MUKENE - Mix Supplementary Diet For Treatment of Malnutrition

Report from two NuLife sites:

 Jinja Referral Hospital & Iganga General Hospital

April 2011
Mukene Mix Food Supplements for Management of Moderately Acute Malnutrition

Background

Uganda is among the resource constraint countries that continue to have high levels of undernutrition, particularly among young children, adolescents, pregnant/lactating women and adults with chronic diseases. undernutrition poses a serious threat to the vulnerable group and compromises growth development of children and quality of life of adults and contributed to illnesses and over 40 % of pediatric deaths. In 2006, over 38% of children under the age of five years were stunted, 6% wasted, and 16% underweight (UDHS 2006). The double-burden of malnutrition among the pregnant women was 12% (6% urban and 13% rural) underweight (BMI < 18.5), (Uganda Bureau of Statistics; UBOS, 2007). Likewise, the prevalence of anemia prevalence increased in 2006 to 73% in children 6-59 months of age, 49% in women of reproductive age, and 28% in 15-54 year old males (UBOS, 2007).

The Government of Uganda (GOU) recognizes the potential dangers of under nutrition to health and prosperity of its population and has adopted a multi-pronged strategy to combat the problem. These strategies include food diversification, food fortification, and micronutrient supplementation to vulnerable groups, therapeutic feeds to the affected individuals, education, and behavior change communication. New interventions such as biofortification are being tested in the country. Like other health sectors, the engagement and involvement of public-private partnership in the fight against malnutrition is very crucial.

NuLife - Food and Nutrition interventions for Uganda is a three year USAID PEPFAR funded program started in April 2008 designed to integrate Nutrition into on-going  HIV/AIDS (PLHIV)  treatment, care and support services. The program is being implemented in 54 Health facilities within 47 districts.

In September 2010, NuLife received a donation of 8000 Kg of Maize - Mukene mix flour from AKIBA International Ltd a company owned by Gen. Caleb Akandwanaho Salim Saleh Oriba (Rtd) worth UGX 14,400,000/= to complement to the effort of NuLife in the management of acute malnutrition in 54 Health facilities country wide. The donation was locally manufactured from foods commonly eaten by average Ugandan, designated for distribution to the moderately malnourished clients with the intent of supplementing their diets, and improving their nutritional status through weight gain.

The donated food product, made from maize and silver fish (Mukene) flour was manufactured by AKIBA International Ltd, analyzed at the department of Food Science and Technology Laboratory. Prior to donation, NuLife was reliably informed by the food scientist in charge of production that acceptability test had been performed, the shelf life studies were ongoing and at the time a period of 2.5 months from the time of production was considered okay. The process of certification of the product with UNBS was underway. NuLife was further informed that Silver fish (Mukene), a by-product of the supplementary food is not so rich in oils hence the issue of rancidity was very minimal.

Table 1: Comparison of the nutrient content of the products separately and mixed

Nutritional Content/ 100 G	Maize flour (MF)	Fish Flour (FF)	MF Enhanced with FF
Calories (Kcal)	342	333.2	344.2
Protein    (g)	8.48	75.7	15.58
Fats (Lipids)  (g)	1.65	2.9	1.85
Carbohydrates  (g)	77.68	Not  measured	77.9
Dietary Fibers   (g)	7.4	Not measured	7.6
Minerals
Calcium  (mg)	4	7.0	9.3
Iron  (mg)	0.52	1.9	1.1
Magnesium (mg)	37	13.9	49.5
Phosphorus (mg)	90	800	131.2
Potassium  (mg)	162	1391	184.9
Sodium       (mg)	3	33.5	27.7
Zinc      (mg)	0.72	2.2	0.82
Vitamins
Vitamin C   (mg)	7.3	6.1	7.35
vitamin B-1  (mg)	0.0254	0.2	0.1
vitamin B-2  (mg)	0.085	0.3	0.1
Vitamin B-6 (mg)	0.071	1.1	0.2
Folic Acid (µg)	1.85	29	5.1

Preparatory Phase

Prior to dispatch of the donated product, decisions had to be made on the potential beneficiaries, the number and type of health facility to benefit and the quantities to be dispatched and rations sizes.

The targeted beneficiaries were identified as:

1.      All orphans, vulnerable and children (OVCs) diagnosed with moderate acute malnutrition HIV/AIDS uninfected who were not beneficiaries of the Ready to Use Therapeutic food (RUF) supplied by NuLife the day of exit as “cured”.

