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Kiguli S, Olupot-Olupot P, Hamaluba M, Giallongo E, Thomas K, Alaroker F, Opoka RO, Tagoola A, Oyella S, Nalwanga D, Nabawanuka E, Okiror W, Nakuya M, Amorut D, Muhindo R, Ayub Mpoya, Mnjalla H, Oguda E, Williams TN, Harrison DA, Rowan K, Briend A, Maitland K. Nutritional supplementation in children with severe pneumonia in Uganda and Kenya (COAST-Nutrition): a phase 2 randomised controlled trial. EClinicalMedicine 2024; 72:102640. [PMID: 38774673 PMCID: PMC11106534 DOI: 10.1016/j.eclinm.2024.102640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/24/2024] Open
Abstract
Background Severe pneumonia in African children results in poor long-term outcomes (deaths/readmissions) with undernutrition as a key risk factor. We hypothesised additional energy/protein-rich Ready-to-Use Therapeutic Foods (RUTF) would meet additional nutritional requirements and improve outcomes. Methods COAST-Nutrition was an open-label Phase 2 randomised controlled trial in children (aged 6 months-12 years) hospitalised with severe pneumonia (and hypoxaemia, SpO2 <92%) in Mbale, Soroti, Jinja, Masaka Regional Referral Hospitals, Uganda and Kilifi County Hospital, Kenya (ISRCTN10829073 (registered 6th June 2018) PACTR202106635355751 (registered 2nd June 2021)). Children were randomised (ratio 1:1) to enhanced nutritional supplementation with RUTF (plus usual diet) for 56 days vs usual diet (control). The primary outcome was change in mid-upper arm circumference (MUAC) at 90 days as a composite with mortality. Secondary outcomes include anthropometric status, mortality, and readmissions at Days 28, 90 and 180. Findings Between 12 August 2018 and 22 April 2022, 846 eligible children were randomised, 424 to RUTF and 422 to usual diet, and followed for 180-days [12 (1%) lost-to-follow-up]. RUTF supplement was initiated in 417/419 (>99%). By Day 90, there was no significant difference in the composite endpoint (probabilistic index 0.49, 95% CI 0.45-0.53, p = 0.74). Respective 90-day mortality (13/420 3.1% vs 14/421 3.3%) and MUAC increment (0.54 (SD 0.85) vs 0.55 (SD 0.81)) were similar between arms. There was no difference in any anthropometric secondary endpoints to Day 28, 90 or 180 except skinfold thickness at Day 28 and Day 90 was greater in the RUTF arm. Serious adverse events were higher in the RUTF arm (n = 164 vs 108), mainly due to hospital readmission for acute illness (54/387 (14%) vs 37/375 (10%). Interpretation Our study suggested that nutritional supplementation with RUTF did not improve outcomes to 180 days in children with severe pneumonia. Funding This trial is part of the EDCTP2 programme (grant number RIA-2016S-1636-COAST-Nutrition) supported by the European Union, and UK Joint Global Health Trials scheme: Medical Research Council, Department for International Development, Wellcome Trust (grant number MR/L004364/1, UK).
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Affiliation(s)
- Sarah Kiguli
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
| | - Peter Olupot-Olupot
- Busitema University Faculty of Health Sciences, Mbale Campus, Uganda
- Mbale Regional Referral Hospital Mbale, Uganda
| | - Mainga Hamaluba
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elisa Giallongo
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | | | - Robert O. Opoka
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
- Jinja Regional Referral Hospital Jinja, Uganda
| | | | - Shela Oyella
- Masaka Regional Referral Hospital Masaka, Uganda
| | - Damalie Nalwanga
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
| | - Eva Nabawanuka
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
- Department of Radiology, School of Medicine, Makerere University, P.O Box 7072, Kampala, Uganda
| | - William Okiror
- Busitema University Faculty of Health Sciences, Mbale Campus, Uganda
- Mbale Regional Referral Hospital Mbale, Uganda
| | | | - Denis Amorut
- Soroti Regional Referral Hospital, Soroti, Uganda
| | | | - Ayub Mpoya
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Hellen Mnjalla
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Emmanuel Oguda
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Thomas N. Williams
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Kathy Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Andre Briend
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Kathryn Maitland
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
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Gizaw G, Bahwere P, Argaw A, Wells JCK, Friis H, Olsen MF, Abdissa A, Wibaek R, Abera M, Sadler K, Boyd E, Collins S, Girma T. Growth and Body Composition 5 y After Treatment for Severe Acute Malnutrition: A 5-y Prospective Matched Cohort Study in Ethiopian Children. Am J Clin Nutr 2023; 118:1029-1041. [PMID: 37923494 DOI: 10.1016/j.ajcnut.