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La Banudi LB, Leksono P, Anasiru MA. Effect of Fish-Based Diet on Malnourished Children: A Systematic Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2024; 49:137-146. [PMID: 38584649 PMCID: PMC10997854 DOI: 10.30476/ijms.2023.96986.2863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/19/2022] [Accepted: 01/27/2023] [Indexed: 04/09/2024]
Abstract
Background Malnutrition in children is mainly caused by the lack of protein and fat intake which harms their ability to grow and survive. Accurate data on the benefits of fish-based foods on the nutritional status of children is limited. The present systematic review aimed to provide an overview of published articles on the nutritional value of fish-based foods for children. Methods A systematic review was performed during 2000-2021 by searching Science Direct, Cochrane Library, PubMed, ProQuest, and Wiley Online Library databases. The full text of selected articles in English was screened based on the inclusion and exclusion criteria. Included articles were all experimental studies (randomized control trial, quasi-randomized trial) or mixed methods studies involving malnourished children. The study was reported under the preferred reporting items for systematic reviews and meta-analyses guidelines. The risk of bias was assessed using the Cochrane tool. Results A total of 330,859 articles were screened, out of which eight articles were included in the systematic review. Interventions included fish-based foods and beverages such as wafer bars, Jemawut-tuna cookies, Amizate in chocolate drink, dried fish powder, flaxseed oil supplemented with fish oil capsules, and porridge fortified with fish powder. Primary or secondary outcomes were the determination of zinc level, height growth, erythrocyte n-3 polyunsaturated fatty acid content, safety and acceptability, intestinal integrity, and cognitive development. The results showed that dried fish powder produced the most significant effect on body weight. Conclusion The consumption of dried fish powder had positive effects on the recovery of malnourished children.
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Affiliation(s)
- La Banudi La Banudi
- Mother and Child Nutrition, Department of Nutrition, School of Health, Health Polytechnic of Kendari, Kendari, Indonesia
| | - Purnomo Leksono
- Mother and Child Nutrition, Department of Nutrition, School of Health, Health Polytechnic of Kendari, Kendari, Indonesia
| | - M Anas Anasiru
- Department of Nutrition, School of Health, Health Polytechnic of Gorontalo, Kendari, Indonesia
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Addae HY, Apprey C, Kwarteng A. Gut Microbiome-Targeted Nutrition Interventions and Growth among Children in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Curr Dev Nutr 2024; 8:102085. [PMID: 38455707 PMCID: PMC10918490 DOI: 10.1016/j.cdnut.2024.102085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 03/09/2024] Open
Abstract
Background Childhood malnutrition is a public health challenge of much interest and concern globally. However, a perturbed gut microbiome (GM) may limit some nutrition interventions' effects among healthy children with undernutrition. Objectives This review aimed to evaluate the effects of GM-targeted nutrition interventions on growth outcomes among children (0-59 mo) using published studies in low- and middle-income countries. Methods The methods were guided by the Cochrane methodology. The literature search was conducted to include articles published from inception to July 2023 in PubMed, Google Scholar, and Cochrane Databases. We identified and included 35 studies among 11,047 children. The analysis was conducted considering various growth parameters in the qualitative synthesis and weight gain (kg) in the meta-analysis. Results In the qualitative synthesis, 55.6% of prebiotics, 66.7% of probiotics, 71.4% of synbiotics, and 28.6% of "microbiome complementary feed" studies had significant effects on growth outcomes. Also, prebiotics had more studies with significant effects among healthy children, whereas probiotics, synbiotics, and "microbiome complementary feeds" had more studies with significant effects among children with undernutrition. Nineteen studies were included in the meta-analyses, of which 7 (36.8%) measured GM outcomes. The meta-analysis showed that prebiotics exhibited heterogeneity but had significant effects on weight in the intervention as compared with the control (mean difference [MD]: 0.14 kg; 95% CI: 0.02, 0.25; I2 = 63%, P = 0.02; 4 studies, n = 932). Probiotics had significant effects on weight in the intervention (MD: 0.15 kg; 95% CI: 0.06, 0.25; I2 = 42%, P = 0.05; 8 studies, n = 2437) as compared to the control. However, synbiotics (MD: 0.26 kg; 95% CI: -0.04, 0.56; I2 = 41%, P = 0.17; 4 studies, n = 1896] and "microbiome complementary feed" (MD: -0.03 kg; 95% CI: -0.18, 0.11; I2 = 0%, P = 0.60; 3 studies, n = 733] had no significant effects on weight in the intervention as compared with control. Conclusions Although probiotics and synbiotics may be effective at enhancing growth among children, the selection of interventions should be contingent upon health status.This trial was registered at www.crd.york.ac.uk/prospero/ as CRD42023434109.
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Affiliation(s)
- Hammond Yaw Addae
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
- Nursing Department, Nursing and Midwifery Training College, Kpembe, Ghana
| | - Charles Apprey
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Alexander Kwarteng
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
- Kumasi Centre for Collaborative Research in Tropical Medicine, KNUST, Kumasi, Ghana
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Mwita FC, PrayGod G, Sanga E, Setebe T, Joseph G, Kunzi H, Webster J, Gladstone M, Searle R, Ahmed M, Hokororo A, Filteau S, Friis H, Briend A, Olsen MF. Developmental and Nutritional Changes in Children with Severe Acute Malnutrition Provided with n-3 Fatty Acids Improved Ready-to-Use Therapeutic Food and Psychosocial Support: A Pilot Study in Tanzania. Nutrients 2024; 16:692. [PMID: 38474820 PMCID: PMC10934689 DOI: 10.3390/nu16050692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/08/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Children with severe acute malnutrition (SAM) are at high risk of impaired development. Contributing causes include the inadequate intake of specific nutrients such as polyunsaturated fatty acids (PUFAs) and a lack of adequate stimulation. We conducted a pilot study assessing developmental and nutritional changes in children with SAM provided with a modified ready-to-use therapeutic food and context-specific psychosocial intervention in Mwanza, Tanzania. We recruited 82 children with SAM (6-36 months) and 88 sex- and age-matched non-malnourished children. We measured child development, using the Malawi Development Assessment Tool (MDAT), measures of family and maternal care for children, and whole-blood PUFA levels. At baseline, the mean total MDAT z-score of children with SAM was lower than non-malnourished children; -2.37 (95% confidence interval: -2.92; -1.82), as were their total n-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) levels. After 8 weeks of intervention, MDAT z-scores improved in all domains, especially fine motor, among children with SAM. Total n-3 and EPA levels increased, total n-6 fatty acids decreased, and DHA remained unchanged. Family and maternal care also improved. The suggested benefits of the combined interventions on the developmental and nutritional status of children with SAM will be tested in a future trial.
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Affiliation(s)
- Fredrick Cyprian Mwita
- Mwanza Research Centre, National Institute for Medical Research, Mwanza P.O. Box 1462, Tanzania; (F.C.M.); (E.S.); (T.S.); (G.J.); (H.K.)
| | - George PrayGod
- Mwanza Research Centre, National Institute for Medical Research, Mwanza P.O. Box 1462, Tanzania; (F.C.M.); (E.S.); (T.S.); (G.J.); (H.K.)
| | - Erica Sanga
- Mwanza Research Centre, National Institute for Medical Research, Mwanza P.O. Box 1462, Tanzania; (F.C.M.); (E.S.); (T.S.); (G.J.); (H.K.)
| | - Theresia Setebe
- Mwanza Research Centre, National Institute for Medical Research, Mwanza P.O. Box 1462, Tanzania; (F.C.M.); (E.S.); (T.S.); (G.J.); (H.K.)
| | - Gaudensia Joseph
- Mwanza Research Centre, National Institute for Medical Research, Mwanza P.O. Box 1462, Tanzania; (F.C.M.); (E.S.); (T.S.); (G.J.); (H.K.)
| | - Happyness Kunzi
- Mwanza Research Centre, National Institute for Medical Research, Mwanza P.O. Box 1462, Tanzania; (F.C.M.); (E.S.); (T.S.); (G.J.); (H.K.)
| | - Jayne Webster
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK;
| | - Melissa Gladstone
- Department of Women and Children’s Health, University of Liverpool, Alder Hey Children’s Hospital, Liverpool L12 2AP, UK; (M.G.); (R.S.)
| | - Rebecca Searle
- Department of Women and Children’s Health, University of Liverpool, Alder Hey Children’s Hospital, Liverpool L12 2AP, UK; (M.G.); (R.S.)
| | - Maimuna Ahmed
- Department of Paediatrics, Bugando Medical Centre, Mwanza P.O. Box 1370, Tanzania; (M.A.); (A.H.)
| | - Adolfine Hokororo
- Department of Paediatrics, Bugando Medical Centre, Mwanza P.O. Box 1370, Tanzania; (M.A.); (A.H.)
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK;
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200 Copenhagen, Denmark; (H.F.); (A.B.); (M.F.O.)
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200 Copenhagen, Denmark; (H.F.); (A.B.); (M.F.O.)
- Tampere Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere University, Arvo Ylpön Katu 34, 33100 Tampere, Finland
| | - Mette Frahm Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200 Copenhagen, Denmark; (H.F.); (A.B.); (M.F.O.)
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark
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Nienaber A, Conradie C, Manda G, Chimera-Khombe B, Nel E, Milanzi EB, Dolman-Macleod RC, Lombard MJ. Effect of fatty acid profiles in varying recipes of ready-to-use therapeutic foods on neurodevelopmental and clinical outcomes of children (6-59 months) with severe wasting: a systematic review. Nutr Rev 2023:nuad151. [PMID: 38134960 DOI: 10.1093/nutrit/nuad151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
CONTEXT In 2020, 13.6 million children under 5 years suffered from severe acute malnutrition (SAM)/wasting. Standard ready-to-use therapeutic foods (RUTFs) improve polyunsaturated fatty acid (PUFA) status but contain suboptimal amounts of omega-3 (n-3) PUFAs with unbalanced n-6-to-n-3 PUFA ratios. OBJECTIVES The aim was to compare the effects of RUTFs with different essential fatty acid contents on PUFA status, neurodevelopmental, and clinical outcomes (mortality, comorbidities, and recovery) of children with severe wasting. DATA SOURCES Twelve databases, trial repositories, and article references with no publication limitations. DATA EXTRACTION Ten studies from randomized, quasi, and cluster-randomized controlled trials providing RUTFs as home treatment to children 6-59 months with SAM/wasting were included. DATA ANALYSIS Plasma phospholipid eicosapentaenoic acid content was higher in children receiving RUTF with altered essential fatty acid contents compared with standard RUTF (0.20 [0.15-0.25], P < 0.00001). Docosahexaenoic acid (DHA) status only improved in children receiving RUTF with added fish oil (0.33 [0.15-0.50], P = 0.0003). The Malawi Developmental Assessment tool (MDAT) global development and problem-solving assessment scores were higher in global assessment and gross motor domains in children receiving added fish oil compared with standard formulation (0.19 [0.0-0.38] and 0.29 [0.03-0.55], respectively). Children receiving high-oleic-acid RUTF (lowering the n-6:n-3 PUFA ratio of the RUTF) with or without fish oil had significantly higher scores in social domains compared with those receiving the standard formulation (0.16 [0.00-0.31] and 0.24 [0.09-0.40]). Significantly higher mortality risk was found in children receiving a standard formulation compared with RUTF with a lower n-6:n-3 PUFA ratio (0.79 [0.67-0.94], P = 0.008). CONCLUSION Although lowering n-6:n-3 PUFA ratios did not increase plasma DHA, it improved specific neurodevelopmental scores and mortality due to lower linoleic acid (high-oleic-acid peanuts), higher alpha-linolenic acid (altered oil), or both. Additional preformed n-3 long-chain PUFAs (fish oil) with RUTF improved the children's DHA status, neurodevelopmental outcomes, and weight-for-height z score. More research is needed regarding cost, availability, stability, acceptability, and the appropriate amount of n-3 long-chain PUFAs required in RUTFs for the best clinical outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42022303694.
