Helene B. Roberson Professor of Pediatrics, School of Medicine, Washington University in St. Louis.
Category of Humanitarian Benefit: Health and Medical
Dr. Mark J. Manary is a pediatrician currently appointed as the Helen B. Roberson Professor of Pediatrics at Washington University School of Medicine in St. Louis. Since 1994, Dr. Manary has made it his life’s work to eradicate childhood malnutrition in Africa and has since become known as one of the world’s foremost experts in childhood malnutrition. Dr. Manary was at the forefront of the advent of ready-to-use-therapeutic food (RUTF), an energy-dense, peanut butter paste with proven efficacy treating children with severe acute malnutrition (SAM). Prior to the United Nations adopting RUTF as the standard of care, Dr. Manary conducted 10 large clinical trials with various formulations of RUTF to find the most efficient way to treat the children.
However, in true Manary fashion, Dr. Manary’s work did not end with the success of this revolutionized treatment. He also wanted to make certain that this lifesaving treatment was available, feasible and continuously advancing. He saw an opportunity to make RUTF a more sustainable solution, founding a nonprofit organization, Project Peanut Butter, which makes treating children with malnutrition a local endeavor. As CEO and founder of Project Peanut Butter, Dr. Manary currently overseas local production of RUTF in Malawi, Sierra Leone, Ghana and Cote D’Ivoire and operates 145 mobile clinics. PPB also supports small-scale production efforts in partnership with other nonprofits in Somalia, Kenya, Ethiopia, Pakistan, India and the Philippines.
These local production facilities employ all local staff and procure all ingredients locally available from local suppliers. He has established feeding clinics in these countries spearheaded by local nurses and drivers. He recognized that these countries not only needed an alternative treatment to improve the suboptimal SAM recovery rates of inpatient treatment in settings of chronic poverty, but they needed a shift in the treatment paradigm and a solution that would empower. As Dr. Manary has successfully shown with Project Peanut Butter, it does more than increase capacity for local production of these lifesaving RUTFs, but it also empowers local scientists, engineers, and staff to join the team to produce the treatment with the assurance that the production equipment and food is made with the highest standards and quality. It also allows local nurses not to just simply save lives, but to empower mothers and caregivers to treat and prevent malnutrition. Finally, it shows communities that sustainable solutions can come from local resources within their country which inspires and empowers them to continue to take collective action and generate solutions to other problems in their communities.
On the flip side of the coin, Dr. Manary is housed at Washington University in St. Louis, a world leader in academic research. He is able to combine these two worlds to conduct extensive research through field work in Malawi, Ghana, Sierra Leone and Ethiopia. Also understanding that the eradication of malnutrition needs multifaceted approaches, he utilizes his position within the University to study the pathophysiology and metabolic disturbances that underlie malnutrition. Additionally, his lab uses state of the art biomedical techniques and runs carefully designed clinical trials. This work grounds his efforts in science and informs other ventures such as the design of new food formulations that could supplement therapy, promote optimal health and prevent children from becoming malnourished.
The development and trialing of the first RUTF and Project Peanut Butter are only glimpses of a 24-year career of significant achievements in the health and nutrition field. Other notable achievements include providing robust evidence that the inclusion of antibiotics in the treatment of uncomplicated SAM is effective for improving recovery and mortality rates. The World Health Organization quickly integrated these finding into their guidelines for treatment of severe malnutrition. His work has also contributed to understanding the relationship between the microbes in the gut and malnutrition. He studied the bowel microbiome of twins with and without kwashiorkor (a form of severe malnutrition characterized by edema and high mortality) and found that a certain composition of the microbiota was an essential element and cause of kwashiorkor.
Dr. Manary has contributed to the nutrition field’s understanding of zinc homeostasis and zinc deficiency, once purported to be the cause of stunting worldwide. In 1998-2008 he used a dual stable isotope technique to characterize how much zinc was absorbed and retained by the human intestine, showing that it was not a reduction in zinc intake, but rather an inability of the gut to conserve zinc in rural African children that compromised their health. This changed the focus of the nutrition community away from zinc supplementation toward efforts to heal the leaky gut.
