditions
locally produced. using an electric oven:
Nine new recipes of RUF biscuits
using local (Nias) and national The local production of PMP-Nias 170°C, 20 minutes; 170°C, 25 min-
(Indonesian) food sources were relied on previous experience from utes;180°C, 15 minutes; 180°C, 20
developed in Germany4 and their a similar study in Uganda.5 minutes
nutrient composition was analyzed Contrary to that experience, accept-
at the Institute of Biological Che- ance issues occurred with the PMP-
mistry and Nutrition, University Nias during the field testing.
Hohenheim. The goal was to make Modifications to the recipe (includ-
the macro- and micronutrient con- ing heating the oil, adding

30
RUF Magazine Issue 1/2009

PMP-Nias. Results and discussion

Children dis-
charged from Recipes and nutritional composi-
this study (Part tion
I) were admitted
into the HBF PMP-Nias and the new RUF-Nias
with Micro- biscuits were made from local
nutrient Powder ingredients produced either nation-
(MNP) inter- ally (peanuts, milk powder, palm
vention study oil, sugar, wheat flour) or on Nias
(Part II). Both Island (soybeans, seeds, eggs).
studies included Originally, the nine newly designed
participatory recipes used ingredients such as
RUF-Nias biscuits nutrition educa- rice, wheat, manioc, groundnut,
tion interven- cashewnut, coconut, sesame seed,
Feeding trials/intervention study tions, based on the FAO Family soybean, kidney bean, mungbean,
for moderately and mildly wasted Nutrition Guide,6 in randomly fish flour, milk powder, sunflower
children selected areas. oil, palm oil, eggs, and sugar. The
ingredients of the two recipes final-
A feeding trial was conducted After final discharge, children are ly selected are shown in Table 1.
among children aged 6–60 months followed for six months to assess the
in the CWS project area, followed long-term effects of the above- It was critical to select the best
by an intervention study that com- described interventions. Further quality (and more expensive)
pared the results (e.g., mean weight description of the groups and their nationally produced peanuts to
gain, average duration of stay, and characteristics (sample size calcula- minimize microbiological contami-
anthropometric and health data) tions, mean age, sex, and other fam- nation caused by improper post-
from among 230 children who were ily background information) goes harvest handling. The taste and
given locally produced RUF-Nias beyond this publication and will be flavour of whole milk powder were
biscuits versus locally produced presented elsewhere. originally disliked in the project

Table 1: Recipes of locally produced peanut/milk paste (PMP-Nias) and RUF-Nias biscuits

PMP-Nias with PMP-Nias with whole RUF 1 –Nias biscuit* RUF 8 –Nias biscuit*
skimmed milk powder milk powder with soybean with mungbean
Ingredients Weight (g) Ingredients Weight (g) Ingredients Weight (g) Ingredients Weight (g)
Wheat flour 25 Wheat flour 22
Peanut flour 26 Peanut flour 25 Peanut flour 25 Peanut flour 22
Skimmed milk powder 25 Whole milk powder 30 Soy bean flour 9 Mungbean flour 9
Palm oil 34 Palm oil 34 Palm oil 20 Palm oil 24
Refined sugar 27 Refined sugar 28 Refined sugar 18 Refined sugar 21
Egg white and Egg white and
egg yolk 10 egg yolk 10
Vitamin-mineral Vitamin-mineral Vitamin-mineral Vitamin-mineral
premix 2.7 premix 2.7 premix 2.7 premix 2.7
TOTAL 114.7 g TOTAL 119.7 g TOTAL 109.7 TOTAL 110.7
Energy Energy Energy Energy
(per 100 g) 569 kcal (per 100 g) 590 kcal (per 100 g) 536 kcal (per 100 g) 523 kcal
Fat 63% Fat 67% Fat 58% Fat 60%
Protein 10% Protein 7% Protein 10% Protein 8%
Carbohydrate 27% Carbohydrate 26% Carbohydrate 32% Carbohydrate 32%
*RUF 1 and 8 Nias biscuits were selected based on local acceptability from nine recipes developed in Germany

31
32
Table 2: Micronutrient composition of Plumpy’nutTM and RUF-Nias biscuits in comparison to recommendations. Source: World Health Organization, the
World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund. Community-Based
Management of Severe Acute Malnutrition. WHO, WFP, UN-SCN and UNICEF Joint Statement. Geneva: WHO/WFP/UN-SCN/UNICEF, 2007.

