Web Exclusive

Solving Global Hunger With an American Staple
By Amelia R. Sherry

One pediatrician’s quest to eradicate severe acute malnutrition in children turns a ready-to-use therapeutic food into an effective medical nutrition therapy.

In 2005, children living in Malawi, Africa, who were fortunate to receive treatment for severe acute malnutrition faced a two-month stay in a medical clinic and a 25% chance of recovery.1

Today, the mothers of these malnourished children can treat them at home, giving them up to a 95% chance of recovery.2 What accounts for this extraordinary turnaround is the persistence of Mark Manary, MD, and the St Louis–based organization he founded called Project Peanut Butter, which provides a high-calorie, fortified peanut butter–based spread as a ready-to-use therapeutic food (RUTF) to help eradicate the scourge of severe malnutrition.2

Searching for a Better Solution
When Manary took his first trip to Africa in 1985, he was shocked by to the number of children he saw dying “simply because they didn’t have enough to eat.” In his eyes, severe acute malnutrition was preventable, but it was killing twice the number of children as HIV/AIDS and malaria.3

While the milk-based powder F-100 was available and used as the standard of care for severe acute malnutrition, Manary refused to believe that, with a 25% cure rate, it was as effective as could be expected. According to Margo Stoner, a nutritionist and quality control specialist with Project Peanut Butter, the root of the problem was the fact that F-100 had to be administered in an inpatient setting. “F-100 formula needs clean water and heat to be prepared safely,” she says.

Since few mothers have access to these resources, children must be brought to health care centers to receive treatment with F-100, which can last up to two months.2 “Most mothers have to travel tens of miles to get to an inpatient setting. Being that far away from their homes and separated from their other children for that length of time isn’t feasible for most,” Stoner explains. What’s more, “as inpatients, children are often passing infections to one another. So they might be cured of severe acute malnutrition, but they leave the clinic with tuberculosis, diarrhea, or worse.”

In 1999, Manary spent 10 weeks in Malawi and had a chance “to think about what a home-based treatment for severe acute malnutrition might look like.” During that time, “I knew we needed a product that required no cooking or refrigeration, had full fat, and contained protein. As an American, to me that was peanut butter.”

Putting Peanut Butter to the Test
By 2001, Manary had teamed up with French pediatrician Andre Briend, MD, PhD, who also was working on RUTF as a treatment for severe acute malnutrition. Together, they conducted a series of clinical trials testing different versions of home-based therapies, including a corn/soy flour, a multivitamin mineral supplement, and a paste containing a blend of ground and roasted peanuts, milk powder, vegetable oil, sugar, vitamins, and minerals. Ultimately, the clinical trials found that the peanut butter–like paste resulted in a 95% recovery rate.

Initially, the research team approached the medical community with its home-based treatment, but “they thought the idea was reckless and careless,” Manary says, adding that food manufacturers also dismissed their idea. Undeterred, the team decided that if they wanted their RUTF to reach the Malawi children, they’d have to make it themselves. So in 2004, Project Peanut Butter was born.2

Setting a New Standard
Since the peanut-based paste produced such a high recovery rate in severely malnourished children in Manary’s clinical studies, in 2007 the World Health Organization (WHO) recognized RUTF as the standard of care for the treatment of severe acute malnutrition. Subsequently, organizations such as UNICEF, Doctors Without Borders, and the World Food Programme have become the largest purchasers of RUTF.

Since it was designated the standard of care, more than one dozen food manufacturers have begun producing such items. In addition, some manufacturers offer different versions, such as an energy-dense, vitamin-fortified bar. However, peanut-based pastes remain the most widely used RUTF.

To meet international demand for RUTF, a team at Project Peanut Butter’s St Louis headquarters worked closely with staff members at production factories in Malawi, Sierra Leone, and Ghana. Together they ensure factories comply with international food safety standards set by ISO, Codex, and Hazard Analysis and Critical Control Points guidelines.

“Codex requires RUTF to follow the same standards as infant formula, which means they can be especially cumbersome and strict,” Stoner says. Given that there are major food safety issues with peanuts (such as the risk of contamination with aflatoxin, Salmonella, and Listeria) plus the fact that all of Project Peanut Butter’s factories are operating in the developing world, adhering to the specifications is challenging. Still, Project Peanut Butter works hard to ensure that RUTF ingredients come from local farmers in Malawi, Sierra Leone, and Ghana whenever possible.

Targeting the Tiniest for Maximum Impact
A day in the life of Project Peanut Butter clinical staff members involves identifying children between the ages of 6 months and 5 years who may have severe acute malnutrition, characterized by being at least three standard deviations below the WHO weight-for-height standard, having a mid–upper arm circumference less than 115 mm (about 4 1/2 inches), and/or suffering from edema.4

“After six months, breast milk no longer provides all the nutrients needed for healthy development. From this point until about 5 years is when children’s cognitive and physical development are the most vulnerable to the effects of severe malnutrition. If we can safely get them to age five, they’ll have a good chance of surviving as productive members of society,” Stoner says.

Once a child is considered eligible for treatment, mothers are given a two-week supply of RUTF.2 After starting their children on the RUTF, they return to the local malnutrition clinic every two weeks so their children can be reassessed. “On average, it takes two to three visits for full recovery,” Stoner says.

A Prevention-Focused Future
Currently, Project Peanut Butter successfully has treated more than 100,000 children and is on its way to reaching its 2015 goal of treating 2 million children. “Since we started Project Peanut Butter in Malawi, we’ve reduced the number of children who will die of severe acute malnutrition by the time they’re five to 7%, which we are very, very proud of,” Manary says.

Manary’s success has inspired at least one member of his staff to set even higher goals: “Malnutrition is a complex problem that burdens a large portion of the world,” Stoner says. “Yes, we’ve learned to treat it effectively. Now, the important question is, how can we come together as a community of nutrition experts to improve prevention?”

* Project Peanut Butter operates on a cost-recovery basis and primarily is funded by donations. To find out how to help support or publicize the organization’s efforts, visit its Facebook page or website at www.projectpeanutbutter.org.

— Amelia R. Sherry is a graduate student of nutrition and a freelance writer in New York City. She blogs about pediatric nutrition at www.feedingisla.com.


1. Ciliberto MA, Sandige H, Ndekha MJ, et al. Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr. 2005;81(4):864-870.

2. Solutions. Project Peanut Butter website. http://www.projectpeanutbutter.org/solution.html. Accessed March 12, 2014.

3. Obbagy JE, Blum-Kemelor DM, Essery EV, Lyon JM, Spahn JM. USDA Nutrition Evidence Library: methodology used to identify topics and develop systematic review questions for the birth-to-24-mo population. Am J Clin Nutr. 2014;99(3):692S-696S.

4. World Health Organization, United Nations Children’s Fund. WHO child growth standards and the identification of severe acute malnutrition in infants and children: a joint statement by the World Health Organization and the United Nations Children's Fund. http://whqlibdoc.who.int/publications/2009/9789241598163_eng.pdf?ua=1. Published 2009.