Possible use of spreads as a FOODlet for improving the diets of infants and young children

Effect of a newly developed ready-to-use supplementary food on growth indicators in children with mild to moderate malnutrition

OBJECTIVES

Malnutrition is one of the leading causes of death among children younger than five years. In this study, we aimed to formulate a ready-to-use supplementary food (RUSF), based on local food products, and investigate its efficacy on growth indicators in children with mild to moderate malnutrition.

STUDY DESIGN

This is a randomized controlled clinical trial.

METHODS

This study was performed in six health centers in Shahr-e-Rey, Tehran, Iran, between April and October 2017. One hundred children, aged 24-59 months, with mild to moderate malnutrition (weight-for-height Z-score [WHZ] between -3 and -1) were randomly assigned to two groups to receive either 1-3 sachets of RUSF or normal diet for 8 weeks. All mothers and caregivers received nutrition education. Growth indicators including weight and height, WHZ, and body mass index (BMI), along with clinical outcomes, were assessed.

RESULTS

Children who received RUSF had a significant increase in weight (1.44 ± 0.38 vs 0.7 ± 0.32 kg, respectively, P < 0.001), and BMI (1.2 ± 0.47 vs 0.35 ± 0.33 kg/m², respectively, P < 0.001) compared with the control group. There was a greater daily weight gain during the first 4 weeks (P < 0.001) and throughout the study (P = 0.013) in the RUSF group. Daily height gain was considerably higher in the RUSF group during the first 4 weeks (P = 0.027). Children in the RUSF group had more improvement in WHZ (1.18 ± 0.41 vs 0.41 ± 0.31, P < 0.001) after supplementation. Besides, 92% of the RUSF and 12% of the control group reached to WHZ > -1 at the end of the study (P < 0.001). There was lower prevalence of diarrhea (12% vs 28.6%, respectively, P = 0.01) and marginally lower fever (16% vs 36.7%, respectively, P = 0.05) in the intervention than in the control group.

CONCLUSIONS

A newly developed RUSF improved growth indicators and clinical outcomes in children with mild to moderate malnutrition.

CLINICAL TRIAL REGISTRY NUMBER

IRCT2017021315536N6 (registered at www.irct.ir).

Iron Deficiency: Global Prevalence and Consequences

Iron deficiency is considered to be one of most prevalent forms of malnutrition, yet there has been a lack of consensus about the nature and magnitude of the health consequences of iron deficiency in populations. This paper presents new estimates of the public health importance of iron-deficiency anemia (IDA), which were made as part of the Global Burden of Disease (GBD) 2000 project. Iron deficiency is considered to contribute to death and disability as a risk factor for maternal and perinatal mortality, and also through its direct contributions to cognitive impairment, decreased work productivity, and death from severe anemia. Based on meta-analysis of observational studies, mortality risk estimates for maternal and perinatal mortality are calculated as the decreased risk in mortality for each 1 g/dl increase in mean pregnancy hemoglobin concentration. On average, globally, 50% of the anemia is assumed to be attributable to iron deficiency. Globally, iron deficiency ranks number 9 among 26 risk factors included in the GBD 2000, and accounts for 841,000 deaths and 35,057,000 disability-adjusted life years lost. Africa and parts of Asia bear 71% of the global mortality burden and 65% of the disability-adjusted life years lost, whereas North America bears 1.4% of the global burden. There is an urgent need to develop effective and sustainable interventions to control iron-deficiency anemia. This will likely not be achieved without substantial involvement of the private sector.

The Evolving Applications of Spreads as a Foodlet for Improving the Diets of Infants and Young Children

