The Peanut Butter Project

It’s ooey, gooey, good:
Most American kids grow up enjoying tasty,
nutritious peanut butter. A malnutrition
research initiative uses this inexpensive food
to get Malawian children to their next birthday.

BY DIANE DUKE WILLIAMS

Ninety-three percent of children who received the peanut butter mixture recovered fully, reaching 100 percent of weight for height.

“In addition to surviving, they were thriving.”

MARK J. MANARY, MD

THE OUTCOME FOR STARVING CHILDREN WAS DISMAL when Mark J. Manary, MD, began studying malnutrition in Malawi, Africa. The most severely malnourished were treated with milk diets at inpatient feeding centers. Back at home, they resumed eating the traditional diet—corn dough boiled over an open fire and mixed with beans or green vegetables. Only a fourth of these children recovered fully.

“This is happening all over sub-Saharan Africa and other poor places in the world, and no one really follows up with these kids,” says Manary, an associate professor of pediatrics in the division of emergency medicine.
Manary and his fellow health care workers in Malawi agreed: Simply reviving children at the feeding centers and then sending them home wasn’t enough. They determined that a more nutritious food should be sent home with these young patients to improve their chances of survival.

Manary consulted a French nutritionist working with the international group, Doctors Without Borders, who was developing recipes involving peanut butter. In January 2001, Manary started the yearlong Peanut Butter Project at Queen Elizabeth Central Hospital, Malawi’s largest health care facility.

Children treated for malnutrition in the Peanut Butter Project were discharged with packets of a peanut butter mixture to eat three times a day for the following five weeks. The conveniently packaged mixture included peanut butter, vitamins, minerals, sugar and vegetable oil.
Milika, a child who weighed only 11 pounds at 18 months of age, was one of the children who motivated Manary to try this different approach. After six weeks of eating the peanut butter mixture, she had made tremendous health progress, doubling her weight.

An inexpensive food could prove to be a lifeline for treating the effects of malnutrition.

“When children like Milika start the program, they look like very small, ill babies that you have a hard time being hopeful about,” says Manary. After treatment, Milika began to walk and play like other healthy children.
Ninety-three percent of the Malawian children who received the peanut butter mixture recovered fully, reaching 100 percent of their weight for height.

Manary was pleasantly surprised with the study’s results. “I thought the recovery rate would definitely be better than 25 percent,” he says, “but when it was 93 percent, I thought, ‘This is really quite impressive.’”

Six months later, children who were fed the peanut butter mixture continued to develop normally, indicating the special food is only necessary when children are critically ill.

Alan L. Schwartz, PhD, MD, the Harriet B. Spoehrer Professor and head of the Department of Pediatrics, says Manary’s studies are changing the way people think about childhood nutrition.

“Mark’s work has the potential to better the lives of thousands of children in the developing world,” says Schwartz.

Working together as doctor and nurse at a rural hospital in Tanzania, Manary and his wife, Mardi, first visited Africa in 1985. Additional short work stints in Africa followed over the next few years. In 1994, Manary spent a year in a faculty exchange program at the University of Malawi’s College of Medicine. It was then that he became interested in the problem of severe malnutrition.

Using dietary therapies such as adding large amounts of potassium to children’s diets, Manary and his staff decreased the case fatality rate from 40 to 10 percent in local children.

When he returned to the School of Medicine—having developed significant research interests and ties to colleagues in Malawi—Manary knew he wanted to return to the country for a part of each year. He now travels to Malawi several times a year, staying for a few weeks. Mardi and the couple’s two children, Megan, 14, and Micah, 12, often accompany him.

The majority of Malawians make their livings by farming, usually on a couple of acres. Extended families live together in homemade mud and thatch buildings, grow their own food, and spend time each day searching for firewood and collecting water. Electricity and modern transportation are not a part of their lives; most people have never ventured more than 30 miles from home.

Most children in Malawi don’t become malnourished until they are between 18 and 30 months old—the time frame in which breastfeeding stops, says Manary. Because food is scarce, most families eat just once or twice a day, gathering around a pot and grabbing pieces of a corn dough mixture. “So a two-year-old who just stopped breastfeeding a month ago may be right next to his
26-year-old uncle and his eight-year-old brother,” says Manary. “Physically, the child can’t compete.”

Ill children are taken to one of the country’s 100 inpatient feeding centers, established solely for the treatment of starving children. Those designated as severely malnourished are referred to Queen Elizabeth Central Hospital, home of Manary’s Peanut Butter Project.
Operating in a sparsely furnished clinic room in the hospital’s outpatient section, Manary and his family, two nurses and a faculty member from the hospital enrolled about 500 children in the project.

The mothers of the children who received the peanut butter mixture were surprised at the results. After the standard treatment for malnutrition, children typically survive and return home but show no growth. Those who received the peanut butter mixture did much better.
“In addition to surviving, they were thriving,” says Manary. “We got some big smiles out of moms.”

Once they determined the treatment was working, Manary and his staff began to produce the peanut butter mixture themselves (peanuts are grown locally) using a large mixer in a corner of the clinic room.

Manary now plans to conduct studies similar to the Peanut Butter Project in district, rural and mission hospitals throughout Africa. He has the backing of two international groups — the World Health Organization and the U.S. Agency for International Development — both of which have contacted him about continuing and expanding the Peanut Butter Project.

Manary believes his studies may change the way children in the developing world are fed, possibly in as little as five years.

“Our goal is to make this type of treatment available to everyone who’s interested,” he says. “If we can do that, it will mean that I’ve done my job successfully.”