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Short-term anthropometric outcomes are well documented for children treated for severe acute malnutrition (SAM). However, anthropometric recovery may not indicate restoration of healthy body composition. OBJECTIVES This study aimed to evaluate long-term associations of SAM with growth and body composition of children 5 y after discharge from community-based management of acute malnutrition (CMAM). METHODS We conducted a 5-y prospective cohort study, enrolling children aged 6 to 59 mo discharged from CMAM (post-SAM) (n = 203) and nonmalnourished matched controls (n = 202) from Jimma Zone, Ethiopia in 2013. Anthropometry and body composition (bioelectrical impedance) were assessed. Multiple linear regression models tested differences in height-for-age (HAZ), weight-for-age (WAZ), and body mass index-for-age (BAZ) z-scores; height-adjusted fat-free mass index (FFMI); and FM index (FMI) between groups. RESULTS Post-SAM children had higher stunting prevalence than controls at discharge (82.2% compared with 36.0%; P < 0.001), 1 y (80.2% compared with 53.7%; P < 0.001), and 5 y postdischarge (74.2% compared with 40.8%; P < 0.001). Post-SAM children remained 5 cm shorter throughout follow-up, indicating no HAZ catch-up. No catch-up in WAZ or BAZ was observed. Post-SAM children had lower hip (-2.05 cm; 95% CI: -2.73, -1.36), waist (-0.92 cm; CI: -1.59, -0.23) and mid-upper arm (-0.64 cm; CI: -0.90, -0.42) circumferences and lower-limb length (-1.57 cm; 95% CI: -2.21, -0.94) at 5 y postdischarge. They had larger waist-hip (0.02 cm; 95% CI: 0.008, 0.033) and waist-height (0.013 cm; 95% CI: 0.004, 0.021) ratios, and persistent deficits in FFMI at discharge and 6 mo and 5 y postdischarge (P < 0.001 for all). No difference was detected in head circumference, sitting height, or FMI. CONCLUSIONS Five y after SAM treatment, children maintained deficits in HAZ, WAZ, BAZ, and FFMI, with preservation of FMI, sitting height, and head circumference at the expense of lower-limb length, indicating a "thrifty growth" pattern. Research is urgently needed to identify effective clinical and public health interventions to mitigate these consequences of malnutrition.
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Affiliation(s)
- Getu Gizaw
- Department of Human Nutrition and Dietetics, Jimma University, Jimma, Ethiopia; Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.
| | - Paluku Bahwere
- Valid International, Oxford, United Kingdom; Center for Epidemiology, Biostatistics, and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
| | - Alemayehu Argaw
- Department of Human Nutrition and Dietetics, Jimma University, Jimma, Ethiopia; Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Mette Frahm Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Alemseged Abdissa
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Laboratory Sciences, Jimma University, Jimma, Ethiopia; Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Rasmus Wibaek
- Clinical Epidemiology, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Mubarek Abera
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Psychiatry, Jimma University, Jimma, Ethiopia
| | | | - Erin Boyd
- United States Agency for International Development, Washington DC, USA
| | | | - Tsinuel Girma
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
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Padhani ZA, Cichon B, Das JK, Salam RA, Stobaugh HC, Mughal M, Rutishauser-Perera A, Black RE, Bhutta ZA. Systematic Review of Management of Moderate Wasting in Children over 6 Months of Age. Nutrients 2023; 15:3781. [PMID: 37686813 PMCID: PMC10490450 DOI: 10.3390/nu15173781] [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: 08/03/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
The effective management of the 33 million children with moderate acute malnutrition (MAM) is key to reducing childhood morbidity and mortality. In this review, we aim to evaluate the effectiveness of specially formulated foods (SFFs) compared to non-food-based approaches to manage MAM in children >6 months old. We conducted a search on ten databases until 23 August 2021 and included five studies, covering 3387 participants. Meta-analysis of four studies comparing SFFs to counselling or standard of care showed that SFFs likely increase recovery rate, reduce non-response, and may improve weight-for-height z-score, weight-for-age z-score and time to recovery, but have little or no effect on MUAC gain. One study on a multicomponent intervention (SFFs, antibiotics and counselling provided to high-risk MAM) compared to counselling only was reported narratively. The intervention may increase weight gain after 24 weeks but may have little or no effect on weight gain after 12 weeks and on non-response and mortality after 12 and 24 weeks of enrollment. The effect of this intervention on recovery was uncertain. In conclusion, SFFs may be beneficial for children with moderate wasting in humanitarian contexts. Programmatic recommendations should consider context and cost-effectiveness.
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Affiliation(s)
- Zahra A. Padhani
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, SA 5000, Australia
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan; (J.K.D.); or (Z.A.B.)
| | | | - Jai K. Das
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan; (J.K.D.); or (Z.A.B.)
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Rehana A. Salam
- Centre of Research Excellence, Melanoma Institute Australia, University of Sydney, Sydney, NSW 2006, Australia;
| | - Heather C. Stobaugh
- Action against Hunger USA, Technical Services and Innovation Department, Washington, DC 20463, USA;
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA
| | - Muzna Mughal
- Action against Hunger UK, London SE10 0ER, UK; (M.M.); (A.R.-P.)
| | | | - Robert E. Black
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA;
| | - Zulfiqar A. Bhutta
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan; (J.K.D.); or (Z.A.B.)
