Our projects in Burundi

Van Norman Clinic

Bujumbura, 18 december 2014

A pilot for the Tenfold project was started in the Van Norman Clinic in Bujumbura on 17 November 2014. This clinic can accommodate 60 patients. At the point you are reading this, we will have provided more than 3000 people with a daily nourishing meal.

With your money, we want to continue providing nutrition in the Van Norman Clinic, but also expand the range of our project. The situation of the patients in the clinics Prince Louis Rwagasore (130 beds) and the Regent Charles (600 beds) is possibly even more harrowing. We would like to start there too and begin with helping the hospitalised children and their ‘garde de malade’ (often the mother).



Dr. Noel Niyondiko  

Medical Director of the Van Norman Clinic, Bujumbura.


1) What can you tell about the eating pattern of patients in hospitals in Bujumbura?  

Many families do not have enough incomes to cover all their needs, this is particularly due to the tragic periods of war. Therefore in many Burundian hospitals patients do not get adequate and enough food for a good recovery.  


2) What do you think of the Tenfold project in the Van Norman clinic?  

I think the project is and will remain helpful for our patients in general, and for those who come from impoverished families in particular; these patients sometimes do not have caretakers.  


3) Did you receive any feedback from patients?  

The feedback I received from patients is that the provided meal has been a blessing for them.  


4) Would you recommend the Tenfold project to other hospitals in Bujumbura?  

I really recommend the project to other hospitals because their patients are in the same conditions as ours.

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Tenfold’s hospital feeding programme

25 december 2014

Have you ever complained about hospital food? Maybe it was flavourless or overcooked, or lacking variety? Now imagine if hospitals would not provide any meals at all. Could you count on the culinary skills and readiness of family and friends to help out? This is the only opportunity for patients in Burundian hospitals to eat, as there is no hospital catering service available. Tenfold is bringing change.

Nutrition in Burundi 
Burundi is a small, very poor country in East Africa. Over 80% of the population has less than US$ 1.25 a day to spend (1). The health situation in Burundi is fragile, caused by the weakness of the healthcare system, vulnerability of mothers and children, a heavy burden of diseases, and high levels of malnutrition (2).

The level of malnutrition in Burundi is ranked as ‘extremely alarming’ (3). The proportion of undernourished people has been rising steadily over the past two decades. More then half of all children under five years old are chronically malnourished (4).


What is malnutrition? 
The term malnutrition describes an imbalance in a person’s nutrition, which can manifest as either over-­nutrition or under-nutrition.

Over-­nutrition occurs when we eat more then our body requires and is most frequently seen in the developed world. It can result in overweight and obesity.

Under-­nutrition is generally caused by deficiencies in dietary intake and is most often found in developing countries. However, under-­nutrition may also be present in hospitals in developed countries, where it is referred to as disease-­related under-­nutrition. Under-­nutrition has a negative effect on our immune system. Underweight children have a higher risk of contracting infectious diseases, and they have higher risk of dying from illnesses such as diarrhoea and pneumonia. Under-­nutrition of a pregnant woman frequently leads to low birth weight and irreparable mental and physical damage of the baby (5).


Under-­nutrition caused by deficiencies in dietary intake

Acute malnutrition Protein-­energy deficiency, also called acute malnutrition, results from a deficit in all major macronutrients (carbohydrates, fats and proteins). This type of malnutrition is common during famine, and is relatively easy to observe. Acutely malnourished children and adults are very thin and have little body fat and muscle mass, whilst others have oedema (swollen arms, legs or belly). In Burundi, the prevalence of acute malnutrition in children under five years of age has decreased significantly over the last decade, to 6% (4).


Chronic malnutrition

Malnutrition is not only related to the quantity of food consumed, also to its quality. Many populations in rural Africa subsist on monotonous diets based on grains, starchy roots and tubers. These diets provide energy, but lack important micronutrients. Consumption of these undiversified diets over an extended period of time results in micronutrient deficiencies. Chronic malnutrition is more difficult to observe, but has a very high prevalence. In Burundi, 58% of all children under five years of age are chronically malnourished (4).