2.   All Pregnant and lactating mothers who are moderately malnourished

3.      HIV negative acutely malnourished Adults

Sites were selected based on the high malnutrition rate and other special considerations.  The product was dispatched as below:

q    Jinja Regional Referral Hospital: 5 MT (200 bags)

q    Iganga General Hospital: 3 MT (118 bags)

q    Rubaga Hospital: 0.5 MT (2 bags)

In order to come up with a realistic ration per client a daily requirement of 1,000 – 1,200 Kcal/person/ day and 35 – 45 grams of protein per day was considered including the possibility of sharing with family members.  A ration size of 300 gm of the maize-mukene flour per day (One Nice cupful/day ) equivalent to 1023 Kcal/day was sufficient as a supplementary food (Mukene-maize mix has 344 Kcal/100 gm).

Site preparation and monitoring

The NuLife supply chain manager made 2 visits to the selected sites, prior to placement of the product (6^th of October 2009) to offer support in modalities of storing the product, dispensing and capturing consumption data and accounting. The second visit was after 2 months, to determine the consumption rates, the condition of the remaining product and the data.

Summary of Findings

A) Enrollment

Jinja Regional Referral Hospital

Period	Adults, Preg & lactating mothers	Children		Total
2009/2010	(HIV +ve)	<5years old	≥ 5years old
October	03	43	11	54
November	11	87	21	108
December	04	20	9	29
January	7
February	14
March	36
Total	91	150	41	191

Iganga Hospital

Period	Adults	Children		Total
2009/2010	(HIV +ve)	<5years old	≥ 5years old
October	0	2	7	9
November	7	2	23	32
December	4	1	13	18
January	11	3	45	59
February	13	0	22	35
March	3	0	12	15
Total	38	8	122	168

C) Weight Gain

Some of the clients’ Outcome recorded

Client’s age	At admission	At Discharge	Increment
8 month	6.9	8.9	2.0
9 months	5.5	6.1	0.6
10 months	7.3	8.2	0.9
1 year	7.0	7.7	0.7
1.5 years	9.0	12	3.0
	8.3	9.0	0.7
2 years	7.9	8.9	1.0
	6.7	10	3.3
2 years	7.2	8.5	1.3
2 years	7.0	9.0	2.0
5 years	14.0	15.0	1.0
13 years	28	30	2.0
29 years	50.0	52.0	2.0
30 years	45.0	53.0	8.0
35 years	41.5	49	8.5
Pregnant women	43.0	49.0	8.0
Lactating Mothers	51.0	52.0	1.0
Average monthly weight gain			2.7

Success Stories

Mukene Mix: one of the beneficiaries on the supplementary feed narrates her experience.

My name is Nakyanzi Hadijah, a 28 year old female staying in Namuwaya village - Mbiko with my 4 month old baby and husband. I sell second hand clothes for a living. I have been a client on septrin for 2 years now and I access my treatment from Jinja Regional Referral Hospital. On one of my routine monthly scheduled appointments to the hospital for follow up and drug refill, I was received by an expert client called Isaac Buzaaka. Isaac asked me how I was feeling, and told me he was going to take my measurements. With him he had a measuring tape, he put around my arm and then told me to stand on a scale. He wasn’t impressed with the results from the readings. I always move with my child everywhere I go because I am breastfeeding him exclusively. After taking the readings the Isaac told me my weight wasn’t good enough and informed me that since I was breastfeeding and on drugs at the same time, I could lose more weight more rapidly, which scared me because I intend to continue breastfeeding.

“When I took Hadijah’s Mid Upper Arm Circumference, a routine assessment for all clients that access care in the HIV/AIDS clinics, she was in the yellow zone, and after counseling and education, I enrolled her on the Mukene flour supplementary feed. I realized that with her breastfeeding her baby exclusively and being moderately malnourished, she could slip into ‘Red’ (severe malnutrition) easily. I gave her 9kg of the flour to last her one month and was given a follow up return date,” Isaac Buzaaka.

The volunteer gave me mukene flour and told me to take it alongside the normal food I have been eating at home. He told me how nutritious it is and taught me how to prepare it and strongly advised me to maintain good hygiene and sanitation to prevent diarrhea.

I reached home so excited to prepare the porridge so I could have my first meal of it. The smell of the porridge was unpleasant for me at first, on a few occasions I experienced nausea but I knew I had to continue taking it to improve my weight. More so, as you drunk from the cup, the porridge left a slight smell of raw eggs, but I persevered. The unpleasant smell dint reduce, I had to get used to it. With time I got more energy, I realized I got more breastmilk to feed my baby, and with the routine visits the volunteer was more impressed with my weight, which made me happy too.