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
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Potani I, Daniel AI, Briend A, Courtney-Martin G, Berkley JA, Voskuijl W, Vresk L, Bourdon C, Kathumba S, Mbale E, Bandsma RHJ. A protocol for a proof-of-concept randomized control trial testing increased protein quantity and quality in ready-to-use therapeutic food in improving linear growth among 6-23-month-old children with severe wasting in Malawi. PLoS One 2023; 18:e0287680. [PMID: 37619218 PMCID: PMC10449476 DOI: 10.1371/journal.pone.0287680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/07/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Ready-to-use therapeutic foods (RUTFs) have successfully promoted recovery from severe wasting and increased treatment coverage. However, RUTFs do not sufficiently improve linear growth, leaving many survivors of severe wasting at risk of persistent stunting, which is associated with high mortality risk, poor child development and non-communicable diseases in adulthood. High protein quantity and quality can stimulate linear growth. AIM The trial aims to assess whether higher-protein-RUTF leads to higher concentrations of markers of linear growth compared to standard RUTF among 6-23 months old children with severe wasting. METHODS We designed a higher protein quantity and quality RUTF for a proof-of-concept (PoC) double-blind randomized controlled trial. OUTCOMES The primary outcome is a change in insulin-like growth factor-1 (IGF-1), a hormone positively associated with linear growth after four weeks of treatment. Secondary outcomes include changes in ponderal and linear growth and in body composition from baseline to eight weeks later; plasma amino acid profile at four weeks; acceptability and safety. IMPLICATIONS These findings will help in informing the potential impact of increased protein in RUTF on linear growth when treating severe wasting towards conducting a larger clinical trial. TRIAL REGISTRATION The trial has been registered on clinicaltrial.gov (NCT05737472).
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Affiliation(s)
- Isabel Potani
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Allison I. Daniel
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Independent Nutrition Consultant, Toronto, Canada
| | - André Briend
- Centre for Child Health Research, University of Tampere School of Medicine, Tampere, Finland
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Glenda Courtney-Martin
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - James A. Berkley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Clinical Research Department, Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Wieger Voskuijl
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Amsterdam Universtair Medische Centra, University of Amsterdam, Amsterdam Centre for Global Child Health, Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Laura Vresk
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Celine Bourdon
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Sylvester Kathumba
- Department of Nutrition and Human Immunodeficiency Virus, Ministry of Health, Lilongwe, Malawi
| | - Emmie Mbale
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Robert H. J. Bandsma
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Lelijveld N, Cox S, Anujuo K, Amoah AS, Opondo C, Cole TJ, Wells JCK, Thompson D, McKenzie K, Abera M, Berhane M, Kerac M. Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi 'ChroSAM' cohort. Public Health Nutr 2023; 26:1658-1670. [PMID: 36876519 PMCID: PMC10466107 DOI: 10.1017/s1368980023000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 01/05/2023] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE To explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition and describe associations with survival and non-communicable disease (NCD) risk 7 years post-treatment. DESIGN Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score and height-for-age z-score (HAZ). Three categorisation methods included no categorisation, quintiles and latent class analysis (LCA). Associations with mortality risk and seven NCD indicators were analysed. SETTING Secondary data from Blantyre, Malawi between 2006 and 2014. PARTICIPANTS A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score < 70 % median and/or MUAC (mid-upper arm circumference) < 110 mm and/or bilateral oedema) at ages 5-168 months. RESULTS Faster weight gain during treatment (g/d) and after treatment (g/kg/day) was associated with lower risk of death (adjusted OR 0·99, 95 % CI 0·99, 1·00; and adjusted OR 0·91, 95 % CI 0·87, 0·94, respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0·02, 95 % CI 0·00, 0·03) and larger HAZ (6·62, 95 % CI 1·31, 11·9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0·02, 95 % CI 0·01, 0·03), an indicator of later-life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/d during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. CONCLUSIONS A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.