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Affiliation(s)
- Arista Nienaber
- Centre of Excellence for Nutrition (CEN), North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Cornelia Conradie
- Centre of Excellence for Nutrition (CEN), North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Geoffrey Manda
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Ettienne Nel
- Department of Paediatrics and Child Health, University Stellenbosch, Bellville, Cape Town, South Africa
| | - Edith B Milanzi
- Medical Research Council Clinical Trials, University College London, London, United Kingdom
| | - Robin C Dolman-Macleod
- Centre of Excellence for Nutrition (CEN), North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Martani J Lombard
- Centre of Excellence for Nutrition (CEN), North-West University, Potchefstroom Campus, Potchefstroom, South Africa
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Sturgeon JP, Njunge JM, Bourke CD, Gonzales GB, Robertson RC, Bwakura-Dangarembizi M, Berkley JA, Kelly P, Prendergast AJ. Inflammation: the driver of poor outcomes among children with severe acute malnutrition? Nutr Rev 2023; 81:1636-1652. [PMID: 36977352 PMCID: PMC10639108 DOI: 10.1093/nutrit/nuad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - James M Njunge
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Ruairi C Robertson
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | | | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Paul Kelly
- is with the Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
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Sigh S, Lauritzen L, Wieringa FT, Laillou A, Chamnan C, Stark KD, Roos N. Changes in polyunsaturated fatty acids during treatment of malnourished children may be insufficient to reach required essential fatty acid levels - A randomised controlled trial. Clin Nutr 2023; 42:1778-1787. [PMID: 37572581 DOI: 10.1016/j.clnu.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND & AIMS Severe acute malnutrition (SAM) is a global concern. Studies on the impact of ready-to-use therapeutic foods (RUTFs) on polyunsaturated fatty acids (PUFA) are almost non-existent. The aim was to investigate the change in whole-blood PUFA and nutrition and health markers among Cambodian children with SAM after treatment with RUTFs. METHODS The trial was an 8-week randomised clinical trial of the effectiveness of locally produced fish-based RUTF (L-RUTF) vs standard milk-based RUFT (S-RUTF). Whole-blood fatty acids were analysed using dried blood spots. Nutrition and health markers were assessed using anthropometric assessment and blood samples for markers of inflammation. The trial was conducted at the National Pediatric Hospital, Phnom Penh, Cambodia, with one hundred and twenty-one 6-59-month-old children in treatment for SAM. RESULTS L-RUTF had a higher content of n-3 PUFA and a higher content of arachidonic acid (AA) and docosahexaenoic acid (DHA), while S-RUTF had the highest content of n-6 PUFA. At baseline, the children presented with a Mead acid level in whole-blood of around 0.08% of total fatty acids (FA%) and an omega-3 index of ∼0.91 ± 0.44. After eight weeks of S-RUTF treatment, linoleic acid (LA), AA, n-6/n-3 PUFA ratio, and Mead acid levels were increased. The L-RUTF intervention did not change the whole-blood PUFAs from baseline. At discharge, the children in the L-RUTF group had a lower n-6/n-3 PUFA ratio than the children in the S-RUTF group, driven by a lower alpha-linolenic acid (ALA) (0.20 vs 0.27 FA%, p = 0.004) and lower LA (15.77 vs 14.21 FA%, p = 0.018) with no significant differences in AA or DHA levels. Weight-for-height z-score at discharge was negatively associated with total PUFA (β -1.4 FA%, 95%CI. -2.7; -0.1), n-6 LCPUFA (β -1.3 FA%, 95%CI. -1.3; -0.3), and AA (β -0.6 FA%, 95%CI. -1.0; -0.2). Age-adjusted height was negatively associated with the Mead acid:AA ratio (β -1.2 FA%, 95%CI. -2.2; -0.2). No significant change was seen in inflammation markers within groups or between groups during treatment, and n-3 and n-6 PUFAs were not associated with markers of inflammation or haemoglobin status at discharge. CONCLUSION The trial found that whole-blood markers of PUFA status were low in children at admission and discharge from SAM treatment, indicating that the currently recommended composition of RUTFs are not able to correct their compromised essential fatty acid status. The higher content of DHA and AA in L-RUTF did not give rise to any improvement in PUFA status. No changes in health markers or associations between PUFA and health markers were found. TRIAL REGISTRATION ClinicalTrials.gov: NCT02907424.
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Affiliation(s)
- Sanne Sigh
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark; Department of Fisheries Post-Harvest Technologies and Quality Control, Fisheries Administration, #186 Preah Norodom Boulevard, 12101 Phnom Penh, Cambodia.
| | - Lotte Lauritzen
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark.
| | - Frank T Wieringa
- UMR QualiSud, Institut de Recherche Pour le Développement (IRD), 34394 Montpellier, France; Qualisud, University of Montpellier, Avignon University, CIRAD, Institut Agro, IRD, Université de la Réunion, 34394 Montpellier, France.
| | - Arnaud Laillou
- Nutrition Section, UNICEF West and Central Africa Region, Dakar 29720, Senegal.
| | - Chhoun Chamnan
- Department of Fisheries Post-Harvest Technologies and Quality Control, Fisheries Administration, #186 Preah Norodom Boulevard, 12101 Phnom Penh, Cambodia.
| | - Ken D Stark
- University of Waterloo, Department of Kinesiology and Health Sciences, 200 University Avenue, Waterloo, ON N2L3G1, Canada.
| | - Nanna Roos
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark.
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James G, Stephenson K, Callaghan-Gillespie M, Kamara MT, Park HG, Brenna JT, Manary MJ. Docosahexaenoic Acid Stability in Ready-to-Use Therapeutic Food. Foods 2023; 12:foods12020308. [PMID: 36673399 PMCID: PMC9858440 DOI: 10.3390/foods12020308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/11/2023] Open
Abstract
Ready-to-use therapeutic food (RUTF) is used to treat young children diagnosed with severe acute malnutrition. RUTF with low and balanced linoleic and alpha-linolenic acid, plus omega-3 docosahexaenoic acid (DHA), supports long-term cognitive recovery. DHA is prone to degradation due to peroxidation, possibly exacerbated by the iron inherently in RUTF. Our goals were to prepare benchtop and manufacturing scale of RUTF formulations that include DHA and measure its retention. Twenty-seven RUTF formulas with base ingredients, including oats, high oleic or commodity peanuts, and encapsulated or oil-based DHA at various levels were prepared at benchtop scale, followed by seven months of climate-controlled storage. These pilot samples had similar relative DHA retention. At the manufacturing scale, DHA was added at one of two stages in the process, either at the initial or the final mixing stage. Samples taken at preliminary or later steps show that less than 20% of DHA added at the early stages disappeared prior to packaging for any recipe tested. Overall, our data indicate that most DHA included in RUTF is retained in the final product and that DHA is best retained when added at the latest manufacturing stage.
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Affiliation(s)
- Genevieve James
- Dell Pediatric Research Institute, The University of Texas at Austin, Austin, TX 78723, USA
| | - Kevin Stephenson
- Department of Medicine, Washington University, St. Louis, MO 63110, USA
| | | | | | - Hui Gyu Park
- Dell Pediatric Research Institute, The University of Texas at Austin, Austin, TX 78723, USA
| | - J. Thomas Brenna
- Dell Pediatric Research Institute, The University of Texas at Austin, Austin, TX 78723, USA
| | - Mark J. Manary
- Department of Pediatrics, Washington University, St. Louis, MO 63110, USA
- Project Peanut Butter, Freetown 47235, Sierra Leone
- Children’s Nutrition Research Center, USDA-Agricultural Research Service, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-(314)-454-2178
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8
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Osorio EY, Gugala Z, Patterson GT, Palacios G, Cordova E, Uscanga-Palomeque A, Travi BL, Melby PC. Inflammatory stimuli alter bone marrow composition and compromise bone health in the malnourished host. Front Immunol 2022; 13:846246. [PMID: 35983045 PMCID: PMC9380851 DOI: 10.3389/fimmu.2022.846246] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Inflammation has a role in the pathogenesis of childhood malnutrition. We investigated the effect of malnutrition and inflammatory challenge on bone marrow composition and bone health. We studied an established murine model of moderate acute malnutrition at baseline and after acute inflammatory challenge with bacterial lipopolysaccharide (LPS), a surrogate of Gram-negative bacterial sepsis, or Leishmania donovani, the cause of visceral leishmaniasis. Both of these infections cause significant morbidity and mortality in malnourished children. Of the 2 stimuli, LPS caused more pronounced bone marrow changes that were amplified in malnourished mice. LPS challenge led to increased inflammatory cytokine expression (Il1b, Il6, and Tnf), inflammasome activation, and inflammatory monocyte accumulation in the bone marrow of malnourished mice. Depletion of inflammatory monocytes in Csfr1-LysMcre-DT malnourished mice significantly reduced the inflammasome activation and IL1-ß production after LPS challenge. The inflammatory challenge also led to increased expansion of mesenchymal stem cells (MSCs), bone marrow adiposity, and expression of genes (Pparg, Adipoq, and Srbp1) associated with adipogenesis in malnourished mice. This suggests that inflammatory challenge promotes differentiation of BM MSCs toward the adipocyte lineage rather than toward bone-forming osteoblasts in the malnourished host. Concurrent with this reduced osteoblastic potential there was an increase in bone-resorbing osteoclasts, enhanced osteoclast activity, upregulation of inflammatory genes, and IL-1B involved in osteoclast differentiation and activation. The resulting weakened bone formation and increased bone resorption would contribute to the bone fragility associated with malnutrition. Lastly, we evaluated the effect of replacing lipid rich in omega-6 fatty acids (corn oil) with lipid-rich in omega-3 fatty acids (fish oil) in the nutrient-deficient diet. LPS-challenged malnourished mice that received dietary fish oil showed decreased expression of inflammatory cytokines and Rankl and reduced osteoclast differentiation and activation in the bone marrow. This work demonstrates that the negative effect of inflammatory challenge on bone marrow is amplified in the malnourished host. Increasing dietary intake of omega-3 fatty acids may be a means to reduce inflammation and improve bone health in malnourished children.