Today am consuming the last cup of the flour, and it makes me sad to know that there will be no more stock at the hospital for refills when it is over. I have ever been a beneficiary of the Corn Soy Blend porridge from world food program. In my view the two porridges have the same end result, and that is making our nutrition state better, but I wish the manufacturers of the Mukene flour would make it with a lesser mukene smell. People living with HIV/AIDS are very prone to nausea, some clients may not stand the smell. I have seen many clients who are worse off than me, to whom I would strongly recommend to benefit from the porridge. It’s easy and very cheap to prepare, and takes a very short time to cook.

“The hospital is now remaining with 4 bags of flour which is going to last us one week. I therefore call upon the manufacturers to keep up supply. I recommend all clients on ARVs to be given the flour as a supplementary feed. Clients discharged as cured on Ready To use therapeutic food (RUTF) request to be given the flour to supplement their foods to prevent slip back into malnutrition. We have seen many clients who have slipped back and re-admitted. But with NuLife phasing out, such clients cant be re-admitted. We therefore request NuLife to access more stock from the manufacturer,” Toko mansur, Jinja RRH Nutritionist.

Compiled and written by;

Isaac Buzaaka- Expert client and Mary Nabisere- NuLife

                                                     

                                                Ministry of Health

Jinja Regional Referral Hospital

Report on the use of Mukene fortified maize flour as a supplementary food in the management of moderate acute malnutrition (MAM)

Compiled by;

Toko Mansur
Nutritionist JRRH

Date 3rd February 2011

Overview

1.1  Introduction

Jinja regional referral hospital is a Government-owned facility located in Jinja district, eastern Uganda. It is the largest hospital in eastern Uganda, with a bed capacity of 600. It is the Regional Referral Hospital for the districts of Bugiri, Namutumba, Iganga, Jinja, Buyende,  Kaliro, Kamuli, Mayuge, parts of Kayunga,  Buikwe, Namaigo, Luuka.

The hospital has two main wings; the Main wing where adults are attended to and the Children’s wing. Both wings conduct HIV/AIDS clinics  on daily basis and the most busiest day being Mondays The hospital has fully integrated nutrition activities not only in the comprehensive care for people living with HIV/AIDS but also in the general maternal and child health packages. The average prevalence of acute malnutrition among children receiving HIV/ART services in the hospital is 18%; one of the highest in the country. In The adult HIV/ART clinic (the main wing)  150-200 adult clients  seen each clinic day while 20- 60 clients( children) are seen Clients in the pediatric HIV clinic per clinic day  are assessed for nutritional every visit

1.2 Implementation of Nutrition Interventions at Jinja Hospital:                                            

Jinja hospital is implementing the integrated management of acute malnutrition with support from its partners. The hospital is one of the facilities supported by HCI and MOH Quality of Care Initiative to integrate nutrition interventions into routine HIV/AIDS care using the Quality Improvement (QI) approach. With support from its partners especially Nulife and individual well-wishers it implementing inpatient therapeutic care (ITC) by formulating Fresh cow’s milk since there no readily packed F75 and F100,  Outpatient Therapeutic Care (OTC), supplementary feeding through the use of Mukene fortified maize flour and has 15 community volunteers to provide linkage between the community and facility. A number of facility staff have being trained on skills and knowledge necessary to implement nutrition programs

Jinja RRH is one of the two sites selected to implement the Baby Friendly Health facility initiative. NuLife is supporting the hospital to transform itself to become Baby Friendly as per the Baby Friendly Health facility Initiative (BFHI) guidance in the Infant and Young Child Feeding policy document. Jinja RRH will  implements the Sixteen Steps to Successful Breastfeeding, accept no free supplies or samples and no promotional material from companies that manufacture or distribute breast-milk substitutes, and foster optimal feeding and care for those infants that are not breastfed.

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2.0 Utilization of Mukene fortified maize as a supplementary food

2.1 Introduction

Jinja regional referral hospital in September 2010 received food support (fortified Mukene maize flour) from Nulife to support the hospital in implement one of the four components of IMAM. The hospital received 5 metric tones (200 bags of 25 Kg each). Before the implementation the nutrition team held a meeting to discuss issues concerning the target groups, how much of the ration to give, follow up arrangement, packaging to the clients and reporting.