In both adults and children, micronutrient deficiencies can cause various diseases and problems. Children are still growing and developing, making the effects of chronic malnutrition worse. Children that are deficient in one or more nutrients are often smaller and shorter for their age, but otherwise appear normal. This is called stunting. Stunting can result in more frequent illness, increased risk of death before five years of age, poor physical capability, and lower school grades (5).


Disease related under-­nutrition

Disease-­related under-nutrition develops as a consequence of illness. It can be caused by reduced dietary intake, higher nutritional requirements, impaired absorption of nutrients and/or increased losses due to sickness, or a combination of these factors (6, 7). Even in developed countries, as many as 40% of patients are under-­‐nourished when they enter hospital (8, 9).

The consequences of under-­nutrition in hospitalized patients can be severe. It is associated with negative patient outcomes, including slower recovery (10), higher risk of infections and complications (6, 11-­14), increased muscle loss (8, 10, 15), impaired wound healing (7, 10), increased length of hospital stay (16-­19), higher risk of hospital readmission (20), and increased morbidity and mortality (8, 10, 19, 21).

Feeding hospitalized patients in Burundi

The information above illustrates why is it extremely important to pay additional attention to the nutrition of those who are hospitalized. Patients in hospitals in Burundi, and other developing countries, are often double burdened. Many are suffering from under-­nutrition before becoming ill, and additionally there is a considerable risk of disease-­‐related under-­‐nutrition as a result of illness and hospitalization. However, facilities in Burundian hospitals are very limited. Hospital catering does not exist and patients are dependent on family and friends for their daily meals. Providing a hospitalized friend or family member with three meals a day is a heavy burden for caregivers, both practically and financially, and therefore not always feasible. Family and friends often live far away from the hospital, and transportation is expensive and time-consuming. Moreover, caregivers may have their own families to take care of. Those with a limited social network are very vulnerable. Consequently, many hospitalized patients do not consume three meals a day.


Tenfold’s hospital feeding programme 
To give hospital patients the best chance of a healthy recovery, Tenfold provides a tasty and nutritious porridge to all patients hospitalized at the Van Norman Clinic in Bujumbura, Burundi. The porridge is served to each patient for breakfast. 

Eating breakfast is important. It activates the digestive system and it provides energy and nutrients for a good start of the day. In the interior of Burundi most people consume a maize-­based porridge in the morning, which provides energy but lacks sufficient vitamins, minerals and protein. Tenfold uses BUSOMA flour to prepare the porridge, which is based on maize, but adds 25% sorghum flour and 25% soybean flour (hence the name BUSOMA -­‐Burundi Sorghum Soybeans Maize). BUSOMA flour contains 6% fat and 13% protein.

  • Sorghum and soybeans are good sources of iron. Iron is vital for the transport oxygen in the circulatory system and supports metabolism (22). Iron deficiency (anaemia) affects half of the African population. Iron deficiency during childhood and adolescence impairs brain development and learning capacity. In adults, it reduces the ability to do physical labour and increases the risk of women dying in childbirth (5, 23).
  • Soybeans are an excellent source of protein. Protein supports the development of muscle mass, which might otherwise be lost due to disease and a lack of physical activity. Proteins consist of amino acids that are essential for building and maintaining our muscles, bones and blood. Soy is the only source of plant-­‐derived protein that is considered nutritionally ‘complete’, because it contains sufficient quantities of all the amino acids required for human nutrition (22).
  • Oil is added to the porridge as a source of fat. Fat is an important provider of energy and it transports vitamins that are only soluble in fat (vitamin A, D and E). The oil also improves the flavour of the porridge.
  • Finally, sugar is added to sweeten the porridge. It is important that patients enjoy their breakfast and consume the entire serving. 