Action is needed to reduce the burden of micronutrient malnutrition in developing countries, and because low-income populations are vulnerable to deficiencies of multiple micronutrients, we need to move beyond approaches that comprise only single nutrients. The normal and evolutionary manner in which to consume nutrients is in the context of foods, both snacks and meals. Spreads are high-viscosity-fat products prepared by mixing dried powdered ingredients with a vegetable fat chosen for its viscosity. Spreads are not traditionally used for feeding infants or young children and were initially proposed as a way to treat children recovering from severe malnutrition. In preparation for the International Research Group on Infant Supplementation (IRIS) III intervention, a sequel to the IRIS I study (which was the focus of a workshop in Lima, Peru, from May 30–June 1, 2001), the feasibility of preparing a FOODlet for feeding infants and young children was explored. Within the spectrum of intervention tools for micronutrient supplementation, tablets are a pharmaceutical form, fortified spreads are a food, and sprinkles are an intermediate approach. The issues still to be discussed and resolved with regard to creating such a spread include its specific micronutrient formulation, the capacity of young children to consume the required amounts (from either the FOODlet alone or the FOODlet mixed with other foods), the iron content and overall antioxidant protection of the spread matrix and its vitamins, potential allergenicity of proteins, and the economic implications of using such a FOODlet in low-income societies.

Local Production and Provision of Ready-To-Use Therapeutic Food (Rutf) Spread for the Treatment of Severe Childhood Malnutrition

Background

Ready-to-use therapeutic food (RUTF) spread has been shown to be very effective in the rehabilitation of severely malnourished children and facilitates home-based therapy of these children.

Objective

To describe how RUTF spread can be manufactured on a variety of production scales.

Principles of production

RUTF spread is an edible lipid-based paste that is energy dense, resists bacterial contamination, and requires no cooking. The primary production principles include grinding all ingredients to a particle size < 200 microns, producing the food without the introduction of water, and embedding the protein and carbohydrate components of the food into the lipid matrix. The most widely used RUTF spread is a mixture of milk powder, sugar, vegetable oil, peanut butter, vitamins, and minerals.

Scale of production

RUTF spread can be produced in quantities sufficient to treat several hundred children using a planetary mixer in a clinic. Production of larger quantities of RUTF spread can be achieved in partnership with local food companies. Production sufficient to meet the needs of several thousand children can be achieved with a dedicated production facility using technology appropriate for use in the developing world. Care must be taken to avoid aflatoxin contamination, and quality control testing of the product is essential.

Conclusions

RUTF spread can be safely and easily produced in small or large quantities in most settings worldwide. The local availability of the necessary ingredients limits its use in some settings, and further investigation of alternative ingredients is needed to overcome this limitation.

The health of HIV-exposed children after early weaning

There are potential health risks associated with the use of early weaning to prevent mother-to-child transmission of human immunodeficiency virus (HIV) in resource-poor settings. Our objective was to examine growth and nutrient inadequacies among a cohort of children weaned early. Children participating in the Breastfeeding Antiretrovirals and Nutrition (BAN) Study in Lilongwe, Malawi, had HIV-infected mothers, were weaned at 6 months and fed LNS until 12 months. 40 HIV-negative, BAN-exited children were compared with 40 HIV-negative, community children matched on age, gender and local health clinic. Nutrient intake was calculated from 24-h dietary recalls collected from BAN-exited children. Anthropometric measurements were collected from BAN-exited and matched community children at 15-16 months, and 2 months later. Longitudinal random effects sex-stratified models were used to evaluate anthropometric differences between the two groups. BAN-exited children consumed adequate energy, protein and carbohydrates but inadequate amounts of fat. The prevalence of inadequate micronutrient intakes were: 46% for vitamin A; 20% for vitamin B6; 69% for folate; 13% for vitamin C; 19% for iron; 23% for zinc. Regarding growth, BAN-exited girls gained weight at a significantly lower rate {0.02 g kg(-1) per day [95% confidence interval (CI): 0.01, 0.03]} than their matched comparison [0.05 g kg(-1) per day (95% CI: 0.03, 0.07)]; BAN girls grew significantly slower [0.73 cm month(-1) (95% CI: 0.40,1.06)] than their matched comparison (1.55 cm month(-1) [95% CI: 0.98, 2.12]). Among this sample of BAN-exited children, early weaning was associated with dietary deficiencies and girls experienced reduced growth velocity. In resource-poor settings, HIV prevention programmes must ensure that breastfeeding stop only once a nutritionally adequate and safe diet without breast milk can be provided.