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Affiliation(s)
- Natasha Lelijveld
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Emergency Nutrition Network (ENN), Oxford, UK
- Centre for Maternal, Adolescent & Reproductive Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Sioned Cox
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Kenneth Anujuo
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Abena S Amoah
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Charles Opondo
- Department of Medical Statistics, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim J Cole
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jonathan CK Wells
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Debbie Thompson
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | - Kimberley McKenzie
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | | | | | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Centre for Maternal, Adolescent & Reproductive Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
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6
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Mbabazi J, Pesu H, Mutumba R, Filteau S, Lewis JI, Wells JC, Olsen MF, Briend A, Michaelsen KF, Mølgaard C, Ritz C, Nabukeera-Barungi N, Mupere E, Friis H, Grenov B. Effect of milk protein and whey permeate in large quantity lipid-based nutrient supplement on linear growth and body composition among stunted children: A randomized 2 × 2 factorial trial in Uganda. PLoS Med 2023; 20:e1004227. [PMID: 37220111 DOI: 10.1371/journal.pmed.1004227] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/29/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Despite possible benefits for growth, milk is costly to include in foods for undernourished children. Furthermore, the relative effects of different milk components, milk protein (MP), and whey permeate (WP) are unclear. We aimed to assess the effects of MP and WP in lipid-based nutrient supplement (LNS), and of LNS itself, on linear growth and body composition among stunted children. METHODS AND FINDINGS We performed a randomized, double-blind, 2 × 2 factorial trial among 12 to 59 months old stunted children in Uganda. Children were randomized to 4 formulations of LNS with MP or soy protein isolate and WP or maltodextrin (100 g/day for 12 weeks) or no supplementation. Investigators and outcome assessors were blinded; however, participants were only blinded to the ingredients in LNS. Data were analyzed based on intention-to-treat (ITT) using linear mixed-effects models adjusted for age, sex, season, and site. Primary outcomes were change in height and knee-heel length, and secondary outcomes included body composition by bioimpedance analysis (ISRCTN13093195). Between February and September 2020, we enrolled 750 children with a median age of 30 (interquartile range 23 to 41) months, with mean (± standard deviation) height-for-age z-score (HAZ) -3.02 ± 0.74 and 12.7% (95) were breastfed. The 750 children were randomized to LNS (n = 600) with or without MP (n = 299 versus n = 301) and WP (n = 301 versus n = 299), or no supplementation (n = 150); 736 (98.1%), evenly distributed between groups, completed 12-week follow-up. Eleven serious adverse events occurred in 10 (1.3%) children, mainly hospitalization with malaria and anemia, all deemed unrelated to the intervention. Unsupplemented children had 0.06 (95% confidence interval, CI [0.02, 0.10]; p = 0.015) decline in HAZ, accompanied by 0.29 (95% CI [0.20, 0.39]; p < 0.001) kg/m2 increase in fat mass index (FMI), but 0.06 (95% CI [-0.002; 0.12]; p = 0.057) kg/m2 decline in fat-free mass index (FFMI). There were no interactions between MP and WP. The main effects of MP were 0.03 (95% CI [-0.10, 0.16]; p = 0.662) cm in height and 0.2 (95% CI [-0.3, 0.7]; p = 0.389) mm in knee-heel length. The main effects of WP were -0.08 (95% CI [-0.21, 0.05]; p = 220) cm and -0.2 (95% CI [-0.7; 0.3]; p = 403) mm, respectively. Interactions were found between WP and breastfeeding with respect to linear growth (p < 0.02), due to positive effects among breastfed and negative effects among non-breastfed children. Overall, LNS resulted in 0.56 (95% CI [0.42, 0.70]; p < 0.001) cm height increase, corresponding to 0.17 (95% CI [0.13, 0.21]; p < 0.001) HAZ increase, and 0.21 (95% CI [0.14, 0.28]; p < 0.001) kg weight increase, of which 76.5% (95% CI [61.9; 91.1]) was fat-free mass. Using height-adjusted indicators, LNS increased FFMI (0.07 kg/m2, 95% CI [0.0001; 0.13]; p = 0.049), but not FMI (0.01 kg/m2, 95% CI [-0.10, 0.12]; p = 0.800). Main limitations were lack of blinding of caregivers and short study duration. CONCLUSIONS Adding dairy to LNS has no additional effects on linear growth or body composition in stunted children aged 12 to 59 months. However, supplementation with LNS, irrespective of milk, supports linear catch-up growth and accretion of fat-free mass, but not fat mass. If left untreated, children already on a stunting trajectory gain fat at the expense of fat-free mass, thus nutrition programs to treat such children should be considered. TRIAL REGISTRATION ISRCTN13093195.
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Affiliation(s)
- Joseph Mbabazi
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Hannah Pesu
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Rolland Mutumba
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Suzanne Filteau
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jack I Lewis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mette F Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian Ritz
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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Cazes C, Phelan K, Hubert V, Boubacar H, Bozama LI, Sakubu GT, Senge BB, Baya N, Alitanou R, Kouamé A, Yao C, Gabillard D, Daures M, Augier A, Anglaret X, Kinda M, Shepherd S, Becquet R. Optimising the dosage of ready-to-use therapeutic food in children with uncomplicated severe acute malnutrition in the Democratic Republic of the Congo: a non-inferiority, randomised controlled trial. EClinicalMedicine 2023; 58:101878. [PMID: 36915287 PMCID: PMC10006445 DOI: 10.1016/j.eclinm.2023.101878] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Current standard management of severe acute malnutrition uses ready-to-use therapeutic food (RUTF) at a single weight-based calculation resulting in an increasing amount of RUTF provided to the family as the child's weight increases during recovery. Using RUTF at a gradually reduced dosage as the child recovers could reduce costs while achieving similar growth response. METHODS We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 115 mm or a weight-for-height z-score (WHZ) of less than -3 or bipedal oedema and without medical complication were randomly assigned (1:1 ratio) using a specially developed software and random blocks (size was kept confidential), to either the current standard treatment (increasing the RUTF amount with increasing weight) or the