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Affiliation(s)
- E. Yaneth Osorio
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX, United States
- *Correspondence: Peter C. Melby, ; E. Yaneth Osorio,
| | - Zbigniew Gugala
- Department of Orthopedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, United States
| | - Grace T. Patterson
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX, United States
| | - Genesis Palacios
- Department of Parasitology, Universidad de la Laguna, San Cristóbal de La Laguna, Spain
| | - Erika Cordova
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX, United States
| | - Ashanti Uscanga-Palomeque
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX, United States
| | - Bruno L. Travi
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX, United States
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
- Center for Tropical Diseases and Institute for Human Infection and Immunity, University of Texas Medical Branch, Galveston, TX, United States
| | - Peter C. Melby
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX, United States
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
- Center for Tropical Diseases and Institute for Human Infection and Immunity, University of Texas Medical Branch, Galveston, TX, United States
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
- *Correspondence: Peter C. Melby, ; E. Yaneth Osorio,
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9
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Imdad A, Rogner JL, François M, Ahmed S, Smith A, Tsistinas OJ, Tanner-Smith E, Das JK, Chen FF, Bhutta ZA. Increased vs. Standard Dose of Iron in Ready-to-Use Therapeutic Foods for the Treatment of Severe Acute Malnutrition in a Community Setting: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14153116. [PMID: 35956294 PMCID: PMC9370784 DOI: 10.3390/nu14153116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
The optimal dose of iron in ready-to-use therapeutic foods (RUTF) used to treat uncomplicated severe acute malnutrition (SAM) in community settings is not well established. The objective of this systematic review was to assess if an increased iron dose in RUTF, compared with the standard iron dose in the World Health Organization (WHO)-recommended peanut-based RUTF, improved outcomes in children aged six months or older. We searched multiple electronic databases and only included randomized controlled trials. We pooled the data in a meta-analysis to obtain relative risk (RR) and reported it with a 95% confidence interval (CI). Three studies, one each from Zambia, the Democratic Republic of Congo, and Malawi, were included. In all studies, the RUTF used in the intervention group was milk-free soya–maize–sorghum-based RUTF. The pooled results showed that, compared to the control group, a high iron content in RUTF may lead to increase in hemoglobin concentration (mean difference 0.33 g/dL, 95% CI: 0.02, 0.64, two studies, certainty of evidence: low) and a decrease in any anemia (RR 0.66, 95% CI: 0.48, 0.91, two studies, certainty of evidence: low), but also decrease recovery rates (RR 0.91, 95% CI: 0.84, 0.99, three studies, certainty of evidence: low) and increase mortality (RR 1.30, 95% CI: 0.87, 1.95, three studies, certainty of evidence: moderate). However, the CIs were imprecise for the latter outcome. Future studies with large sample sizes are needed to confirm the beneficial versus harmful effects of high iron content in RUTF in treating uncomplicated SAM in children aged 6-59 months in community settings.
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Affiliation(s)
- Aamer Imdad
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY 13210, USA
- Correspondence: ; Tel.: +1-315-464-8444
| | - Jaimie L. Rogner
- Departments of Medicine and Pediatrics, University of Rochester Medical Center, Rochester, NY 13210, USA;
| | - Melissa François
- College of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA; (M.F.); (F.F.C.)
| | - Shehzad Ahmed
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY 13210, USA;
| | - Abigail Smith
- Health Science Library, SUNY Upstate Medical University, Syracuse, NY 13210, USA; (A.S.); (O.J.T.)
| | - Olivia J. Tsistinas
- Health Science Library, SUNY Upstate Medical University, Syracuse, NY 13210, USA; (A.S.); (O.J.T.)
| | - Emily Tanner-Smith
- Department of Counseling Psychology and Human Services, College of Education, University of Oregon, Eugene, OR 97403, USA;
| | - Jai K. Das
- Department of Pediatrics and Child Health and Institute of Global Health and Development, Aga Khan University, Karachi 74800, Pakistan;
| | - Fanny F. Chen
- College of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA; (M.F.); (F.F.C.)
| | - Zulfiqar Ahmed Bhutta
- Department of Global Child Health, Hospital for SickKids, Toronto, ON M5G 0A4, Canada;
- Center for Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
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10
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Bauer KC, Littlejohn PT, Ayala V, Creus-Cuadros A, Finlay BB. Nonalcoholic Fatty Liver Disease and the Gut-Liver Axis: Exploring an Undernutrition Perspective. Gastroenterology 2022; 162:1858-1875.e2. [PMID: 35248539 DOI: 10.1053/j.gastro.2022.01.058] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 12/31/2021] [Accepted: 01/07/2022] [Indexed: 02/08/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a chronic condition affecting one quarter of the global population. Although primarily linked to obesity and metabolic syndrome, undernutrition and the altered (dysbiotic) gut microbiome influence NAFLD progression. Both undernutrition and NAFLD prevalence are predicted to considerably increase, but how the undernourished gut microbiome contributes to hepatic pathophysiology remains far less studied. Here, we present undernutrition conditions with fatty liver features, including kwashiorkor and micronutrient deficiency. We then review the gut microbiota-liver axis, highlighting key pathways linked to NAFLD progression within both overnutrition and undernutrition. To conclude, we identify challenges and collaborative possibilities of emerging multiomic research addressing the pathology and treatment of undernourished NAFLD.
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Affiliation(s)
- Kylynda C Bauer
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada; Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada; Thoracic and Gastrointestinal Malignancies Branch, National Institutes of Health, National Cancer Institute, Center for Cancer Research, Bethesda, Maryland
| | - Paula T Littlejohn
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada; Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria Ayala
- Institut de Recerca Biomèdica de Lleida (IRB-Lleida), Lleida, Spain; Department of Experimental Medicine, Universitat de Lleida, Lleida, Spain
| | - Anna Creus-Cuadros
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada
| | - B Brett Finlay
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada; Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada; Biochemistry and Molecular Biology Department, University of British Columbia, Vancouver, British Columbia, Canada.
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11
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Zúñiga-Hernández J, Sambra V, Echeverría F, Videla LA, Valenzuela R. N-3 PUFAs and their specialized pro-resolving lipid mediators on airway inflammatory response: beneficial effects in the prevention and treatment of respiratory diseases. Food Funct 2022; 13:4260-4272. [PMID: 35355027 DOI: 10.1039/d1fo03551g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Respiratory diseases include a wide range of pathologies with different clinical manifestations, affecting the normal airways and lung function. An increase in the inflammatory response is considered a characteristic hallmark of these diseases, being also a critical factor for their progression. The n-3 polyunsaturated fatty acids (n-3 PUFAs) eicosapentaenoic acid (C20:4n-3, EPA), docosahexaenoic acid (C22:6n-3, DHA) and their lipid mediators are known to have an inflammation pro-resolution effect. The effects of these n-3 PUFAs in the prevention and treatment of respiratory diseases are beginning to be understood. Consequently, this article aims to analyze the influence of n-3 PUFAs and their lipid mediators on the inflammatory response in respiratory health, emphasizing recent data concerning their beneficial effects in the prevention and possible treatment of different respiratory diseases, particularly asthma, airway allergic syndromes and chronic obstructive pulmonary disease. The review includes studies regarding the effects of EPA, DHA, and their specialized pro-resolving lipid mediators (SPMs) on in vivo and in vitro models of respiratory disease, concluding that EPA and DHA have a positive impact in attenuating the pro-inflammatory response in respiratory diseases, reducing symptoms like nasal congestion, fever and difficulty in breathing. Controversial data reported are probably due to differences in several factors, including the dosages, administration vehicles, and the supplementation times employed, which are aspects that remain to be addressed in future studies.
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Affiliation(s)
| | - Verónica Sambra
- Nutrition Department, Faculty of Medicine, University of Chile, Santiago, Chile.
| | - Francisca Echeverría
- Nutrition Department, Faculty of Medicine, University of Chile, Santiago, Chile. .,Carrera de Nutrición y Dietética, Departamento Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A Videla
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Science, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Rodrigo Valenzuela
- Nutrition Department, Faculty of Medicine, University of Chile, Santiago, Chile.
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12
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Validity and Predictive Performance of Mini Nutritional Assessment Tool for Institutionalized Elders in Ethiopia. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6764657. [PMID: 35445139 PMCID: PMC9015874 DOI: 10.1155/2022/6764657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/21/2022] [Accepted: 03/29/2022] [Indexed: 11/18/2022]
Abstract
Background Despite the high burden of malnutrition in the country, there is a lack of a simple and valid tool to screen elders in Ethiopia. The Mini Nutritional Assessment (MNA) tool has been validated for comprehensive geriatric assessment to identify malnutrition in other countries. However, there is a lack of evidence on the potential validity and reliability of the tool for institutionalized elders in Ethiopia. This study was aimed at determining the validity and predictive performance of MNA tool for malnutrition among Ethiopian institutionalized elderly. Methods A facility-based survey was conducted on randomly selected 164 elders in geriatric centers to evaluate the validity, reliability, and predictive performance of full MNA against hemoglobin (Hgb) and ideal body weight (IBW) measured under standard procedures. The data was presented in ROC graphs, and reliability was evaluated with Cronbach alpha. The receiver-operating characteristic curve (ROC) analysis was used to assess the predictive performance of the tool. The area under the curve (AUC) with its 95% CI was reported. The Youden index, at maximum sensitivity and specificity, was used to obtain optimal cutoff points. Results The internal consistency of the tool was good (α = 0.80). The full MNA score can better predict Hgb (AUC = 0.845; 0.783-0.899) and percentage of IBW (AUC = 0.90; 0.842-0.941) at specified cutoff points. A full MNA can predict malnutrition or risk of malnutrition based on percentage IBW at a sensitivity and specificity of 97.3% and 72.2%, respectively. Conclusions The full MNA has the potential to be a reliable and valid nutritional assessment tool for institutional elders.
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13
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Imdad A, François M, Chen FF, Smith A, Tsistinas O, Tanner-Smith E, Das JK, Bhutta ZA. Optimal iron content in ready-to-use therapeutic foods for the treatment of severe acute malnutrition in the community settings: a protocol for the systematic review and meta-analysis. BMJ Open 2022; 12:e057389. [PMID: 35264366 PMCID: PMC8915355 DOI: 10.1136/bmjopen-2021-057389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The current standard of care for children with severe acute malnutrition (SAM) involves using ready-to-use therapeutic food (RUTF) to promote growth; however, the precise formulation to achieve optimal recovery remains unclear. Emerging research suggests that alternative RUTF formulations may be more effective in correcting SAM-related complications such as anaemia and iron deficiency. This systematic review commissioned by the WHO aims to synthesise the most recent research on the iron content in RUTF and related products in the community-based treatment of uncomplicated severe malnutrition in children aged 6 months and older. METHODS AND ANALYSIS We will search multiple electronic databases. We will include randomised controlled trials and non-randomised studies with a control arm. The intervention group will be infants who received RUTF treatments other than the current recommended guidelines set forth by the WHO. The comparison group is children receiving RUTF containing iron at the current WHO-recommended level of 1.9 mg/100 kcal (10-14 mg/100 g). The primary outcomes of interest include blood haemoglobin concentration, any anaemia, severe anaemia, iron-deficiency anaemia, recovery from SAM and any adverse outcomes. We will use meta-analysis to pool findings if sufficient homogeneity exists among included studies. The risk of bias in studies will be evaluated using the Cochrane risk of bias-2. We will use the Grading of Recommendations Assessment, Development, and Evaluation(GRADE) approach to examine the overall certainty of evidence. ETHICS AND DISSEMINATION This is a systematic review and will not involve direct contact with human subjects. The findings of this review will be published in a peer-reviewed journal and will guide the WHO's recommendation on the optimal iron content in RUTFs for the treatment of SAM in children aged 6-59 months.