Micronutrients WHO, WFP, UN-SCN, Plumpy’nutTM RUF 1-Nias RUF 8-Nias Premix RUF 1-Nias RUF 8-Nias
UNICEF (for 100 g) (in 100 g) biscuits biscuits biscuits biscuits
Min Max Min Max No added premix No added premix (for 100 g) (in 100 g) (in 100 g)
SIGHT AND LIFE

Vitamins
Vitamin A µg 800 1100 800 1,200 49.0 40.8 930.0 979.0 970.8
Vitamin D µg 15 20 15 18 0.3 0.2 16.2 16.5 16.4
Vitamin C mg 50 - 50 132 0.3 0 54.0 54.3 54
Thiamine B1 mg 0.5 - 0.5 0.8 0.1 0.1 0.8 0.9 0.9
Riboflavin mg 1.6 - 1.6 2 0.1 0.1 1.8 1.9 1.9
Vitamin B6 mg 0.6 - 0.6 0.7 0.1 0.1 0.6 0.7 0.7
Vitamin B12 µg 1.6 - 1.6 2.0 0.1 0.1 1.8 1.9 1.9
Niacin mg 5 - 5.0 5.9 4.0 3.5 7.7 11.7 11.2
Biotin µg 60 - 60 72 3.1 2.6 62.9 66.0 65.5
Folic acid µg 200 - 200 230 52.0 53.4 203.8 255.8 257.2
Vitamin K µg 15 30 15 25 8.0 6.9 20.3 28.3 27.2
Vitamin E mg 20 - 20 25 3.9 3.2 16.2 20.1 19.4
Pantothenate mg 3 - 3 3.7 0.7 0.6 3.3 4.0 3.9
Minerals
Calcium mg 300 600 300 600 58.0 32.3 287.9 345.9 320.2
Iron mg 10 14 10 14 3.1 1.8 10.8 13.9 12.6
Iodine µg 70 140 70 140 0.9 0.8 119.9 120.8 120.7
Zinc mg 11 14 11 14 1.6 1.1 13.3 14.9 14.4
Sodium mg - 290 - 290 16.0 14.8 0 16.0 14.8
Potassium mg 1,110 1,400 1,100 1,400 353.0 202.5 600.9 953.9 803.4
Magnesium mg 80 140 80 140 69.0 44.4 22.6 91.6 67
Phosphorus mg 300 600 300 600 206.0 141.8 144.7 350.7 286.5
Copper mg 1.4 1.8 1.4 1.8 0.5 0.3 1.8 2.3 2.1
Selenium µg 20 40 20 40 0 0 30.6 30.6 30.6
RUF
RUF Magazine Issue 1/2009

Vitamin A in RUF-Nias Biscuit Vitamin C in RUF-Nias Biscuit

1.20 70.0

1.00 60.0

Viamin C (mg/100g)
Viamin A (mg/100g)

50.0
0.80
40.0
0.60
30.0
0.40
20.0
0.20 10.0

0 0

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21
unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21
Temp 170, 20 min. Temp 170, 25 min. Temp 180, 15 min. Temp 180, 20 min. Temp 170, 20 min. Temp 170, 25 min. Temp 180, 15 min. Temp 180, 20 min.