OptiMA strategy (decreasing the RUTF dose with increasing weight and MUAC). The main endpoint was proportion of children who achieved recovery over the 6 months follow up period, as defined as meeting the following criteria for two consecutive weeks after a minimum of 4 weeks' treatment: axillary temperature less than 37.5 °C, no bipedal oedema, and anthropometric improvement (either MUAC 125 mm or greater or WHZ -1.5 or higher). We performed analyses on the intention-to-treat (ITT) (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority margin was 10%. This trial is registered at ClinicalTrials.gov, and is now closed NCT03751475. FINDINGS Between July 22, 2019, and January 20, 2020, 491 children were randomly assigned, of whom 482 were analysed (240 in the standard group and 242 in the OptiMA group). In the ITT analysis, 234 (98%) children in the standard group and 231 (96%) children in OptiMA recovered (difference 2.0%, 95% CI -2.0% to 6.4%). In the PP analysis, 234 (98%) children in the standard group and 228 (97%) in OptiMA recovered (difference 1.3%, 95% CI -2.3% to 5.1%). Sensitivity analyses applying the same anthropometric recovery criteria to each group also showed non-inferiority of the OptiMA strategy in ITT and PP analysis. INTERPRETATION This non-inferiority trial treating uncomplicated children with MUAC of less than 115 mm or a WHZ of less than -3 or bipedal oedema with decreasing RUTF dose as MUAC and weight increase demonstrated non-inferiority compared to the standard protocol in a highly food-insecure context in the Democratic Republic of the Congo. These findings add evidence on the safety of RUTF dose reduction with significant RUTF cost savings. FUNDING Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Liévin Izie Bozama
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Gilbert Tshibangu Sakubu
- Kamuesha Health Zone in the Kasaï Province, Ministry of Health, Kamuesha, Democratic Republic of the Congo
| | - Bruno Bindamba Senge
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Norbert Baya
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Antoine Kouamé
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Cyrille Yao
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Augustin Augier
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Xavier Anglaret
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
- Corresponding author. Bordeaux Population Health Centre, Team GHiGS, University of Bordeaux, Bordeaux 33076, France.
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Cichon B, Das JK, Salam RA, Padhani ZA, Stobaugh HC, Mughal M, Pajak P, Rutishauser-Perera A, Bhutta ZA, Black RE. Effectiveness of Dietary Management for Moderate Wasting among Children > 6 Months of Age-A Systematic Review and Meta-Analysis Exploring Different Types, Quantities, and Durations. Nutrients 2023; 15:nu15051076. [PMID: 36904076 PMCID: PMC10005276 DOI: 10.3390/nu15051076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
Currently, no World Health Organization guidelines exist for the management of approximately 31.8 million moderately wasted children globally. The objective of this review was to synthesise evidence on the optimal type, quantity, and duration of dietary treatment for moderate wasting. Ten electronic databases were searched until the 23rd of August 2021. Experimental studies comparing interventions for the dietary management of moderate wasting were included. Meta-analyses were conducted and results were presented as risk ratios or mean differences with 95% confidence intervals. Seventeen studies comparing specially formulated foods were included involving 23,005 participants. Findings suggest little or no difference in recovery between Fortified Blended Foods (FBFs) with improved micronutrient and/or milk content (enhanced FBFs) and lipid-based nutrient supplements (LNS), whereas children treated with non-enhanced FBFs (locally produced FBFs or standard corn-soy blend) may have lower recovery rates than those treated with LNS. There was no difference in recovery when ready-to-use therapeutic and ready-to-use supplementary food were compared. Other outcomes mostly aligned with results for recovery. In conclusion, LNSs improve recovery compared to non-enhanced FBFs, but are comparable to enhanced FBFs. Programmatic choice of supplement should consider factors such as cost, cost-effectiveness, and acceptability. Further research is required to determine optimal dosing and duration of supplementation.
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Affiliation(s)
- Bernardette Cichon
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
- Correspondence:
| | - Jai K. Das
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Rehana A. Salam
- The Daffodil Centre, The University of Sydney, Sydney 2006, Australia
| | - Zahra A. Padhani
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
| | - Heather C. Stobaugh
- Action Against Hunger USA, Technical Services and Innovation Department, Washington, DC 20463, USA
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA
| | - Muzna Mughal
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
| | - Patrizia Pajak
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
| | | | - Zulfiqar A. Bhutta
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Robert E. Black
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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9
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Zubair A, Fatima S, Habib H, Nazli R, Shah I, Shah M. Effects of Oral Lipid-Based nutritional supplements on appetite, energy intake, and lipid profile of moderately underweight children. Food Sci Nutr 2023; 11:903-916. [PMID: 36789036 PMCID: PMC9922128 DOI: 10.1002/fsn3.3125] [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: 05/16/2022] [Revised: 09/26/2022] [Accepted: 10/25/2022] [Indexed: 12/23/2022] Open
Abstract
Oral lipid-based nutritional supplements (LNS) are designed to ensure dietary adequacy and to improve malnourishment in children. Therefore, this study investigated the effects of 4 weeks of LNS on appetite, energy intake, and lipid profile of moderately underweight children (5-10 years old) with BMI-Z score between -2 and - 3 SDS, recruited in a single-blind randomized control trial. In addition to the regular dietary intake, fasting blood samples, anthropometric measurements, energy intake, and appetite responses were obtained before and after 4 weeks of LNS (535 kcal) or PLACEBO (92 kcal). After 4 weeks of supplementation mean energy intake (kcal) (p < .001), body weight (kg) (p < .001), BMI (kg/m2) (p < .01), mid-upper arm circumference (cm) (p < .01), total cholesterol (mg/dl) (p < .01) and fasting glucose (mg/dl) (p < .01) were raised significantly in the LNS group as compared to the PLACEBO group. No significant changes were detected in appetite responses (p > 0.05). In conclusion, LNS increases the overall energy intake, but does not affect the appetite but may induce hyperglycemia and hyperlipidemia.