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Affiliation(s)
- Aamer Imdad
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Melissa François
- College of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Fanny F Chen
- College of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Abigail Smith
- Library Sciences, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Olivia Tsistinas
- Library Sciences, SUNY Upstate Medical University, Syracuse, New York, USA
| | | | - Jai K Das
- Department of Pediatrics, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Ahmed Bhutta
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
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14
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Bauer KC, York EM, Cirstea MS, Radisavljevic N, Petersen C, Huus KE, Brown EM, Bozorgmehr T, Berdún R, Bernier LP, Lee AHY, Woodward SE, Krekhno Z, Han J, Hancock REW, Ayala V, MacVicar BA, Finlay BB. Gut microbes shape microglia and cognitive function during malnutrition. Glia 2022; 70:820-841. [PMID: 35019164 PMCID: PMC9305450 DOI: 10.1002/glia.24139] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/17/2021] [Accepted: 12/20/2021] [Indexed: 12/21/2022]
Abstract
Fecal‐oral contamination promotes malnutrition pathology. Lasting consequences of early life malnutrition include cognitive impairment, but the underlying pathology and influence of gut microbes remain largely unknown. Here, we utilize an established murine model combining malnutrition and iterative exposure to fecal commensals (MAL‐BG). The MAL‐BG model was analyzed in comparison to malnourished (MAL mice) and healthy (CON mice) controls. Malnourished mice display poor spatial memory and learning plasticity, as well as altered microglia, non‐neuronal CNS cells that regulate neuroimmune responses and brain plasticity. Chronic fecal‐oral exposures shaped microglial morphology and transcriptional profile, promoting phagocytic features in MAL‐BG mice. Unexpectedly, these changes occurred independently from significant cytokine‐induced inflammation or blood–brain barrier (BBB) disruption, key gut‐brain pathways. Metabolomic profiling of the MAL‐BG cortex revealed altered polyunsaturated fatty acid (PUFA) profiles and systemic lipoxidative stress. In contrast, supplementation with an ω3 PUFA/antioxidant‐associated diet (PAO) mitigated cognitive deficits within the MAL‐BG model. These findings provide valued insight into the malnourished gut microbiota‐brain axis, highlighting PUFA metabolism as a potential therapeutic target.
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Affiliation(s)
- Kylynda C Bauer
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada
| | - Elisa M York
- Psychiatry Department, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Mihai S Cirstea
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada
| | - Nina Radisavljevic
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Biochemistry and Molecular Biology Department, University of British Columbia, Vancouver, Canada
| | - Charisse Petersen
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada
| | - Kelsey E Huus
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada
| | - Eric M Brown
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada
| | - Tahereh Bozorgmehr
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada
| | - Rebeca Berdún
- Institut de Recerca Biomèdica de Lleida (IRB-Lleida), Lleida, Spain.,Department of Experimental Medicine, Universitat de Lleida (UdL), Lleida, Spain
| | - Louis-Philippe Bernier
- Psychiatry Department, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Amy H Y Lee
- Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada
| | - Sarah E Woodward
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada
| | - Zakhar Krekhno
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada
| | - Jun Han
- The Metabolomics Innovation Centre, University of Victoria, Victoria, Canada
| | - Robert E W Hancock
- Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada
| | - Victoria Ayala
- Institut de Recerca Biomèdica de Lleida (IRB-Lleida), Lleida, Spain.,Department of Experimental Medicine, Universitat de Lleida (UdL), Lleida, Spain
| | - Brian A MacVicar
- Psychiatry Department, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Barton Brett Finlay
- Michael Smith Laboratories, University of British Columbia, Vancouver, Canada.,Microbiology and Immunology Department, University of British Columbia, Vancouver, Canada.,Biochemistry and Molecular Biology Department, University of British Columbia, Vancouver, Canada
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15
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Stephenson K, Callaghan-Gillespie M, Maleta K, Nkhoma M, George M, Park HG, Lee R, Humphries-Cuff I, Lacombe RJS, Wegner DR, Canfield RL, Brenna JT, Manary MJ. Low linoleic acid foods with added DHA given to Malawian children with severe acute malnutrition improve cognition: a randomized, triple-blinded, controlled clinical trial. Am J Clin Nutr 2021; 115:1322-1333. [PMID: 34726694 PMCID: PMC9071416 DOI: 10.1093/ajcn/nqab363] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is concern that the PUFA composition of ready-to-use therapeutic food (RUTF) for the treatment of severe acute malnutrition (SAM) is suboptimal for neurocognitive recovery. OBJECTIVES We tested the hypothesis that RUTF made with reduced amounts of linoleic acid, achieved using high-oleic (HO) peanuts without added DHA (HO-RUTF) or with added DHA (DHA-HO-RUTF), improves cognition when compared with standard RUTF (S-RUTF). METHODS A triple-blind, randomized, controlled clinical feeding trial was conducted among children with uncomplicated SAM in Malawi with 3 types of RUTF: DHA-HO-RUTF, HO-RUTF, and S-RUTF. The primary outcomes, measured in a subset of subjects, were the Malawi Developmental Assessment Tool (MDAT) global z-score and a modified Willatts problem-solving assessment (PSA) intention score for 3 standardized problems, measured 6 mo and immediately after completing RUTF therapy, respectively. MDAT domain z-scores, plasma fatty acid content, anthropometry, and eye tracking were secondary outcomes. Comparisons were made between the novel PUFA RUTFs and S-RUTF. RESULTS Among the 2565 SAM children enrolled, mean global MDAT z-scores were -0.69 ± 1.19 and -0.88 ± 1.27 for children receiving DHA-HO-RUTF and S-RUTF, respectively (difference 0.19, 95% CI: 0.01, 0.38). Children receiving DHA-HO-RUTF had higher gross motor and social domain z-scores than those receiving S-RUTF. The PSA problem 3 scores did not differ by dietary group (OR: 0.92, 95% CI: 0.67, 1.26 for DHA-HO-RUTF). After 4 wk of treatment, plasma phospholipid EPA and α-linolenic acid were greater in children consuming DHA-HO-RUTF or HO-RUTF when compared with S-RUTF (for all 4 comparisons P values < 0.001), but only plasma DHA was greater in DHA-HO-RUTF than S-RUTF (P < 0.001). CONCLUSIONS Treatment of uncomplicated SAM with DHA-HO-RUTF resulted in an improved MDAT score, conferring a cognitive benefit 6 mo after completing diet therapy. This treatment should be explored in operational settings. This trial was registered at clinicaltrials.gov as NCT03094247.
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Affiliation(s)
- Kevin Stephenson
- Department of Medicine, Washington University, St.
Louis, MO, USA
| | | | - Kenneth Maleta
- Department of Public Health, School of Public Health & Family Medicine,
Kamuzu University of Health Sciences, Blantyre,
Malawi
| | - Minyanga Nkhoma
- Department of Public Health, School of Public Health & Family Medicine,
Kamuzu University of Health Sciences, Blantyre,
Malawi
| | - Matthews George
- Department of Public Health, School of Public Health & Family Medicine,
Kamuzu University of Health Sciences, Blantyre,
Malawi
| | - Hui Gyu Park
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA
| | - Reginald Lee
- Department of Pediatrics, Washington University,
St. Louis, MO, USA
| | | | - R J Scott Lacombe
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA
| | - Donna R Wegner
- Department of Pediatrics, Washington University,
St. Louis, MO, USA
| | - Richard L Canfield
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA
| | - J Thomas Brenna
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA,Division of Nutritional Sciences, Cornell University,
Ithaca, NY, USA
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16
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Heuven LAJ, Pyle S, Greyling A, Melse-Boonstra A, Eilander A. Gut Microbiota-Targeted Nutritional Interventions Improving Child Growth in Low- and Middle-Income Countries: A Systematic Review. Curr Dev Nutr 2021; 5:nzab124. [PMID: 34761159 PMCID: PMC8575755 DOI: 10.1093/cdn/nzab124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/19/2021] [Accepted: 09/22/2021] [Indexed: 01/14/2023] Open
Abstract
The objective of this systematic literature review was to evaluate the efficacy of probiotic, prebiotic, and synbiotic interventions compared with control on improving growth outcomes of children living in low- and middle-income countries (LMICs). Probiotics had a beneficial effect on ≥1 of the growth outcomes in 5 out of the 11 included studies. Of these, 3 studies were conducted in undernourished children, 1 in healthy children, and 1 in children without a described health status. No effect of prebiotics on growth outcomes was seen in the 4 included studies. Synbiotics had a beneficial effect on growth outcomes in 3 out of 4 studies. Although a limited number of studies with high heterogeneity indicate that probiotics and synbiotics may have the potential to improve the growth of both undernourished and healthy children living in LMICs, more research is needed to confirm the observed effects. This review was registered at www.crd.york.ac.uk/prospero/ as CRD42020212998.
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Affiliation(s)
- Lise AJ Heuven
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
- Unilever Foods Innovation Centre, Wageningen, Netherlands
| | - Simone Pyle
- Unilever Foods Innovation Centre, Wageningen, Netherlands
| | - Arno Greyling
- Unilever Foods Innovation Centre, Wageningen, Netherlands
| | - Alida Melse-Boonstra
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Ans Eilander
- Unilever Foods Innovation Centre, Wageningen, Netherlands
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17
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Fabusoro OK, Mejia LA. Nutrition in HIV-Infected Infants and Children: Current Knowledge, Existing Challenges, and New Dietary Management Opportunities. Adv Nutr 2021; 12:1424-1437. [PMID: 33439976 PMCID: PMC8321844 DOI: 10.1093/advances/nmaa163] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 11/14/2022] Open
Abstract
HIV infection and undernutrition remain significant public health concerns for infants and children. In infants and children under these conditions, undernutrition is one of the leading causes of death. Proper management of nutrition and related nutrition complications in these groups with increased nutrition needs are prominent challenges, particularly in HIV-prevalent poor-resource environments. Several studies support the complexity of the relation between HIV infection, nutrition, and the immune system. These elements interact and create a vicious circle of poor health outcomes. Recent studies on the use of probiotics as a novel approach to manage microbiome imbalance and gut-mucosal impairment in HIV infection are gaining attention. This new strategy could help to manage dysbiosis and gut-mucosal impairment by reducing immune activation, thereby potentially forestalling unwanted health outcomes in children with HIV. However, existing trials on HIV-infected children are still insufficient. There are also conflicting reports on the dosage and effectiveness of single or multiple micronutrient supplementation in the survival of HIV-infected children with severe acute malnutrition. The WHO has published guidelines that include time of initiation of antiretroviral therapy for HIV-pregnant mothers and their HIV-exposed or HIV-infected children, micronutrient supplementation, dietary formulations, prevention, and management of HIV therapy. However, such guidelines need to be reviewed owing to recent advances in the field of nutrition. There is a need for new intervention studies, practical strategies, and evidence-based guidelines to reduce the disease burden, improve adherence to treatment regimen, and enhance the nutrition, health, and well-being of HIV-infected infants and children. This review provides up-to-date scientific information on current knowledge and existing challenges for nutrition therapy in HIV-infected infants and children. Moreover, it presents new research findings that could be incorporated into current guidelines.