    One serving of Tenfold’s porridge (500 ml) provides approximately 375 kcal. This is 15-­‐ 20% of the daily energy requirements for adults (2000-­2500 kcal/day) and is similar to a healthy Western breakfast based on bread or breakfast cereals, typically 300-­400 kcal (24).


In a nutshell

Unfortunately many patients in hospitals in Burundi do not consume breakfast at all due to practical and financial reasons. This can negatively influence their nutritional status. The consequences of malnutrition in hospitalized patients can be severe. It is associated with negative outcomes for patients like slower recovery and higher risk of infections and complications (6, 10-­‐14). Tenfold’s hospital feeding programme contributes to improved nutritional status and patient outcomes. Breakfast is a meal worth looking forward to at the Van Norman Clinic. 
Bon appétit!

Biography Marieke de Lange
Marieke is a nutritionist and provides technical nutrition advice to Tenfold. She holds an MSc in Health and Nutrition from Wageningen University, the Netherlands, specialising in both Human Nutrition and Communication in Public Health. After working many years for a large international medical food company as a researcher and clinical trial manager, in 2007 she and her husband decided to decamp to Africa.


Starting their adventure in Kenya, Marieke worked for the Netherlands Embassy where she contributed to the sound financial management of Dutch‐funded development cooperation projects, and later for an international market research company. In their spare time they explored Africa by car and tent. Marieke presently lives with her husband and their two children in Bujumbura, Burundi. She consults in the field of nutrition for several non-governmental organisations, hoping to better the nutritional status of all Burundians.



1. Global Health Observatory; WHO, 2014 (online source: apps.who.int/gho/data/node.cco)

2. Country Cooperation Strategy; WHO, 2014 (online source: www.who.int/countryfocus/cooperation_strategy/ccsbrief_bdi_en.pdf)

3. Global Hunger Index – The challenge of hunger: Building resilience to achieve food and nutrition security. International Food Policy Research Institute, Concern Worldwide, Welthungerhilfe, Institute of Development Studies. Bonn / Washington, DC / Dublin October 2013.

4. Government and its partners mobilize for food security and nutrition to ensure child survival and development Burundi; UNICEF, 2011 (online source: www.unicef.org/esaro/5440_Burundi_1st_food_nutrition_forum.html)

5. Scrimshaw NS. The lasting damage of early malnutrition. WFP (online source: one.wfp.org/policies/introduction/background/ending/s1.html)

6. Naber TH, Schermer T, deBree A, Nusteling K, Eggink L, Kruimel JW, Bakkeren J, van Heereveld H, Katan MB. Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am. J. Clin. Nutr. 1997;66:1232–1239.

7. Soeters PB, Reijven PLM, van Bokhorst-­‐de van der Schueren MAE, Schols JMGA, Halfens RJG, Meijers JMM, van Gemert WG. A rational approach to nutritional assessment. Clin. Nutr. 2008;27:706–716.

8. Barker LA, Gout BS, Crowe TC. Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. Int. J. Environ. Res. Public Health. Feb 2011; 8(2): 514–527.

9. Holmes S. The effects of undernutrition in hospitalised patients. Nurs. Stand. 2007;22:35–38.

10. Stuurgroep ondervoeding (online source: www.stuurgroepondervoeding.nl/fileadmin/inhoud/ziekenhuis/congres_9_juni_2009/z akboekje_ondervoeding_ziekenhuizen.pdf)

11. DiMaria-­‐Ghalili RA. Changes in nutritional status and postoperative outcomes in elderly CABG patients. Biol. Res. Nurs. 2002;4:73–84.

12. Baldwin C, Parson TJ. Dietary advice and nutrition supplements in the management of illness-­‐related malnutrition: a systematic review. Clin. Nutr. 2004;23:1267–1279.

13. Hoffer LJ. Clinical Nutrition: 1. Protein-­‐energy malnutrition in the inpatient. Can. Med. Assoc. J. 2001;165:1345–1349.

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