2.2 Objectives of the supplementary food support to clients

1.      To treat moderately malnourished clients and prevent deterioration to severe acute malnutrition

2.      To have an opportunity for health and nutrition education/counseling to the caretakers or the clients themselves

3.      To promote breast feeding in lactating mothers

4.      To promote maternal nutrition during pregnancy and have a better pregnancy outcome

2.3 Target groups identified

1.      moderate acute malnourished HIV negative children since they do not qualify RUTF

2.      moderately acute malnourished HIV negative pregnant and lactating mothers

3.      discharges from ITC who have recovered from the ward and do not qualify for OTC

4.      Incase of RUTF stock the flour to given to client clients who turn up for follow up (OTC) to cover up.

5.       Clients discharge cured from OTC when there are inadequate amounts of RUTF.

2.4 Amount of Ration given to Clients

The objective was to give a daily amount of the ration that can meet at least 50% of the minimum energy requirement of the clients

From the nutritional information on the labels

v  100 g of the mix provides 344.1 Kcal of energy

» 300 g of the mix provides 1023 Kcal of energy

v  The clients were there given 9 Kg to last for a month and counseled to use 300g of the flour on daily basis.

2.5 Follow up arrangements.

v  Clients to come to the facility for follow up on monthly basis

v  Clients were followed for at least three months before discharge from the program.

3.0 Program implementation outcomes

3.1 Acceptability of the product-Mukene Fortified maize flour

 The premix is universal accepted both by children and adults with few cases of adults who do not like the fishy smell from the mix. The mixture is easy to prepare and easily accept it as the mix is from foods locally available hence known to them. It is easy to handle by mothers as they are already to the handling measure.

3.2. Weight Gain

About 85% of the clients who tuned up for follow up gained weight with an average weight gain of 1.24 Kg in children and 2.3 Kg in adults. 

3.3 Number of Beneficiaries

Within the period from October 2010 to February 2011 469 malnourished clients benefited from the Mukene fortified maize flour to supplement their family diets.

4.0 lessons learnt.

4.1 What worked.

v  Acceptability of the premix was high

v  9 Kg ration was sufficient to facilitate weight gain.

v  Moderately malnourish HIV positive clients can still gain weight on Mukene fortified maize flour

v  The supplementation helped to reduce the cases of severe acute malnutrition

v  Team work helped the implementation of the program easy as it involves many steps.

4.2 Areas for Improvement

v  Supply quantity to be reduced for easy handling (storage space) and prevent damages as premix has a shorter self life

v  Packing sizes to reduce to 10 Kg which can be given to clients without opening as the premix from opened bags can easily spoiled or infested.

v  Polythen bags can be added inside the packaging sacks to prevent oxidation

v  Hospital to provide a better Storage space that is spacious with good ventilation and clean environment  for the safety of the food

v  Reporting has been affected as the data collection tools have been improvised and therefore the need to have client ration cards and SFP register foe easy data management.

Ministry of Health

Iganga General Hospital

Report on the use of Mukene fortified maize flour as a supplementary food in the management of moderate acute malnutrition (MAM)

Compiled by;

Monic Bazibu

Public Health Nurse/Breast feeding Counsellor

Date  March  2011

Introduction

Iganga General Hospital is Government owned hospital serving the immediate as well extended catchment area. A nutrition unit has been in existence for a while, where only severely malnourished children are admitted and kept in the hospital until recovery. With time, therapeutic feds became unavailable and cost of inpatient feeding went high with unsatisfactory outcome. In April 2008, NuLife program introduced and supported outpatient therapeutic care for all acutely malnourished children and HIV positive acutely malnourished adults, pregnant and lactating women. The clients were treated with a ready to Use therapeutic food (RUTF) commonly known as plumpyNut (Imported) and later RUTAFA (locally manufactured). However, on discharge, they clients needed some follow-on food for food supplementation for reasons of food inadequacy in their homes.

Majority of clients who access health services in Iganga Hospital are low income earners residing in the peri-urban areas of Iganga Municipal council. Between October, 2010 to February, 2011. In October 2010,  a total of ---MT of a supplementary blended flour from Silver fish (Mukene) and maize flour donated by a private partner to NuLife was placed in the hospital to cater for moderately malnourished individuals. Moderately malnourished children referred from the Iganga-Mayuge T.B study under the district surveillance site program of makerere University Public health college also benefitted from this donation.

Eligibility criteria:

• Moderately malnourished Children 6 months and above
• Moderately malnourished HIV negative adults, pregnant and lactating women,

Distribution and Storage

Initially each adult client received 12.5 kg and children 14 kg 2 weeks twice a month, thereafter, double the amount once a month.

Follow-up

Weight and MUAC of the client were measured and recorded at every visit.  Clients received continued counseling and nutrition education. 

Lesson learned

1. The clients who returned for follow-up more regularly gained better weight.
2. Infants eat the supplementary food more than adults
3. Sick adults needed more encouragement and counseling because of the smell of the fishy smell.
4. The supplementary food is stored well, does not spoil for 6 months. This implies that if the bags had inner polythene lining, the product could remain intact for a longer period