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Affiliation(s)
- Olufemi K Fabusoro
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Luis A Mejia
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL, USA
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18
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Shahunja KM, Sévin DC, Kendall L, Ahmed T, Hossain MI, Mahfuz M, Zhu X, Singh K, Singh S, Crowther JM, Gibson RA, Darmstadt GL. Effect of topical applications of sunflower seed oil on systemic fatty acid levels in under-two children under rehabilitation for severe acute malnutrition in Bangladesh: a randomized controlled trial. Nutr J 2021; 20:51. [PMID: 34092255 PMCID: PMC8183055 DOI: 10.1186/s12937-021-00707-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 05/18/2021] [Indexed: 11/30/2022] Open
Abstract
Background Children with severe acute malnutrition (SAM) have inadequate levels of fatty acids (FAs) and limited capacity for enteral nutritional rehabilitation. We hypothesized that topical high-linoleate sunflower seed oil (SSO) would be effective adjunctive treatment for children with SAM. Methods This study tested a prespecified secondary endpoint of a randomized, controlled, unblinded clinical trial with 212 children with SAM aged 2 to 24 months in two strata (2 to < 6 months, 6 to 24 months in a 1:2 ratio) at Dhaka Hospital of icddr,b, Bangladesh between January 2016 and December 2017. All children received standard-of-care management of SAM. Children randomized to the emollient group also received whole-body applications of 3 g/kg SSO three times daily for 10 days. We applied difference-in-difference analysis and unsupervised clustering analysis using t-distributed stochastic neighbor embedding (t-SNE) to visualize changes in FA levels in blood from day 0 to day 10 of children with SAM treated with emollient compared to no-emollient. Results Emollient therapy led to systematically higher increases in 26 of 29 FAs over time compared to the control. These effects were driven primarily by changes in younger subjects (27 of 29 FAs). Several FAs, especially those most abundant in SSO showed high-magnitude but non-significant incremental increases from day 0 to day 10 in the emollient group vs. the no-emollient group; for linoleic acid, a 237 μg/mL increase was attributable to enteral feeding and an incremental 98 μg/mL increase (41%) was due to emollient therapy. Behenic acid (22:0), gamma-linolenic acid (18:3n6), and eicosapentaenoic acid (20:5n3) were significantly increased in the younger age stratum; minimal changes were seen in the older children. Conclusions SSO therapy for SAM augmented the impact of enteral feeding in increasing levels of several FAs in young children. Further research is warranted into optimizing this novel approach for nutritional rehabilitation of children with SAM, especially those < 6 months. Trial registration ClinicalTrials.gov: NCT02616289. Supplementary Information The online version contains supplementary material available at 10.1186/s12937-021-00707-3.
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Affiliation(s)
- K M Shahunja
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Daniel C Sévin
- Cellzome GmbH, GlaxoSmithKline R&D, Meyerhofstrasse 1, 69117, Heidelberg, Germany
| | - Lindsay Kendall
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Xinyi Zhu
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | - Krishan Singh
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | - Sunita Singh
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | | | - Rachel A Gibson
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, 1701 Page Mill Road, Room 121, Palo Alto, Stanford, CA, 94304, USA.
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Noble CCA, Sturgeon JP, Bwakura-Dangarembizi M, Kelly P, Amadi B, Prendergast AJ. Postdischarge interventions for children hospitalized with severe acute malnutrition: a systematic review and meta-analysis. Am J Clin Nutr 2021; 113:574-585. [PMID: 33517377 PMCID: PMC7948836 DOI: 10.1093/ajcn/nqaa359] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/06/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Children hospitalized with severe acute malnutrition (SAM) have poor long-term outcomes following discharge, with high rates of mortality, morbidity, and impaired neurodevelopment. There is currently minimal guidance on how to support children with SAM following discharge from inpatient treatment. OBJECTIVES This systematic review and meta-analysis aimed to examine whether postdischarge interventions can improve outcomes in children recovering from complicated SAM. METHODS Systematic searches of 4 databases were undertaken to identify studies of interventions delivered completely or partially after hospital discharge in children aged 6-59 mo, following inpatient treatment of SAM. The main outcome of interest was mortality. Random-effects meta-analysis was undertaken where ≥2 studies were sufficiently similar in intervention and outcome. RESULTS Ten studies fulfilled the inclusion criteria, recruiting 39-1781 participants in 7 countries between 1975 and 2015. Studies evaluated provision of zinc (2 studies), probiotics or synbiotics (2 studies), antibiotics (1 study), pancreatic enzymes (1 study), and psychosocial stimulation (4 studies). Six studies had unclear or high risk of bias in ≥2 domains. Compared with standard care, pancreatic enzyme supplementation reduced inpatient mortality (37.8% compared with 18.6%, P < 0.05). In meta-analysis there was some evidence that prebiotics or synbiotics reduced mortality (RR: 0.72; 95% CI: 0.51, 1.00; P = 0.049). Psychosocial stimulation reduced mortality in meta-analysis of the 2 trials reporting deaths (RR: 0.36; 95% CI: 0.15, 0.87), and improved neurodevelopmental scores in ≥1 domain in all studies. There was no evidence that zinc reduced mortality in the single study reporting deaths. Antibiotics reduced infectious morbidity but did not reduce mortality. CONCLUSIONS Several biological and psychosocial interventions show promise in improving outcomes in children following hospitalization for SAM and require further exploration in larger randomized mortality trials. This study was registered with PROSPERO as CRD42018111342 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=111342).
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Affiliation(s)
- Christie C A Noble
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jonathan P Sturgeon
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Paul Kelly
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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20
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Park JJH, Harari O, Siden E, Dron L, Zannat NE, Singer J, Lester RT, Thorlund K, Mills EJ. Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis. Gates Open Res 2020; 3:1660. [PMID: 32259047 PMCID: PMC7096089 DOI: 10.12688/gatesopenres.13083.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 01/14/2023] Open
Abstract
Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) is critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness are currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ellie Siden
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | | | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Data and Methodology Program, CIHR Canadian HIV Trials Network, Vancouver, BC, V6Z 1Y6, Canada
| | - Richard T. Lester
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Kristian Thorlund
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Edward J. Mills
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
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21
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Shokry E, Sadiq K, Soofi S, Habib A, Bhutto N, Rizvi A, Ahmad I, Demmelmair H, Uhl O, Bhutta ZA, Koletzko B. Impact of Treatment with RUTF on Plasma Lipid Profiles of Severely Malnourished Pakistani Children. Nutrients 2020; 12:nu12072163. [PMID: 32708260 PMCID: PMC7401247 DOI: 10.3390/nu12072163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 12/22/2022] Open
Abstract
(1) Background: Little is known on impacts of ready-to-use therapeutic food (RUTF) treatment on lipid metabolism in children with severe acute malnutrition (SAM). (2) Methods: We analyzed glycerophospholipid fatty acids (FA) and polar lipids in plasma of 41 Pakistani children with SAM before and after 3 months of RUTF treatment using gas chromatography and flow-injection analysis tandem mass spectrometry, respectively. Statistical analysis was performed using univariate, multivariate tests and evaluated for the impact of age, sex, breastfeeding status, hemoglobin, and anthropometry. (3) Results: Essential fatty acid (EFA) depletion at baseline was corrected by RUTF treatment which increased EFA. In addition, long-chain polyunsaturated fatty acids (LC-PUFA) and the ratio of arachidonic acid (AA)/linoleic acid increased reflecting greater EFA conversion to LC-PUFA, whereas Mead acid/AA decreased. Among phospholipids, lysophosphatidylcholines (lyso.PC) were most impacted by treatment; in particular, saturated lyso.PC decreased. Higher child age and breastfeeding were associated with great decrease in total saturated FA (ΣSFA) and lesser decrease in monounsaturated FA and total phosphatidylcholines (ΣPC). Conclusions: RUTF treatment improves EFA deficiency in SAM, appears to enhance EFA conversion to biologically active LC-PUFA, and reduces lipolysis reflected in decreased ΣSFA and saturated lyso.PC. Child age and breastfeeding modify treatment-induced changes in ΣSFA and ΣPC.
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Affiliation(s)
- Engy Shokry
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
| | - Kamran Sadiq
- Department of Pediatrics & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (K.S.); (S.S.)
| | - Sajid Soofi
- Department of Pediatrics & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (K.S.); (S.S.)
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Atif Habib
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Naveed Bhutto
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Arjumand Rizvi
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Imran Ahmad
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Hans Demmelmair
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
| | - Olaf Uhl
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
| | - Zulfiqar A. Bhutta
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Correspondence: (Z.A.B.); (B.K.); Tel.: +17-573248424 (Z.A.B.); +49-89-44005-2826 (B.K.); Fax: +49-89-44005-7742 (B.K.)
| | - Berthold Koletzko
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
- Correspondence: (Z.A.B.); (B.K.); Tel.: +17-573248424 (Z.A.B.); +49-89-44005-2826 (B.K.); Fax: +49-89-44005-7742 (B.K.)