Most recently, Dr. Manary has led work investigating the potential benefits of common bean and cowpea to the well-being of rural African children. Using what he calls our most powerful tool, the randomized, double-blind controlled clinical trial, the Manary team has shown that cowpea reduces childhood stunting, one of the only plant-based foods known to do so, and that common bean improves gut health in African toddlers. Dr. Manary has recognized the importance and limitations of the microbiome in human health and disease, as many of his investigations have characterized changes in this key modifier of the human gastrointestinal tract. It is likely that the positive effects of these legumes are in part mediated through their effects on microbial populations. These sustainable, indigenous legume crops can be immediately implemented for the benefit of the world’s most vulnerable children.
Dr. Manary’s achievements have extended into the basic biological laboratory, where he led his team to discover a new diagnostic method of assessing gut health by quantitatively measuring human transcripts (mRNA) in stool samples. This involved truly isolating needles in haystacks, as 99% of transcripts in fecal material is of microbial origin.
Dr. Manary has long understood that humans derive their health from agriculture and invested much of his resources to exploit agriculture for the benefit of human health. He worked with a Gates Grand Challenge project improving cassava in sub-Saharan Africa. The improvements included increased nutrient density of cassava and improved resistance to common pests that reduce cassava’s viability. This brought him into a collaborative relationship with the national agricultural research institutes in Uganda, Kenya, Malawi and Nigeria. Dr. Manary was a key investigator in the Feed-the-Future Innovation Labs focused on peanuts and legumes in the last decade. He held an appointment at the Danforth Plant Science Center for 5 years as a research scientist from 2009-2014.
Currently, Dr. Manary’s research includes working on continued improvements in the RUTF formulation, specifically inclusion of Oat for cost savings and reduction in the amount of emulsifier utilized, and optimization of Fatty Acid profiles. Emulsifier has shown to be damaging to gut health of already malnourished, vulnerable children and the correct inclusion of appropriate percentage of fatty acid N6:3 is important for cognition. He is studying maternal and other interventions in an effort to reduce the causes of stunting striving to help all children reach their full potential.
Dr. Manary is a multi-facetted swiss-army knife researcher that will continue to guide the efforts towards healthy children in Africa. His biggest talent is converting research into real-world solutions. He has published over 130 scientific articles about his research. http://www.ncbi.nlm.nih.gov/myncbi/browse/collection/47421067/?sort=date&direction=ascending
Project Name and Description
Advent of Ready-to-Use Therapeutic Food for the Treatment of Severe Acute Malnutrition using Home-Based Therapy
In 1994 Dr. Manary arrived in Malawi on a faculty exchange program at a new medical school. He accepted the charge to improve care for severely malnourished children, who at the time were treated with prolonged hospitalization in filthy, overcrowded rooms and offered frequent feedings with fortified milks. Untreated, half of these children died in 3 months. With treatment, the recovery rates in these facilities were about 25%. Even substantial efforts to improve facilities and foods used to treat severe acute malnutrition could not affect recovery in 50% of such unfortunate children. Dr. Manary worked tirelessly for 5 years implementing interventions for severe acute malnutrition only to understand this limitation.
After an extended time living in a rural Malawian village, Dr. Manary concluded that if therapy for severe acute malnutrition was to succeed outside of the hospital, it would require a food that was full of fat and protein, one that bacteria could not grow in it, one that required no cooking and that did not spoil when at ambient temperature for an extended period of time. The experience of living in the village was essential because it provided a true understanding of village life in Malawi and became the key to developing a workable solution. Just after that time, Andre Briend sent a cold call e-mail to Dr. Manary to ask if he had any interest in a ready-to-use food. A range of potential products was discussed, and a peanut paste-based food was deemed most promising.