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Affiliation(s)
- Aqsa Zubair
- Department of BiochemistryInstitute of Basic Medical Sciences (IBMS), Khyber Medical University (KMU)PeshawarPakistan
| | - Sadia Fatima
- Department of BiochemistryInstitute of Basic Medical Sciences (IBMS), Khyber Medical University (KMU)PeshawarPakistan
| | - Hamid Habib
- Department of PhysiologyInstitute of Basic Medical Sciences (IBMS), Khyber Medical University (KMU)PeshawarPakistan
| | - Rubina Nazli
- Department of BiochemistryInstitute of Basic Medical Sciences (IBMS), Khyber Medical University (KMU)PeshawarPakistan
| | - Inayat Shah
- Department of PhysiologyInstitute of Basic Medical Sciences (IBMS), Khyber Medical University (KMU)PeshawarPakistan
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10
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Lewis JI, Friis H, Mupere E, Wells JC, Grenov B. Calibration of Bioelectrical Impedance Analysis Against Deuterium Dilution for Body Composition Assessment in Stunted Ugandan Children. J Nutr 2023; 153:426-434. [PMID: 36894235 DOI: 10.1016/j.tjnut.2022.12.028] [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: 09/14/2022] [Revised: 12/09/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND BIA represents an important tool in body composition (BC) assessment, especially in low-income settings in which simple and affordable options are preferred. There is a particular need to measure BC in stunted children, in which cases population-specific BIA estimating equations are lacking. OBJECTIVES We calibrated an equation to estimate body composition from BIA using deuterium dilution (2H) as the criterion method in stunted children. METHODS We measured BC with 2H and performed BIA in stunted Ugandan children (n = 50). Multiple linear regression models were constructed to predict 2H-derived FFM from BIA-derived whole-body impedance and other relevant predictors. Model performance was expressed as adjusted R2 and RMSE. Prediction errors were also calculated. RESULTS Participants were aged 16-59 mo, of whom 46% were girls, and their median (IQR) height-for-age z-score (HAZ) was -2.58 (-2.92 to -2.37) according to the WHO growth standards. Impedance index (height2/impedance measured at 50 kHz) alone explained 89.2% variation in FFM and had an RMSE of 583 g (precision error 6.5%). The final model contained age, sex, impedance index, and height-for-age z-score as predictors and explained 94.5% variation in FFM with an RMSE of 402 g (precision error 4.5%). CONCLUSIONS We present a BIA calibration equation for a group of stunted children with a relatively low prediction error. This may help evaluate the efficacy of nutritional supplementation in large-scale trials in the same population. J Nutr 20XX;xxx:xx.
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Affiliation(s)
- Jack I Lewis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Population, Policy, and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.
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11
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Ritz C, Olsen MF, Grenov B, Friis H. Sample size calculations for continuous outcomes in clinical nutrition. Eur J Clin Nutr 2022; 76:1682-1689. [PMID: 35804148 DOI: 10.1038/s41430-022-01169-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/06/2022] [Accepted: 05/24/2022] [Indexed: 11/09/2022]
Abstract
In nutrition research, sample size calculations for continuous outcomes are important for the planning phase of many randomized trials and could also be relevant for some observational studies such as cohort and cross-sectional studies. However, only little literature dedicated to this topic exists within nutritional science. This article reviews the most common methods for sample size calculations in nutrition research. Approximate formulas are used for explaining concepts and requirements and for working through examples from the literature. Sample size calculations for the various study designs, which are covered, may all be seen as extensions of the sample size calculation for the basic two-group comparison through the application of suitable scaling factors and, possibly, modification of the significance level. The latter is needed for sample size calculations for multi-group designs and designs involving multiple primary outcomes. Like cluster-randomized designs, these types of study designs may be more challenging than standard sample size calculations. In such non-standard scenarios, there may be a need for consulting a biostatistician. Finally, it should be stressed that there may be many ways to plan a study. The final sample size calculation provided for a grant applicant, study protocol, or publication will often not only depend on considerations and input information as described in this article but will also involve restrictions in terms of logistics and/or resources.