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22
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Das JK, Salam RA, Saeed M, Kazmi FA, Bhutta ZA. Effectiveness of interventions to manage acute malnutrition in children under 5 years of age in low- and middle-income countries: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2020; 16:e1082. [PMID: 37131422 PMCID: PMC8356333 DOI: 10.1002/cl2.1082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Childhood malnutrition is a major public health concern as it is associated with significant short- and long-term morbidity and mortality. Objectives To comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization protocol using facility- and community-based approaches as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use and vitamin A supplementation. Search methods We searched relevant electronic databases till 11 February 2019. No date or language restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and quasi-experimental studies including controlled before-after (CBA) studies and interrupted time series (ITS) studies. Data collection and analysis Two review authors independently screened studies for relevance, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software and set out the main findings of the review in "Summary of findings" tables. Main results This review summarises findings from a total of 42 studies (48 papers) including 35,017 children. Thirty-three of the included studies were RCTs; six studies were quasi-experimental and three studies were cost studies. Majority of the studies were judged to be at high risk of bias for blinding of the participants, personnel and outcome assessment. Majority of the outcomes were rated as either moderate or low quality. Outcomes were downgraded mainly due to study limitations, high heterogeneity, imprecision and small sample size. Community-based strategies to screen and manage SAM/MAM versus no community-based strategies (two studies): Integrated community-based management probably improves recovery rate by 4% [risk ratio (RR): 1.04; 95% confidence interval (CI): 1.00 to 1.09; one study; 1,957 participants; moderate-quality outcome], and reduces weight gain by 0.8 g·kg-1·day-1 [mean difference (MD): -0.80 g·kg-1·day-1; 95% CI: -0.82 to -0.78; one study; 1,957 participants; moderate-quality outcome] compared with no community-based strategies, while mortality was similar between the two groups (RR: 0.93; 95% CI: 0.60 to 1.45; one study; 1,957 participants; moderate-quality outcome). Facility-based strategies to screen and manage uncomplicated SAM versus other standard of care (four studies): There was no evidence of effect on recovery (RR: 1.00; 95% CI: 0.80, 1.25; one study; 60 participants; very-low-quality evidence) and mortality (RR: 1.21; 95% CI: 0.75 to 1.94; two studies; 473 participants; low-quality outcome). Facility-based management with RUTF versus F100 ("catch-up" formula to rebuild wasted tissues containing 100 kcal and 2.9 g protein per 100 ml) for SAM (three studies): There was no evidence of effect on weight gain (MD: 2 g·kg-1·day-1; 95% CI: -0.23 to 4.23; three studies; 266 participants; very-low-quality outcome) and mortality (RR: 1.20; 95% CI: 0.34 to 4.22; two studies; 168 participants; low-quality outcome). Community-based management of SAM with standard RUTF compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUTF was compared to non-milk/peanut butter-based RUTF (RR: 1.03; 95% CI: 0.99 to 1.08; five studies; 5743 participants; I2 50%; moderate quality outcome), energy-dense, home-prepared food (RR: 1.14; 95% CI 0.95 to 1.36; four studies; 959 participants; I2 75%; low quality outcome), or high oleic RUTF (RR: 1.06; 95% CI: 0.85 to 1.31; one study; 141 participants; moderate quality outcome). Standard RUTF may improve weight gain by 0.5 g·kg-1·day-1 (MD: 0.5 g·kg-1·day-1; 95% CI: 0.02 to 0.99; three studies; 3,069 participants; low-quality outcome) when compared with non-milk/peanut butter-based RUTF and by 5.5 g·kg-1·day-1 when compared with F100 (MD: 5.50 g·kg-1·day-1; 95% CI: 2.92 to 8.08; one study; 70 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUTF was compared with other foods (RR: 0.99; 95% CI: 0.69 to 1.41; nine studies; 7,667 participants; low-quality outcome). RUSF for MAM compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUSF was compared with local/home made food (RR: 0.92; 95% CI: 0.64 to 1.33; three studies; 435 participants; low-quality outcome) and whey RUSF (RR: 0.96; 95% CI: 0.92 to 1.00; one study; 2230 participants; high-quality outcome); while standard RUSF may improve recovery by 7% when compared with corn-soy blend (CSB) (RR: 1.07; 95% CI: 1.02 to 1.13; six studies; 5,744 participants; low-quality outcome). There was no evidence of effect on weight gain when standard RUSF was compared with local home made food (MD: -0.75 g·kg-1·day-1; 95% CI: -2.03 to 0.43; one study; 73 participants; low-quality outcome) and whey RUSF (MD: -0.16 g·kg-1·day-1; 95% CI: -0.33 to 0.01; one study; 2,230 participants; high-quality outcome); while standard RUSF may improve weight gain by 0.49 g·kg-1·day-1 when compared with CSB (MD: 0.49 g·kg-1·day-1; 95% CI: 0.10 to 0.87; five studies; 4,354 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUSF was compared with other foods (RR: 0.98; 95% CI: 0.57 to 1.68; eight studies; 8,310 participants; moderate-quality outcome). Prophylactic antibiotic versus no antibiotic (three studies): Prophylactic antibiotic therapy for uncomplicated SAM improves recovery rate by 6% (RR: 1.06; 95% CI: 1.03 to 1.08; two studies; 5,166 participants; high-quality outcome), probably improves weight gain by 0.67 g·kg-1·day-1 (MD: 0.67 g·kg-1·day-1; 95% CI: 0.28, 1.06; two studies; 5,052 participants; moderate-quality outcome) and probably reduces mortality by 26% (RR: 0.74; 95% CI: 0.55, 0.98; three studies; 6944 participants; moderate quality outcome) compared to no antibiotics group. High-dose vitamin A versus low-dose vitamin A (two studies): There was no evidence of effect on weight gain (MD: 0.05 g·kg-1·day-1; 95% CI: -0.08 to 0.18; one study; 207 participants; moderate-quality outcome) and mortality (RR: 7.07; 95% CI: 0.37 to 135.13; one study; 207 participants; moderate-quality outcome). Authors’ conclusions Limited data show some benefit of integrated community-based screening, identification and management of SAM and MAM on improving recovery. Facility-based screening and management of uncomplicated SAM has no benefit on recovery and mortality, while the effect of F100 for SAM is similar to RUTF for weight gain and mortality. Local food and whey RUSF have similar effects as standard RUSF on recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate, weight gain and reduces mortality, while limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.
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Affiliation(s)
- Jai K. Das
- Division of Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Rehana A. Salam
- Division of Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Marwah Saeed
- Division of Women and Child Health, Aga Khan UniversityKarachiPakistan
| | - Faheem Ali Kazmi
- Division of Women and Child Health, Aga Khan UniversityKarachiPakistan
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick ChildrenTorontoOntarioCanada
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Rahmawaty S, Meyer BJ. Stunting is a recognized problem: Evidence for the potential benefits of ω-3 long-chain polyunsaturated fatty acids. Nutrition 2020; 73:110564. [DOI: 10.1016/j.nut.2019.110564] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 07/11/2019] [Indexed: 02/06/2023]
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Chunda-Liyoka C, Lubeya MK, Imakando M, Kisling S, Majid S, Willis MS, Wood C, Kankasa C, DiRusso CC. Healthy pregnancies and essential fats: focus group discussions with Zambian women on dietary need and acceptability of a novel RUSF containing fish oil DHA. BMC Pregnancy Childbirth 2020; 20:93. [PMID: 32041569 PMCID: PMC7011535 DOI: 10.1186/s12884-020-2783-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 01/30/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Nut butter-based Ready to Use Supplemental Foods (RUSF) are an effective way to add nutrients and calories to diets of malnourished and food insecure populations. The RUSF formulations have been further modified to add micronutrients including iron and folic acid needed during pregnancy and lactation. Because docosahexaenoic acid (DHA, C22:6 n-3) enhances fetal development and birth outcomes, it has been suggested that perhaps RUSF formulations for pregnancy should also include this Omega 3 fatty acid. The goal of the present study was to gain an understanding of Zambian women's knowledge of nutritional needs in pregnancy through structured focus group discussions, and to formulate and determine the acceptability of a RUSF with DHA. METHODS Structured focus group sessions were conducted among women attending an antenatal clinic at the University Teaching Hospitals in Lusaka, Zambia. Dietary and nutrition knowledge was surveyed through structured dialogue that was recorded by audio and transcribed verbatim. An RUSF containing 400 mg DHA from fish oil in 50 g RUSF was designed and assessed for fatty acid content and product stability. Participants then sampled the RUSF-DHA, provided feedback on taste, and were surveyed about willingness to consume the novel formula using a standardized hedonic instrument. RESULTS The participants' knowledge of foods recommended for use in pregnancy included fruits, vegetables, meat, and fish. Most women reported eating fish at least once per week, although the specific type of fish varied. Most did not have prior knowledge of the importance of consuming fish during pregnancy or that some fish types were more nutritional than others as they included omega 3 fatty acids. The participants were uniformly accepting of the RUSF-DHA for the purpose of enhancing birth and developmental outcomes, but were critical of the aroma in hedonic testing. CONCLUSIONS Women were committed to consuming a healthy diet that would impact the outcome of pregnancy, and were receptive to advice on the importance of consuming foods such as fish as a source of DHA. The RUSF-DHA formulation was acceptable due to the potential benefits for the developing infant, however, the fishy odor may be limiting for long-term daily use.
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Affiliation(s)
- Catherine Chunda-Liyoka
- University Teaching Hospitals, Lusaka Children's Hospital, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Mwansa Ketty Lubeya
- University Teaching Hospitals, Women and Newborn Hospital, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Mercy Imakando
- University Teaching Hospitals, Women and Newborn Hospital, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Sophia Kisling
- Nebraska Center for Integrated Biomolecular Communications, Department of Biochemistry, N241 Beadle Center, University of Nebraska-Lincoln, Lincoln, NE, 68588, USA
| | - Sonoor Majid
- Nebraska Center for Integrated Biomolecular Communications, Department of Biochemistry, N241 Beadle Center, University of Nebraska-Lincoln, Lincoln, NE, 68588, USA
| | - Mary S Willis
- Department of Nutrition and Health Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Charles Wood
- Nebraska Center for Virology, School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Chipepo Kankasa
- University Teaching Hospitals, Lusaka Children's Hospital, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Concetta C DiRusso
- Nebraska Center for Integrated Biomolecular Communications, Department of Biochemistry, N241 Beadle Center, University of Nebraska-Lincoln, Lincoln, NE, 68588, USA.
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Das JK, Salam RA, Saeed M, Kazmi FA, Bhutta ZA. Effectiveness of Interventions for Managing Acute Malnutrition in Children under Five Years of Age in Low-Income and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients 2020; 12:nu12010116. [PMID: 31906272 PMCID: PMC7019612 DOI: 10.3390/nu12010116] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/15/2019] [Accepted: 12/22/2019] [Indexed: 11/17/2022] Open
Abstract
Childhood malnutrition is a major public health concern, as it is associated with significant short- and long-term morbidity and mortality. The objective of this review was to comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization (WHO) protocol using facility- and community-based approaches, as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use, and vitamin A supplementation. We searched relevant electronic databases until 11 February 2019, and performed a meta-analysis. This review summarizes findings from a total of 42 studies (48 papers), including 35,017 children. Limited data show some benefit of integrated community-based screening, identification, and management of SAM and MAM on improving recovery rate. Facility-based screening and management of uncomplicated SAM has no effect on recovery and mortality, while the effect of therapeutic milk F100 for SAM is comparable to RUTF for weight gain and mortality. Local food and whey RUSF are comparable to standard RUSF for recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate and probably improves weight gain and reduces mortality. Limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.
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Affiliation(s)
- Jai K. Das
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (J.K.D.); (R.A.S.); (F.A.K.)
| | - Rehana A. Salam
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (J.K.D.); (R.A.S.); (F.A.K.)
| | - Marwah Saeed
- Medical Student, Aga Khan University, Karachi 74800, Pakistan;
| | - Faheem Ali Kazmi
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (J.K.D.); (R.A.S.); (F.A.K.)
| | - Zulfiqar A. Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
- Centre for Global Child Health, the Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Correspondence:
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Park JJH, Harari O, Siden E, Dron L, Zannat NE, Singer J, Lester RT, Thorlund K, Mills EJ. Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis. Gates Open Res 2019; 3:1660. [PMID: 32259047 PMCID: PMC7096089 DOI: 10.12688/gatesopenres.13083.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 08/29/2023] Open
Abstract
Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) are critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness is currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ellie Siden
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | | | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Data and Methodology Program, CIHR Canadian HIV Trials Network, Vancouver, BC, V6Z 1Y6, Canada
| | - Richard T. Lester
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Kristian Thorlund
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Edward J. Mills
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
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Schoonees A, Lombard MJ, Musekiwa A, Nel E, Volmink J. Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age. Cochrane Database Syst Rev 2019; 5:CD009000. [PMID: 31090070 PMCID: PMC6537457 DOI: 10.1002/14651858.cd009000.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch-up growth is the main focus and the recommended energy and protein requirements are much higher. In-hospital rehabilitation of children with SAM is not always desirable or practical - especially in rural settings - and home-based care can offer a better solution. Ready-to-use therapeutic food (RUTF) is a widely used option for home-based rehabilitation, but the findings of our previous review were inconclusive. OBJECTIVES To assess the effects of home-based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. SEARCH METHODS We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost-effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. DATA COLLECTION AND ANALYSIS We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random-effects meta-analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. MAIN RESULTS We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source.The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta-analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV-infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV-uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes.We found seven studies with 2261 children comparing home-based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate-quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low-quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low-quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low-quality evidence).Two quasi-randomised cluster trials compared standard, home-based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta-analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low-quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low-quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low-quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI - 0.74 to 3.16; very low-quality evidence).Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home-based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre- and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high-quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high-quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate-quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI -0.32 to 0.54; 6 studies, 3807 children; low-quality evidence) whether standard or alternative formulation RUTF is used. AUTHORS' CONCLUSIONS Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well-designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed.