RUF-Nias Biscuits (unbaked vs baked) RUF-Nias (unbaked vs baked)

Vitamin E in RUF-Nias Biscuit Vitamin B1 in RUF-Nias Biscuit

21.0 1.00
0.90
18.0
0.80
Viamin B1 (mg/100g)
Viamin E (mg/100g)

15.0 0.70
12.0 0.60
0.50
9.0 0.40
6.0 0.30
0.20
3.0
0.10
0 0
unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21

unbaked

day 1

day 15–21
Temp 170, 20 min. Temp 170, 25 min. Temp 180, 15 min. Temp 180, 20 min. Temp 170, 20 min. Temp 170, 25 min. Temp 180, 15 min. Temp 180, 20 min.
RUF-Nias (unbaked vs baked) RUF-Nias (unbaked vs baked)

Figure 1: Vitamin concentration in RUF-Nias biscuits, unbaked, baked, and after 15–21 days of
storage

area. More expensive skimmed milk powder was with and without the vitamin/mineral premix, is shown
therefore introduced during the initial months of the in Table 2.
PMP-Nias production. Once the children and care-
givers became familiar with the taste of PMP-Nias, Laboratory examination of RUF 1-Nias biscuits
both skimmed and whole milk powders were used,
depending mainly on price and availability in the dif- As shown in Figure 1, a baking temperature of 180°C
ferent project areas. Palm oil was the only available for 15 minutes resulted in the lowest loss of vitamins
type of oil on Nias Island and was therefore used as the while the greatest loss was observed at 170°C for 25
oil source for PMP-Nias and RUF-Nias biscuits. minutes and 180°C for 20 minutes. Heat-sensitive
micronutrients should be added in slightly higher
Selection of biscuits for use in daily and weekly inter- amounts in the vitamin-mineral premix to make up for
vention programs losses during the baking process.

Of the nine newly designed RUF recipes, RUF-1 and Storage at room temperature for two to three weeks
RUF-8 biscuits were selected on the bases of the con- produced no further loss of the investigated micronu-
stant availability and accessibility of the ingredients on trients. In some trials, the vitamin content was even
Nias Island; the high acceptability of the biscuits by slightly higher after two to three weeks. This can only
children aged 6 to 60 months and their caregivers; and be explained by the fact that the premix was probably
the stability in taste, color, consistency and texture not well mixed into the dough. Therefore, for local
after baking and up to three weeks of storage under production, we recommend producing smaller
local weather conditions (on average 30°C). The com- amounts of biscuits (a maximum of 1 kg was mixed in
position of the RUF-1 and RUF-8 selected biscuits, Nias), more regularly and according to the demand