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Affiliation(s)
- Christian Ritz
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455, Copenhagen K, Denmark.
| | - Mette Frahm Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, DK-1958, Frederiksberg C, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, DK-1958, Frederiksberg C, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, DK-1958, Frederiksberg C, Denmark
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12
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Small-quantity lipid-based nutrient supplements, with or without added zinc, do not cause excessive fat deposition in Burkinabe children: results from a cluster-randomized community trial. Eur J Nutr 2022; 61:4107-4120. [PMID: 35829783 PMCID: PMC9596589 DOI: 10.1007/s00394-022-02936-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 06/07/2022] [Indexed: 11/10/2022]
Abstract
Purpose Public health interventions to address stunting and wasting should be evaluated for possibly contributing to obesity risk. The present study tested the hypothesis that small-quantity lipid-based nutrient supplements (SQ-LNS) might increase fat deposition, and that additional zinc provided via SQ-LNS or in the form of dispersible tablets would increase fat-free mass (FFM) accretion. Methods Using a two-stage, cluster-randomized trial design, 34 communities were randomly assigned to the intervention cohort (IC) or non-intervention cohort (NIC), and family compounds within the IC were randomly assigned to receive different amounts of zinc (0, 5 or 10 mg zinc) incorporated in SQ-LNS or 5 mg zinc in the form of dispersible tablets along with treatment for diarrhea, malaria and fever. Body composition was assessed in a subset of IC (n = 201) and NIC (n = 74) children at 9 and 18 months using the deuterium dilution method. A mixed linear model was used to examine average change in FFM and % fat mass (%FM) among intervention groups and by cohort. Results Children in the IC had significantly greater change in FFM (Mean (95% Confidence Interval)) (1.57 (1.49, 1.64) kg) compared to the NIC (1.35 (1.23, 1.46) kg; p = 0.005). There were no significant differences in the change in %FM between the NIC and IC or among the intervention groups. Conclusion SQ-LNS, along with morbidity treatment increased weight gain and FFM in young children from 9 to 18 months of age without increasing FM deposition. Additional zinc supplementation did not affect changes in FFM or %FM. Trial registration The study was registered as a clinical trial with the US National Institute of Health (www.ClinicalTrials.gov; NCT00944281). Supplementary Information The online version contains supplementary material available at 10.1007/s00394-022-02936-6.
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13
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Sinha RK, Kumar P, Daniel A, Shah H, Sriswan R, Kokane A, Mohapatra A, Kashyap V, Goel AK, Kumar V, Kiran A, Arlappa N, Joshi A, Nayak RR, Sayal S, de Wagt A. Association between anthropometric criteria and body composition among children aged 6-59 months with severe acute malnutrition: a cross-sectional assessment from India. BMC Nutr 2022; 8:56. [PMID: 35739560 PMCID: PMC9219132 DOI: 10.1186/s40795-022-00551-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/14/2022] [Indexed: 12/01/2022] Open
Abstract
A multicentric study is being conducted in which children with severe acute malnutrition (SAM) aged 6–59 months are identified with only weight-for-height z-score (WHZ) < − 3 criteria. The present study aimed to assess associations of anthropometric parameters and body composition parameters, to improve treatment of SAM. We conducted a cross-section assessment using the enrolment data of children who participated in a multi-centric longitudinal controlled study from five Indian states. Fat-free mass (FFM) and fat mass (FM) were determined by bio-electrical impedance analysis (BIA). Six hundred fifty-nine children were enrolled in the study using WHZ < -3 criteria. Available data shows that WHZ, WAZ and BMIZ were significantly associated with FFMI while MUACZ was significantly associated with both FMI and FFMI. Children with both severe wasting and severe stunting had significantly lower FFMI compared to those who were only severely wasted. All forms of anthropometric deficits appear to adversely impact FFM and FM. Trial registration The study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 dated 24/09/2020).
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Affiliation(s)
- Rajesh Kumar Sinha
- National Centre of Excellence for Management of Children with Severe Acute Malnutrition (NCoE-SAM), Kalawati Saran Children's Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001, India.