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Affiliation(s)
- Anel Schoonees
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
| | - Martani J Lombard
- North‐West UniversityCentre of Excellence for Nutrition (CEN)Hoffman StreetPotchefstroomPotchefstroomNorth West ProvinceSouth Africa2025
| | - Alfred Musekiwa
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
| | - Etienne Nel
- Stellenbosch UniversityDepartment of Paediatrics and Child Health, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
| | - Jimmy Volmink
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
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Callaghan-Gillespie M, Mui M. Useful Tools for Food Aid: Linear Programming and Protein Quality Tools. Food Nutr Bull 2018; 39:S80-S86. [PMID: 30238799 DOI: 10.1177/0379572118792759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The development of a superior treatment option for severe acute malnutrition (SAM) which allowed for home-based therapy put in place constraints that are crucial for ensuring the feasibility and nutritional integrity of the treatment. Soon after the initial success of ready-to-use therapeutic food (RUTF), there were attempts to modify the formulation for cost and other areas of acceptability. While alternative formulations have been taken on in clinical trials, they have been inferior to the standard RUTF recipe. Linear programming (LP) technology, however, has streamlined the formulation process allowing the user to account for the crucial constraints required to maintain the feasibility and nutritional integrity of standard RUTF. With the aid of an LP tool and other functional tools for assessing nutrient quality, nutrition researchers can use innovative approaches in food development that could potentially revolutionize food aid products.
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Affiliation(s)
| | - Melody Mui
- 1 Washington University School of Medicine, St Louis, Missouri, USA
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Huang TH, Wang PW, Yang SC, Chou WL, Fang JY. Cosmetic and Therapeutic Applications of Fish Oil's Fatty Acids on the Skin. Mar Drugs 2018; 16:E256. [PMID: 30061538 PMCID: PMC6117694 DOI: 10.3390/md16080256] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/20/2018] [Accepted: 07/28/2018] [Indexed: 02/07/2023] Open
Abstract
Fish oil has been broadly reported as a potential supplement to ameliorate the severity of some skin disorders such as photoaging, skin cancer, allergy, dermatitis, cutaneous wounds, and melanogenesis. There has been increasing interest in the relationship of fish oil with skin protection and homeostasis, especially with respect to the omega-3 polyunsaturated fatty acids (PUFAs), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA). The other PUFAs, such as α-linolenic acid (ALA) and linoleic acid (LA), also show a beneficial effect on the skin. The major mechanisms of PUFAs for attenuating cutaneous inflammation are the competition with the inflammatory arachidonic acid and the inhibition of proinflammatory eicosanoid production. On the other hand, PUFAs in fish oil can be the regulators that affect the synthesis and activity of cytokines for promoting wound healing. A systemic review was conducted to demonstrate the association between fish oil supplementation and the benefits to the skin. The following describes the different cosmetic and therapeutic approaches using fatty acids derived from fish oil, especially ALA, LA, DHA, and EPA. This review summarizes the cutaneous application of fish oil and the related fatty acids in the cell-based, animal-based, and clinical models. The research data relating to fish oil treatment of skin disorders suggest a way forward for generating advances in cosmetic and dermatological uses.
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Affiliation(s)
- Tse-Hung Huang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital at Keelung, Keelung 20401, Taiwan.
- School of Traditional Chinese Medicine, Chang Gung University, Kweishan, Taoyuan 33303, Taiwan.
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei 11219, Taiwan.
| | - Pei-Wen Wang
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan.
| | - Shih-Chun Yang
- Department of Cosmetic Science, Providence University, Taichung 43301, Taiwan.
| | - Wei-Ling Chou
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital at Keelung, Keelung 20401, Taiwan.
| | - Jia-You Fang
- Pharmaceutics Laboratory, Graduate Institute of Natural Products, Chang Gung University, Kweishan, Taoyuan 33302, Taiwan.
- Chinese Herbal Medicine Research Team, Healthy Aging Research Center, Chang Gung University, Kweishan, Taoyuan 33302, Taiwan.
- Research Center for Food and Cosmetic Safety and Research Center for Chinese Herbal Medicine, Chang Gung University of Science and Technology, Kweishan, Taoyuan 33302, Taiwan.
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan 33305, Taiwan.
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30
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Abstract
PURPOSE OF REVIEW Advances in our understanding of the treatment of severe acute malnutrition (SAM) in a resource-limited environment are needed to improve outcome. RECENT FINDINGS Ready-to-use therapeutic foods (RUTFs) made from local products and with reduced milk content lower costs and may be effective in older children. None of the therapeutic foods used to treat severely malnourished children correct long chain polyunsaturated fatty acid deficiencies.Routine short-term antibiotic (amoxicillin) treatment, in the context of adequate healthcare supervision, does not improve the recovery rate. Long-term antibiotic (cotrimoxazole) treatment also does not provide significant benefit to non-HIV-infected children.Increased pathogenic bacteria have been found in the intestinal microbiome of malnourished children and candidate organisms for use as probiotics have been identified. There is, however, no evidence to support the routine use of probiotics in these children. Although exocrine pancreatic function is reduced in malnourished children, routine pancreatic enzyme supplementation does not lead to accelerated recovery. SUMMARY Alternative RUTF may provide a cheaper and more acceptable alternative to standard RUTF in the near future. Further research is needed to understand the implications of fatty acid deficiencies and dysbiosis that occur in malnourished children. Routine antibiotic administration in the appropriate setting is unnecessary.
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Affiliation(s)
- Etienne Nel
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
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Development and Physico-Chemical Characterization of a Shea Butter-Containing Lipid Nutrition Supplement for Sub-Saharan Africa. Foods 2017; 6:foods6110097. [PMID: 29117103 PMCID: PMC5704141 DOI: 10.3390/foods6110097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/03/2017] [Accepted: 11/06/2017] [Indexed: 11/28/2022] Open
Abstract
Lipid-based nutrient supplements (LNS) are used to prevent and treat moderate and severe acute malnutrition, a leading cause of mortality in children-under-five. The physical and chemical changes of two new LNS products were evaluated before and after accelerated shelf life testing (ASLT) according to protocols suggested by the U.S. Agency for International Development (USAID) and Doctors without Borders and compared against USAID’s A-20 paste as a control. LNS formulas containing Shea butter from the Shea nut tree (Vitellaria paradoxa), a common fat source in parts of Sub-Saharan Africa, with and without flax-seed oil, as a source of omega-3 fatty acids, were developed. LNS formulas were batched (0.8 kg) in a wet grinder, sealed under nitrogen in three-layer mini-pouches (20 g), and underwent ASLT at 40 ± 2 °C for six months with sampling every eight weeks. At each time point, water activity, moisture, peroxide value, oil separation, vitamin C content, and hardness were evaluated. Results showed comparable stability among all formulas with an increase in Aw (p < 0.05) but no change in vitamin C, oil separation, or peroxide value. Addition of Shea butter improved the LNS’s hardness, which remained stable over time. Modifying fat profile in LNS can improve its texture and essential fatty acid content without affecting its storage stability.
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Abstract
The global impact of childhood malnutrition is staggering. The synergism between malnutrition and infection contributes substantially to childhood morbidity and mortality. Anthropometric indicators of malnutrition are associated with the increased risk and severity of infections caused by many pathogens, including viruses, bacteria, protozoa, and helminths. Since childhood malnutrition commonly involves the inadequate intake of protein and calories, with superimposed micronutrient deficiencies, the causal factors involved in impaired host defense are usually not defined. This review focuses on literature related to impaired host defense and the risk of infection in primary childhood malnutrition. Particular attention is given to longitudinal and prospective cohort human studies and studies of experimental animal models that address causal, mechanistic relationships between malnutrition and host defense. Protein and micronutrient deficiencies impact the hematopoietic and lymphoid organs and compromise both innate and adaptive immune functions. Malnutrition-related changes in intestinal microbiota contribute to growth faltering and dysregulated inflammation and immune function. Although substantial progress has been made in understanding the malnutrition-infection synergism, critical gaps in our understanding remain. We highlight the need for mechanistic studies that can lead to targeted interventions to improve host defense and reduce the morbidity and mortality of infectious diseases in this vulnerable population.
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Abstract
The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - James A Berkley
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, UK
| | - Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Laos
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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Gaur S, Sloffer EM, Ojha A, Patra F, Shukla D, Engeseth NJ, Patel PR, Andrade JE. Omega-3-Fortified Lipid-Based Nutrient Supplement: Development, Characterization, and Consumer Acceptability. Food Nutr Bull 2017; 38:158-171. [DOI: 10.1177/0379572117701234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Incorporation of omega-3 polyunsaturated fatty acid (PUFA) sources to lipid-based nutrition supplement (LNS) formulations for undernourished populations presents a challenge due to reduced shelf life and poor consumer acceptability. Objective: To systematically develop an omega-3-fortified LNS formulation, using flaxseed oil (FO), by optimizing its processing stability and evaluating its sensory acceptance. Methods: LNS formulations were formulated to yield approximately 452 kcal, 13.2 g of protein, 30 g of fat, and 53 g of carbohydrates per 100 g. Response surface methodology (RSM) with 4-factor-3-level: omega-3 fatty acid source (FO; 0%-10%), antioxidant (ascorbyl palmitate: 0.0%-0.03%), emulsifier (soy lecithin: 0.5%-1.5%), and storage time (0-6 months at 40°C) was used to optimize LNS’s functionality and storage stability. Factor effects were evaluated for peroxide value, oil separation, water activity, moisture content, hardness, and vitamin C content of the samples. Consumer acceptability was assessed using a 9-point hedonic scale. Results: After 6 months of accelerated storage, the addition of FO to LNS formula resulted in increased peroxide values (7.75 mEq/kg fat) and lipid separation and a reduction in vitamin C and water activity. Optimal levels to maximize storage time and FO and minimize oxidation were 0.02% antioxidant, 1.5% emulsifier, and 4.9% FO. Indian women and students accepted LNS formulations with or without FO similar to other commercial supplements. Conclusion: An LNS containing FO with improved omega-6/omega-3 PUFA ratio was successfully formulated with staple Indian ingredients and optimized for storage stability using RSM.