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SIGHT AND LIFE RUF

Table 3: Cost of ingredients per kg of PMP-Nias and RUF-1 (in euros) ed to cover about 50% of the
daily energy requirements of
Ingredient PMP- Nias RUF 1-Nias individual children, based on the
Peanuts 0.55 – 0.57 0.46 child’s weight. Energy require-
ments were taken from FAO/-
Wheat flour 0.40
WHO/UNU recommendations
Soybean/mungbean 0.11
for children’s dietary energy
Palm oil 0.39 0.20 – 0.30 intakes.7
Sugar 0.27 0.18
Egg 0.13 After field testing, the number of
Whole-, skim milk powder 1.44 - 2.99 biscuits to be consumed was
Vitamin/mineral premix 0.04 0.04 increased by 10% to cover 60%
Total 2.69 – 4.26 1.52 – 1.62 of the daily energy requirements
of children, in line with
Indonesian guidelines.8 The
(number of malnourished children admitted to the pro- increase takes into consideration the possible sharing
gram). of the biscuits within families. Children aged 6–24
months, with a weight of about 6–10 kg received 4–7
Iron and zinc content in the RUF biscuits after baking biscuits per day (50–90 g); children aged 2–5 years,
was similar to the calculated amounts, confirming that weighing 10–15 kg, were given 7–11 biscuits (90–150
the right amount of these essential minerals had been g) per day.
mixed into the dough.
As the locally produced PMP-Nias quickly sours under
It is important to note that a kerosene stove was used local temperatures of about 30°C, it was produced and
in Nias which cannot keep exact temperature. distributed on the same day with close supervision.
Therefore, the CWS staff was advised to bake the The same holds true for commercially produced
RUF-Nias biscuits until they were light brown (which Plumpy’nut™, which can be used for only one day
took about 20 minutes at about 170–180°C). after the packaging is opened.9,10 (In the Uganda expe-
rience, a local substitute of Plumpy’nut™ was pro-
Feeding recommendations duced on a weekly basis because it could be stored in
a refrigerator.5) For a child aged 6–24 months, with a
The RUF-Nias biscuits were mainly developed as an weight range of 6–10 kg, half to one portion of PMP-
alternative to locally produced PMP-Nias for wasted Nias (50–100 g) was distributed each day; children
children aged 6–60 months during the rehabilitation aged 2–5 years, weighing about 10–15 kg, received
phase. For younger children, especially infants aged 1–1.5 portions per day (100–150 g).
6–12 months, the biscuits were crushed into small
quantities of boiled drinking water and offered by the Cost estimation
spoonful. Mothers/caretakers were instructed to offer
the biscuits between family meals and after breastfeed-The costs of the RUF1-Nias biscuits and PMP-Nias
were calculated according to local prices for the ingre-
ing. Caretakers were informed that the biscuits are sup-
plementary foods designed to support weight and dients (Table 3). In general, prices are higher on Nias
height gain in malnourished children. Originally, the Island compared to other parts of Indonesia, mainly
recommended number of biscuits per day was calculat- because transportation costs are exacerbated by
uneven deliveries resulting from
Table 4: Price comparison (Note: the calculation does not include costs bad weather.
of equipment and salaries for NGO staff responsible for pro-
duction, distribution and monitoring) Table 4 presents an overview of
the calculated costs per 100 g of
RUF- PMP/RUF- RUF1-Nias two locally-produced PMPs
Price for 100 g, Uganda Nias biscuits (Uganda and Nias) and the
about 500 kcal (2006) (2007) (2007) RUF1-Nias biscuits. The cost of
(in euros) the PMP produced in Uganda is
0.22 – 0.30 0.27 – 0.43 0.15 – 0.16 included to illustrate the vari-
ability of local production costs

34
RUF Magazine Issue 1/2009

Box 1: Ready-to-Use Therapeutic Food (RUTF)