The acceptance and feasibility of replacement feeding at 6 months as an HIV prevention method in Lilongwe, Malawi: results from the BAN study

International guidelines recommend EBF to age 6 months among HIV-infected mothers choosing to breast-feed and cessation thereafter if replacement feeding is acceptable, feasible, affordable, sustainable, and safe. When mothers wean, they are challenged to provide an adequate replacement diet. This study investigates the use and acceptability of a lipid-based nutrient supplement (LNS) as a breast-milk substitute when provided to infants (6-12 mo) of HIV-positive mothers, as part of the Breast-feeding, Antiretroviral, and Nutrition (BAN) Study. A sub-sample of mothers (n = 45) participated in interviews that explored EBF, weaning, and strategies to feed LNS. Mothers reported several weaning strategies, including gradual reduction of breast-feeding, expressing breast-milk into a cup, and separation of mother and child. LNS, a peanut-based micronutrient fortified paste, was highly accepted and incorporated into the traditional diet. Weaning is a feasible HIV prevention method among this population in Malawi when supported by the provision of LNS as a breast-milk substitute.

Feeding patterns and behaviors during home supplementation of underweight Malawian children with lipid-based nutrient supplements or corn-soy blend

The way caregivers use supplementary food for undernourished children and integrate it into feeding patterns may influence the benefits achieved by supplementation. We studied feeding patterns and behaviors in 170 underweight 6-17-month-olds who received either lipid-based nutrient supplements (LNS) (n=85) or corn-soy blend (CSB) (n=85) during a 12-week intervention trial in southern Malawi. Observational data were collected during one 11h home visit per participant. Differences were assessed by study group and by mode of serving LNS. Associations between selected caregiver behaviors and child growth were also tested. We found no difference between the CSB and LNS groups in mean number of feeding episodes per day or mean daily feeding time. Caregivers fed the child with a spoon, washed their hands before feeding, and there were leftovers significantly more often in the CSB than LNS group and when LNS mixed with porridge and plain LNS were compared. This suggests that differences between the groups were linked to the mode of serving LNS. Presence of leftovers was negatively associated with change in child's WAZ. Programs promoting LNS in Malawi should consider behaviors related to mode of serving and provide advice to caregivers in order to minimize leftovers during supplement use.

Malawian mothers' attitudes towards the use of two supplementary foods for moderately malnourished children

The efficacy of lipid-based nutrient supplements (LNS) versus corn-soy blend (CSB) in promoting the growth of moderately malnourished children is currently being tested, but information about maternal attitudes towards the two supplements is lacking. This research studied 504 Malawian mothers' attitudes about LNS and CSB through exit interviews completed at the end of three 12-week clinical trials and compared differences between the groups. Exploratory analyses of factors associated with withholding of supplements during fever, diarrhea, and cough were performed using logistic regression. Mothers generally had similar, positive attitudes towards LNS and CSB. Both supplements were said to be highly acceptable, children learned to eat them within two weeks, and mothers were willing to use them again. Mothers in the LNS group were reportedly more likely to withhold supplements from their children during cough, due to its sweetness, and were willing to pay more for a one-week supply of supplement than mothers in the CSB group. Maternal literacy was negatively and child's weight-for-height z-score was positively associated with withholding of supplements during illness. Our results indicate that the sweetness in LNS should be reduced, and programs using supplements in Malawi could include advice on appropriate feeding of supplements during illness.

An energy-dense complementary food is associated with a modest increase in weight gain when compared with a fortified porridge in Malawian children aged 6-18 months

Poor complementary feeding practices are associated with stunting and growth faltering throughout the developing world. The objective was to compare the effect of using peanut-/soy-based fortified spread (FS) and corn porridge fortified with fish powder (FP) as complementary foods on growth in rural Malawian children. A total of 240 children were enrolled at the age of 6 mo and randomized to receive FS or FP. Both complementary foods provided 836 kJ/d from 6 to 9 mo of age and 1254 kJ/d from 9 to 18 mo of age. Children were followed monthly for anthropometry and fortnightly for the symptoms of fever, cough, or diarrhea until they were 18 mo old. Zn and Se status were assessed at 6 and 12 mo. The primary outcomes were the rates of weight and length gain from 6-12 mo and from 12-18 mo. Children who received FS gained 110 g more (95% CI 220 to 10) from 6-12 mo of age than children receiving FP. Weight gain did not differ between children receiving FS and FP between 12 and 18 mo of age, nor did statural growth from 6 to 12 mo or 12 to 18 mo. A total of 23% of all children were Zn deficient at 6 mo of age and this increased to 37% at 12 mo of age. Neither FS nor FP was associated with significantly improved Zn status. FS was associated with better weight gain from 6-12 mo of age and may be useful in conjunction with additional interventions to improve infant growth in the developing world.