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Affiliation(s)
- Shashank Gaur
- Department of Food Science and Human Nutrition, University of Illinois, Urbana–Champaign, Urbana, IL, USA
| | - Elizabeth M. Sloffer
- Department of Food Science and Human Nutrition, University of Illinois, Urbana–Champaign, Urbana, IL, USA
| | - Ankur Ojha
- Mansinhbhai Institute of Dairy and Food Technology, Mehsana, Gujarat, India
| | - Falguni Patra
- Mansinhbhai Institute of Dairy and Food Technology, Mehsana, Gujarat, India
| | - Dharmendra Shukla
- Mansinhbhai Institute of Dairy and Food Technology, Mehsana, Gujarat, India
| | - Nicki J. Engeseth
- Department of Food Science and Human Nutrition, University of Illinois, Urbana–Champaign, Urbana, IL, USA
| | - Pramthesh R. Patel
- Mansinhbhai Institute of Dairy and Food Technology, Mehsana, Gujarat, India
| | - Juan E. Andrade
- Department of Food Science and Human Nutrition, University of Illinois, Urbana–Champaign, Urbana, IL, USA
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Picklo MJ, Johnson L, Idso J. PPAR mRNA Levels Are Modified by Dietary n-3 Fatty Acid Restriction and Energy Restriction in the Brain and Liver of Growing Rats. J Nutr 2017; 147:161-169. [PMID: 27927977 DOI: 10.3945/jn.116.237107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/07/2016] [Accepted: 11/15/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Without dietary sources of n-3 (ω-3) long-chain polyunsaturated fatty acids (LCPUFAs), α-linolenic acid (ALA; 18:3n-3) is the precursor for docosahexaenoic acid (DHA; 22:6n-3). It is not known how energy restriction (ER) affects ALA conversion to DHA. OBJECTIVE We tested the hypothesis that ER reduces n-3 LCPUFA concentrations in tissues of growing rats fed diets replete with and deficient in ALA. METHODS Male Sprague-Dawley rats (23 d old) were provided AIN93G diets (4 wk) made with soybean oil (SO; ALA sufficient) or corn oil (CO; ALA deficient) providing 16% of energy as fat. For each dietary oil, ER rats were individually pair-fed 75% of another rat's ad libitum (AL) intake. Fatty acid (FA) concentrations in brain regions, liver, and plasma were analyzed. Expression of peroxisome proliferator-activated receptors (PPARs), uncoupling proteins (UCPs), and mitochondrial DNA was analyzed in the brain and liver. RESULTS AL rats consuming CO had a 65% lower concentration of n-3 docosapentaenoic acid (22:5n-3) and a 10% lower DHA concentration in the cerebral cortex and cerebellum than did the SO-AL group. ER did not alter cerebral n-3 LCPUFA status. Liver n-3 LCPUFA concentrations were reduced in rats fed CO compared with SO. ER reduced hepatic linoleic acid (18:2n-6), ALA, and arachidonic acid (20:4n-6) regardless of oil. ER and n-3 FA deficiency had independent effects on the mRNA levels of Pparα, Pparβ/δ, and Pparγ in the liver, cerebral cortex, and cerebellum. ER reduced Ucp3 mRNA by nearly 50% in the cerebral cortex, cerebellum, and liver, and Ucp5 mRNA was 30% lower in the cerebellum of rats receiving the CO diet. CONCLUSIONS Small perturbations in PUFA concentration and ER modify the mRNA levels of Ppar and Ucp in the juvenile rat brain. More research is needed to identify the long-term physiologic and behavioral impacts of ER and PUFA restriction in the juvenile brain.
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Affiliation(s)
- Matthew J Picklo
- USDA Agricultural Research Service Grand Forks Human Nutrition Research Center, Grand Forks, ND
| | - LuAnn Johnson
- USDA Agricultural Research Service Grand Forks Human Nutrition Research Center, Grand Forks, ND
| | - Joseph Idso
- USDA Agricultural Research Service Grand Forks Human Nutrition Research Center, Grand Forks, ND
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Tickell KD, Denno DM. Inpatient management of children with severe acute malnutrition: a review of WHO guidelines. Bull World Health Organ 2016; 94:642-651. [PMID: 27708469 PMCID: PMC5034633 DOI: 10.2471/blt.15.162867] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 02/01/2023] Open
Abstract
Objective To understand how the World Health Organization’s (WHO’s) guidelines on the inpatient care of children with complicated severe acute malnutrition may be strengthened to improve outcomes. Methods In December 2015, we searched Google scholar and WHO’s website for WHO recommendations on severe acute malnutrition management and evaluated the history and cited evidence behind these recommendations. We systematically searched WHO International Clinical Trials Registry Platform, clinicaltrials.gov and the Controlled Trials metaRegister until 10 August 2015 for recently completed, ongoing, or pending trials. Findings WHO’s guidelines provide 33 recommendations on the topic. However, 16 (48.5%) of these recommendations were based solely on expert opinion – unsupported by published evidence. Another 11 (33.3%) of the recommendations were supported by the results of directly relevant research – i.e. either randomized trials (8) or observational studies (3). The other six recommendations (18.2%) were based on studies that were not conducted among children with complicated severe malnutrition or studies of treatment that were not identical to the recommended intervention. Trials registries included 20 studies related to the topic, including nine trials of alternative feeding regimens. Acute medical management and follow-up care studies were minimally represented. Conclusion WHO’s guidelines on the topic have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with severe malnutrition is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.
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Affiliation(s)
- Kirkby D Tickell
- Department of Epidemiology, University of Washington, Seattle, United States of America (USA)
| | - Donna M Denno
- Departments of Pediatrics and Global Health, University of Washington, 6200 NE 74th Street, Suite 110, Box 354920, Seattle, WA 98115, USA
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Jumbe T, Comstock SS, Hahn SL, Harris WS, Kinabo J, Fenton JI. Whole Blood Levels of the n-6 Essential Fatty Acid Linoleic Acid Are Inversely Associated with Stunting in 2-to-6 Year Old Tanzanian Children: A Cross-Sectional Study. PLoS One 2016; 11:e0154715. [PMID: 27137223 PMCID: PMC4854382 DOI: 10.1371/journal.pone.0154715] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 04/18/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In Tanzania, 35% of all children below five years of age are stunted. Dietary fatty acids (FA) are critical for growth and development. However, whole blood FA levels in Tanzanian children are poorly described. OBJECTIVE The objectives of this cross-sectional study were to assess 1) whole blood levels of essential fatty acids and 2) the association between whole blood FA levels and growth parameters in Tanzanian children 2-6 years of age. METHODS A drop of blood was collected on an antioxidant treated card and analyzed for FA composition. Weight and height were measured and z-scores calculated. Relationships between FAs and growth parameters were analyzed by linear regression. RESULTS Of the 334 children that participated, 30.3% were stunted. The average whole blood level of Mead acid was 0.15%. The anthropometric z-score height-for-age (HAZ) was inversely associated with Mead acid, the Mead acid to arachidonic acid (T/T) ratio, and total n-9 FA. Additionally, HAZ was positively associated with linoleic acid and total n-6 FA. BMI-for-age was positively associated with oleic acid, total n-9 FA and T/T ratio but inversely associated with arachidonic acid and total n-6 FA. Weight-for-height was inversely associated with arachidonic acid and total n-6 FAs and positively associated with oleic acid and total n-9 FA. Weight-for-age was not associated with any FA tested. Total n-3 FAs were not associated with any growth parameters measured. CONCLUSIONS The EFA linoleic acid and the markers of FA deficiency were associated with HAZ, an indicator for stunting in 2-6 year old Tanzanian children. Total n-6, total n-9, and a number of individual FAs were associated with growth. Increasing dietary intake of EFA and n-6 FAs may be a strategy to combat stunting in this population.
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Affiliation(s)
- Theresia Jumbe
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
- Sokoine University of Agriculture, Morogoro, Tanzania
| | - Sarah S. Comstock
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
| | - Samantha L. Hahn
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
| | - William S. Harris
- Sanford School of Medicine, University of South Dakota and OmegaQuant Analytics, LLC, Sioux Falls, South Dakota, United States of America
| | - Joyce Kinabo
- Sokoine University of Agriculture, Morogoro, Tanzania
| | - Jenifer I. Fenton
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
- * E-mail:
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Changes in whole-blood PUFA and their predictors during recovery from severe acute malnutrition. Br J Nutr 2016; 115:1730-9. [DOI: 10.1017/s0007114516000817] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractChildren with severe acute malnutrition (SAM) with complications require in-patient management including therapeutic feeding. Little attention has been given to the effects of these feeds on the essential fatty acid status of children with SAM. The objective of this study was to describe changes in the PUFA composition in whole blood in children with SAM during treatment and to determine predictors of change. This prospective study took place in a paediatric nutrition rehabilitation unit in Kampala, Uganda, and assessed whole-blood fatty acid composition of children with SAM at admission, transition, discharge and follow-up (8 and 16 weeks). ANCOVA was used to identify predictors of change in whole-blood PUFA. The study included 120 children with SAM and twenty-nine healthy control children of similar age and sex. Among the SAM children, 38 % were female and 64 % had oedema. Whole-blood n-6 PUFA proportions increased from admission to follow-up, except for arachidonic acid, which decreased by 0·79 (95 % CI 0·46, 1·12) fatty acid percentage (FA%) from admission to transition and 0·10 (95 % CI 0·23, 0·44) FA% at discharge. n-3 Long-chain (LC) PUFA decreased by 0·21 (95 % CI 0·03, 0·40) FA% at discharge and 0·22 (95 % CI 0·01, 0·42) FA% at 8 weeks of follow-up. This decrease was greater in children from families with recent fish intake and those with nasogastric tube feeding. Current therapeutic feeds do not correct whole-blood levels of LCPUFA, particularly n-3 LCPUFA, in children with SAM. Increased attention is needed to the contents of n-3 LCPUFA in therapeutic feeds.
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Brenna JT, Akomo P, Bahwere P, Berkley JA, Calder PC, Jones KD, Liu L, Manary M, Trehan I, Briend A. Balancing omega-6 and omega-3 fatty acids in ready-to-use therapeutic foods (RUTF). BMC Med 2015; 13:117. [PMID: 25980919 PMCID: PMC4433071 DOI: 10.1186/s12916-015-0352-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 04/23/2015] [Indexed: 11/30/2022] Open
Abstract
Ready-to-use therapeutic foods (RUTFs) are a key component of a life-saving treatment for young children who present with uncomplicated severe acute malnutrition in resource limited settings. Increasing recognition of the role of balanced dietary omega-6 and omega-3 polyunsaturated fatty acids (PUFA) in neurocognitive and immune development led two independent groups to evaluate RUTFs. Jones et al. (BMC Med 13:93, 2015), in a study in BMC Medicine, and Hsieh et al. (J Pediatr Gastroenterol Nutr 2015), in a study in the Journal of Pediatric Gastroenterology and Nutrition, reformulated RUTFs with altered PUFA content and looked at the effects on circulating omega-3 docosahexaenoic acid (DHA) status as a measure of overall omega-3 status. Supplemental oral administration of omega-3 DHA or reduction of RUTF omega-6 linoleic acid using high oleic peanuts improved DHA status, whereas increasing omega-3 alpha-linolenic acid in RUTF did not. The results of these two small studies are consistent with well-established effects in animal studies and highlight the need for basic and operational research to improve fat composition in support of omega-3-specific development in young children as RUTF use expands.
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Affiliation(s)
- J Thomas Brenna
- Division of Nutritional Sciences, Savage Hall, Cornell University, Ithaca, NY, 14850, USA.
| | - Peter Akomo
- Valid Nutrition, Cuibín Farm, Derry Duff, Bantry Co., Cork, Republic of Ireland.
| | - Paluku Bahwere
- Valid International, 35 Leopold Street, Oxford, OX4 1TW, UK.
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, 230-80108, Kenya. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine & Global Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.
| | - Philip C Calder
- Faculty of Medicine, University of Southampton, Institute of Developmental Sciences Building (MP887), Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
| | - Kelsey D Jones
- KEMRI-Wellcome Trust Research Programme, Kilifi, 230-80108, Kenya. .,Centre for Global Health Research and Section of Paediatrics, Imperial College, Norfolk Place, London, W2 1PG, UK.
| | - Lei Liu
- Division of Nutritional Sciences, Savage Hall, Cornell University, Ithaca, NY, 14850, USA.
| | - Mark Manary
- Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid, Campus Box 8116, St. Louis, MO, USA.
| | - Indi Trehan
- Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid, Campus Box 8116, St. Louis, MO, USA. .,University of Malawi College of Medicine, P/Bag 360 Chichiri, Blantyre, 3, Malawi.
| | - André Briend
- Department for International Health, University of Tampere School of Medicine, FIN-33014, Tampere, Finland. .,Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 30, DK-1958, Frederiksberg, Denmark.
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