Dr. Manary initiated a clinical trial in 2001 without the financial support of any major organization, and the first 450 children were treated with ready-to-use therapeutic food strictly in home (no hospitalization) for severe malnutrition. The results were incredible, 95% of children recovered! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1719944/ At the conclusion of this one-year trial, Dr. Manary met Andre Briend and they planned how a ready-to-use food could be made locally. Dr. Manary took these discussions and started local production of RUTF in Malawi. He compared outcomes of home-based therapy between local and imported RUTF in 2002, and they were equivalent. Given that 2003 was a famine year in Malawi, Dr. Manary’s research team took this opportunity to directly compare standard in-patient therapy for severe malnutrition with home-based therapy with locally produced RUTF. The famine year designation meant that many of the simple, under-resourced nutritional rehabilitation units were upgraded by international NGOs. Still mothers feeding their own children peanut butter food achieved twice the recovery rate of upgraded standard care. https://academic.oup.com/ajcn/article/81/4/864/4649071
This was enough evidence to convince Dr. Manary that RUTF was a superior food for treating severe acute malnutrition and that home-based therapy should become the standard worldwide. He unwaveringly committed himself to this end, and intensely worked to make this therapy available throughout Malawi and other countries world-wide. https://www.who.int/nutrition/publications/severemalnutrition/978-92-806-4147-9/en/ ; https://www.unicef.org/media/files/Position_Paper_Ready-to-use_therapeutic_food_for_children_with_severe_acute_malnutrition__June_2013.pdf ; https://www.who.int/maternal_child_adolescent/topics/child/malnutrition/en/
Dr. Manary worked relentlessly advocating for RUTF and community-based management of uncomplicated SAM which was officially endorsed by the World Health Organization and other international agencies in 2007.
Across the world, severe acute malnutrition (SAM) is the largest killer of children under five years of age, associated with nearly half of all childhood deaths. Globally, about 50.5 million children less than 5 years are wasted (too thin) at any one time; of these, over 17 million are severely wasted. 150.8 million Children (22.2%) under five years of age are stunted (too short for their age). https://globalnutritionreport.org/reports/global-nutrition-report-2018/burden-malnutrition/ These children are at high risk of death or may suffer from diseases and complications that will greatly affect their future life. Severe Acute Malnutrition is estimated to account for approximately 400,000 child deaths each year. The current standard of care for SAM is ready-to-use therapeutic food (RUTF) used to treat children in the community. Prior to the advent of RUTF the management of acute malnutrition was limited to hospitals, resulting in low coverage rates with high mortality; as cases were identified at later stages often plagued with complications, mothers would also have to withdraw their children before they received full treatment so they could return home to work, and infection risk was increased in the crowded patient wards. RUTF is a novel lipid-based food which has been accepted as the standard of care for uncomplicated severe acute malnutrition (SAM) by the UN agencies. The advent of RUTF and scientific grounded evidence to support home-based care of uncomplicated SAM at the community level, millions more children are receiving this life-saving treatment. This powerful duo is saving lives and has been called a humanitarian revolution.
. Community-based management of acute malnutrition (CMAM) over the past two decades has been adopted by an increasing number of countries and relief agencies with remarkable success leading to widespread acceptance and dissemination of this approach worldwide. https://www.uptodate.com/contents/management-of-uncomplicated-severe-acute-malnutrition-in-children-in-resource-limited-countries/print Where CMAM is available, recovery rates can be expected to exceed 80% and case fatality rates can be expected in the 5 – 10 percent range.
Dr. Manary’s actions have helped to develop ready-to-use therapeutic food (RUTF) and the use of this life saving food in home-based therapy. The development of RUTF for the treatment of uncomplicated cases of SAM has greatly improved survival through the ability to treat large number of malnourished children in the community setting rather than at health facilities during emergencies. This approach has allowed for greater numbers of affected children to receive treatment and reach full recovery. https://www.actionagainsthunger.org/sites/default/files/publications/The_State_of_SAM_Management_Coverage_2012_0.pdf