The World Health Organization (WHO) revised its which is mainly produced in industrialized coun-
guidelines for the management of severe malnutri- tries, can be too expensive for blanket distribution
tiona in 1999 and introduced therapeutic milk for on a large scale.e In order to reduce costs, increase
severely malnourished children with medical com- coverage, supplement local diets, and support local
plications – a treatment that has been successfully economies, experts are advocating the production
implemented in hospitals worldwide. However, of RUTFs from locally available ingredients in
therapeutic milk powder requires clean water for countries with a high prevalence of malnutri-
reconstitution as well as close supervision tion.f–g
because, if left unrefrigerated in hot climates, milk
serves as a favorable medium for bacterial growth. A successful approach in treating and preventing
In much of the world, caretakers are required to mild-to-moderate malnutrition prevents conditions
stay for multiple weeks in clinics with their mal- from worsening to severe forms of malnutrition.
nourished child, which causes considerable incon- Recently, several products for treating and pre-
venience for other family members too. venting different forms of malnutrition have been
proposed by the UN World Food Programme
To reach more children at an earlier stage and to (WFP), under its partnership with DSM.h
bring the services directly to communities, a food
spread called Plumpy’nut™ was developed for References for Box 1
severely malnourished children without clinical
complications. This product can be given as part of a. World Health Organization. Management of severe malnu-
a home-based treatment under a system of weekly trition: a manual for physicians and other senior health
workers. Geneva: WHO, 1999.
supervision.b b. Bahwere P, Binns P, Collins S, Dent N, Guerrero S, Hallam
S, Khara T, Lee J, Mollison S, Myatt M, Saboya M, Sadler
Plumpy’nut™, the first Ready-to-Use Therapeutic K, Walsh A. Community-based Therapeutic Care (CTC) a
Food RUTF developed, is nutritionally compara- Field Manual. Oxford: CTC Research and Development
ble to therapeutic milk, and is made of peanut but- Programme, 2006.
c. Diop el HI, Doussou NI, Ndour MM, Briend A, Wade S.
ter, milk powder, vegetable oil, sugar, and a vita-
Comparison of the efficacy of a solid ready-to-use food and
min-mineral mix. Packed in air-tight sachets, a liquid, milk-based diet for the rehabilitation of severely
Plumpy’nut™ has a relatively long shelf life and malnourished children : a randomized trial. Am J Clin Nutr
can be immediately consumed without further 2003;78:302–7.
preparation. In several studies, Plumpy’nut™ d. Krumbein T, Scherbaum V, Biesalski HK. Locally pro-
(whether imported or locally produced) enabled duced Ready-to-Use Therapeutic Food (RUTF) in an inpa-
tient setting in Uganda. Emergency Nutrition Network
similar weight gain in severely malnourished chil- (ENN) Field Exchange 2006;28:21–3.
dren as therapeutic milk under hospital-based e. Enserink M. The peanut butter debate. Science Magazine
care.c–d RUTFs have thus been successfully used 2008;322:36–38.
in Community-based Therapeutic Care programs, f. Collins S, Henry CJK. Alternative RUTF formulations.
reducing the constraints posed by lack of access to Emergency Nutrition Network 2004;2:S35–7.
g. Manary MJ. Local production and provision of ready-to-
clean water and caretaker separation from fami-
use therapeutic food (RUTF) spread for the treatment of
lies. severe malnutrition. Food Nutr Bull 2006;27(3):S83–9.
h. World Food Programme/DSM. Ten minutes to learn about
For efficiency, the blanket distribution of an nutrition programming. SIGHT AND LIFE Magazine
RUTF is recommended. Plumpy’nut™, however, 3/2008, Supplement.

in different research sites, to date. depending on the type of milk pow- from DSM Singapore to Jakarta,
The cost calculation was based on der (whole or skimmed milk), which was borne by DSM.
the average price of the ingredients while the cost of the vitamin-min-
used in Nias in 2007 (1 euro was eral premix to produce 100 g of Preliminary results
approximately Rp 12,000). The RUF biscuits or PMP-Nias was 0.4
cost of 100 g of PMP-Nias was euro cents. This price does not Of the 230 moderately/mildly wast-
between 27 and 43 euro cents, include the cost of transportation ed (
-3 to < -1.5 WHZ) children

35
SIGHT AND LIFE RUF

Box 2: Energy and macronutrient content (per 100 g) Despite the higher cost of the PMP-
Nias, the RUF-Nias biscuits result-
Plumpy’nut™ PMP-Nias* Average of 9 RUF ed in better weight gain. The best
recipes weight gain (5.5 g per kg body
520–550 kcal 569–590 kcal 500–536 kcal weight per day) was achieved
10–12 % protein 7–10 % protein 8–14 % protein through the use of the biscuits com-
45–60 % fat 63–67 % fat 31–58 % fat bined with participatory nutrition
28–45 % carbohydrate 26–27 % carbohydrate 31–44 % carbohydrate education, followed by the use of
Nutriseta (*whole/skim milk) Shapiro, 2007b the biscuits alone (3.7 g per kg
body weight per day), and finally
The amount of RUF1-Nias biscuits needed each day was calculated as by the use of the PMP-Nias (3.5 g
follows: per kg body weight per day) in
• 100g of biscuit dough contains 536 kcal; daily intervention programs. Data
• 8 individual biscuits are made from about 100 g dough; from weekly programs indicate
• 1 individual biscuit weighs about 13 g and contains about 67 kcal. similar results but somewhat lower
weight gains.
References for Box 2
a. Nutriset. Plumpy’nut™, F-100 therapeutic milk in spread form, 2008. The average length of participation
b. Shapiro O. Development of Ready-to-Use Food (RUF) for malnourished chil- in the program was approximately
dren in Indonesia. Diploma Thesis. Germany: Institute of Biological Chemistry
and Nutrition, University of Hohenheim, Stuttgart, 2007.
3–5 weeks. In the Part II study, of
the 210 mildly wasted ( -1.5 to <
-1 WHZ) children admitted into the
admitted into the ongoing RUF- 152 recovered successfully (dis- ongoing Home-Based Foods with
Nias intervention study (Part I), charged at > -1.5 WHZ). Micronutrient Powder intervention,