Iron deficiency: global prevalence and consequences

Iron deficiency is considered to be one of most prevalent forms of malnutrition, yet there has been a lack of consensus about the nature and magnitude of the health consequences of iron deficiency in populations. This paper presents new estimates of the public health importance of iron-deficiency anemia (IDA), which were made as part of the Global Burden of Disease (GBD) 2000 project. Iron deficiency is considered to contribute to death and disability as a risk factor for maternal and perinatal mortality, and also through its direct contributions to cognitive impairment, decreased work productivity, and death from severe anemia. Based on meta-analysis of observational studies, mortality risk estimates for maternal and perinatal mortality are calculated as the decreased risk in mortality for each 1 g/dl increase in mean pregnancy hemoglobin concentration. On average, globally, 50% of the anemia is assumed to be attributable to iron deficiency. Globally, iron deficiency ranks number 9 among 26 risk factors included in the GBD 2000, and accounts for 841,000 deaths and 35,057,000 disability-adjusted life years lost. Africa and parts of Asia bear 71% of the global mortality burden and 65% of the disability-adjusted life years lost, whereas North America bears 1.4% of the global burden. There is an urgent need to develop effective and sustainable interventions to control iron-deficiency anemia. This will likely not be achieved without substantial involvement of the private sector.

Home-based treatment of malnourished Malawian children with locally produced or imported ready-to-use food

OBJECTIVES

To determine the efficacy of home-based therapy with ready-to-use food (RTUF) in producing catch-up growth in malnourished children and to compare locally produced RTUF with imported RTUF for this purpose.

METHODS

After a brief inpatient stabilization, 260 children with severe malnutrition were enrolled and systematically allocated to receive home therapy with either imported, commercially produced RTUF or locally produced RTUF. Each child received 730 kJ/kg/day and was followed up fortnightly. Children completed the study when they reached a weight-for-height Z score > -0.5 (WHZ), relapsed, died, or failed to achieve WHZ > -0.5 after 16 weeks. Analyses were stratified by human immunodeficiency virus (HIV) status.

RESULTS

78% of all children reached WHZ > -0.5, 95% of those with HIV-negative status and 59% of those with HIV-positive status. Eighty percent of those receiving locally produced RTUF and 75% of those receiving imported RTUF reached WHZ > -0.5. The difference between recovery rates was 5% (95% confidence interval [CI], -5-15%). The rate of weight gain was 0.4 g/kg/day (95% CI, -0.6, 1.4) greater among children receiving locally produced RTUF. The prevalence of diarrhea reported by mothers was 3.7% for locally produced RTUF and 4.3% for imported RTUF. After completion of home therapy and resumption of habitual diet for 6 months, 91% of all children maintained a normal WHZ.

CONCLUSIONS

Home-based therapy with RTUF was successful in affecting complete catch-up growth. In this study, locally produced and imported RTUF were similar in efficacy in treating of severe childhood malnutrition.

Macrolevel approaches to improve the availability of complementary foods

Large numbers of infants and young children suffer from the short- and long-term health effects of poor breastfeeding and complementary feeding practices. Strategies to improve the availability of and access to low-cost fortified complementary foods can play an important corresponding role to that of behavior change in improving nutritional status of young children. However, the nutritional quality of complementary foods used in publicly funded programs is not always optimal, and such programs are costly and reach only a tiny fraction of those who could benefit. To broadly reach the target population, such foods need to be commercially available at affordable prices and promoted in a way that generates demand for their purchase. A sensible long-term policy for the promotion of low-cost fortified complementary foods calls for attention to their nutritional formulations and cost, the economics of production, and the legislative, regulatory, and competitive framework in which marketing occurs. This paper provides information on how to improve the nutritional formulations of fortified complementary foods and outlines the necessary conditions for a market approach to their production and promotion.