Figure A: Proposed feeding programs according to nutritional status

TFP: Inpatient Therapeutic Feeding Programs

OTP: Outpatient Therapeutic Feeding Program
SFP: Supplementary Feeding Program

36
RUF Magazine Issue 1/2009

101 children were discharged suc- Acknowledgements

cessfully ( -1 WHZ). Accom-
panying participatory nutrition edu- This ongoing research has been part-
cation also improved weight gain in ly sponsored by DAAD, SIGHT
this study. AND LIFE, Eiselen Foundation,
Neys van Hoogstraten Foundation,
Recommendations and Church World Service
Indonesia. We would like to thank
Given the efficacy of locally pro- them for their continuous support
duced RUF-Nias biscuits (without and encouragement.
milk powder) in improving weight
gain among moderately/mildly References
wasted children, the biscuits should
next be tested and compared with 1. UNICEF. The Second Health and
PMP-Nias for use in treating Nutrition Assessment in Nanggroe Child receiving PMP-Nias
Aceh Darussalam Province and Nias
severely wasted children. RUF- Island, September 2005. Jakarta:
Nias biscuits with milk powder 6. Burgess A, Glasauer P. Family
UNICEF, 2005. Nutrition Guide. Rome: Food and
(providing high quality protein and 2. Church World Service (CWS). Hasil Agriculture Organization of the United
essential fatty acids) should also be Assessment di Gunung Sitoli, Nias. Nations, 2004.
tested for an impact on weight gain Jakarta: CWS, 2007. 7. World Health Organization. Report of
3. World Health Organization, the World
among severely and moderately a joint FAO/WHO/UNU expert con-
Food Programme, the United Nations sultation. Energy and protein require-
wasted children; if successful, System Standing Committee on ments. WHO Technical Report Series
RUF-Nias biscuits would be appro- Nutrition and the United Nations No. 724. Geneva: WHO.
priate for a wider range of malnu- Children’s Fund. Community-Based 8. Departemen Kesehatan RI. Angka
trition problems. Management of Severe Acute Mal- Kecukupan Gizi 2004 bagi orang
nutrition. WHO, WFP, UN-SCN and Indonesia. Indonesian Nutrition
UNICEF Joint Statement. Geneva: Network, Departemen Kesehatan RI,
Given the improved weight gain WHO/WFP/UN-SCN/UNICEF, 2007.
among wasted children who 2004. Internet: http://www.gizi.net/
4. Shapiro O. Development of Ready-to- lain/gklinis/AKG2004.htm (accessed
received RUF in combination with Use Therapeutic Food (RUTF) for mal- November 21, 2008).
nutritional training for their care- nourished children in Indonesia. Diploma 9. Nutriset. Website of local produc-
takers, the results further suggest Thesis. Germany: Institute of Biological tion of Plumpy’nut™ and infor-
Chemistry and Nutrition, University of
that participatory nutrition educa- mation about the product. Internet:
Hohenheim, Stuttgart, 2007. http://www.nutriset.fr (accessed
tion should accompany nutrition 5. Krumbein T, Scherbaum V, Biesalski August 22, 2008).
interventions. HK. Locally produced Ready-to-Use 10. Nutriset. Storage Conditions and
Therapeutic Food (RUTF) in an inpa- Changes in Products, 2008. Nutriset
tient setting in Uganda. Emergency Instruction Manual for Local Pro-
Nutrition Network (ENN) Field duction of Plumpy’nut™, 2008.
Exchange 2006;28:21-23.

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