| | - Praveen Kumar
- Lady Hardinge Medical College and associated Kalawati Saran Children's Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001, India
| | - Abner Daniel
- UNICEF India Country Office, 73, Lodi Estate, New Delhi, 110003, India
| | - Hemang Shah
- Children's Investment Fund Foundation, The Crescent, Level 3, Lado Sarai, New Delhi, 110030, India
| | - Raja Sriswan
- ICMR-National Institute of Nutrition, Beside Tarnaka Metro Station, Osmania University, Hyderabad, PO, Telangana-500007, India
| | - Arun Kokane
- All India Institute of Medical Sciences, Bhopal Saket Nagar, AIIMS Campus, Saket Nagar, BaghSwaniya, Bhopal, Madhya Pradesh-462020, India
| | - Aditya Mohapatra
- Addl Director, Department of Health and Family Welfare, Government of Odisha Annex Building, SIHFW, Bira Maharana Ln, Nilakantha Nagar, Nayapalli, Bhubaneswar, Odisha-751012, India
| | - Vivek Kashyap
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand-834001, India
| | - Anil Kumar Goel
- All India Institute of Medical Sciences, Raipur Gate No, 1, Great Eastern Rd, opposite Gurudwara, AIIMS Campus, Tatibandh, Raipur, Chhattisgarh-492099, India
| | - Virendra Kumar
- Lady Hardinge Medical College and associated Kalawati Saran Children's Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001, India
| | - Asha Kiran
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand-834001, India
| | - N Arlappa
- ICMR-National Institute of Nutrition, Beside Tarnaka Metro Station, Osmania University, Hyderabad, PO, Telangana-500007, India
| | - Ankur Joshi
- All India Institute of Medical Sciences, Bhopal Saket Nagar, AIIMS Campus, Saket Nagar, BaghSwaniya, Bhopal, Madhya Pradesh-462020, India
| | - Rashmi Ranjan Nayak
- Joint Secretary, Department of Women and Child Development and Mission Shakti, Government of Odisha, Mission Shakti Bhawan, At-Gandamunda, PO-Baramunda, Bhubaneswar, Odisha, Pin-751030, India
| | - Shikha Sayal
- National Centre of Excellence for Management of Children with Severe Acute Malnutrition (NCoE-SAM), Kalawati Saran Children's Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001, India
| | - Arjan de Wagt
- UNICEF India Country Office, 73, Lodi Estate, New Delhi, 110003, India
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Jayasinghe S, Faghy MA, Hills AP. Social justice equity in healthy living medicine - An international perspective. Prog Cardiovasc Dis 2022; 71:64-68. [PMID: 35490871 DOI: 10.1016/j.pcad.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
Irrespective of geographical location, disadvantaged people are disproportionately affected by unnecessary disease and suffering caused by inequalities in health. Although equal access to opportunities for healthy living medicine regardless of legal, political, economic, or other circumstances should be a basic human right, it is increasingly improbable for scores of people, particularly in Africa, Asia, Latin America, and the Caribbean, to acquire this. In recent times, global initiatives have attempted to make 'healthy lifestyles' more equitable by pledging to be relevant to all economies, promoting prosperity, environmental protection, climate change interventions, and purposeful action to meet the needs of vulnerable populations, including women and children. Yet there remains much to be done to address and reduce the substantial international health equity gaps. Reducing disparities that disproportionately affect the lower end of social strata must entail collaborative and systemic action from important stakeholders across the whole system, an approach that translates theory and research into practice. Ideally, realist approaches that appreciate the importance of the context of problems and assume nothing works everywhere or for everyone, should be prioritised over linear/simple and non-scalable intervention strategies.
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Affiliation(s)
- Sisitha Jayasinghe
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia.
| | - Mark A Faghy
- Human Sciences Research Centre, University of Derby, Derby, UK; Department of Physical Therapy, College of Applied Sciences, University of Illinois at Chicago, Chicago, IL, USA; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL, USA
| | - Andrew P Hills
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL, USA
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15
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Serum cobalamin in children with moderate acute malnutrition in Burkina Faso: Secondary analysis of a randomized trial. PLoS Med 2022; 19:e1003943. [PMID: 35263343 PMCID: PMC8906584 DOI: 10.1371/journal.pmed.1003943] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Among children with moderate acute malnutrition (MAM) the level of serum cobalamin (SC) and effect of food supplements are unknown. We aimed to assess prevalence and correlates of low SC in children with MAM, associations with hemoglobin and development, and effects of food supplements on SC. METHODS AND FINDINGS A randomized 2 × 2 × 3 factorial trial was conducted in Burkina Faso. Children aged 6 to 23 months with MAM received 500 kcal/d as lipid-based nutrient supplement (LNS) or corn-soy blend (CSB), containing dehulled soy (DS) or soy isolate (SI) and 0%, 20%, or 50% of total protein from milk for 3 months. Randomization resulted in baseline equivalence between intervention groups. Data on hemoglobin and development were available at baseline. SC was available at baseline and after 3 and 6 months. SC was available from 1,192 (74.1%) of 1,609 children at baseline. The mean (±SD) age was 12.6 (±5.0) months, and 54% were females. Low mid-upper arm circumference (MUAC; <125 mm) was found in 80.4% (958) of the children and low weight-for-length z-score (WLZ; <-2) in 70.6% (841). Stunting was seen in 38.2% (456). Only 5.9% were not breastfed. Median (IQR) SC was 188 (137; 259) pmol/L. Two-thirds had SC ≤222 pmol/L, which was associated with lower hemoglobin. After age and sex adjustments, very low SC (<112 pmol/L) was associated with 0.21 (95% CI: 0.01; 0.41, p = 0.04) and 0.24 (95% CI: 0.06; 0.42, p = 0.01) z-score lower fine and gross motor development, respectively. SC data were available from 1,330 (85.9%) of 1,548 children followed up after 3 months and 398 (26.5%) of the 1,503 children after 6 months. Based on tobit regression, accounting for left censored data, and adjustments for correlates of missing data, the mean (95% CI) increments in SC from baseline to the 3- and 6-month follow-up were 72 (65; 79, p < 0.001) and 26 (16; 37, p < 0.001) pmol/L, respectively. The changes were similar among the 310 children with SC data at all 3 time points. Yet, the increase was 39 (20; 57, p < 0.001) pmol/L larger in children given LNS compared to CSB if based on SI (interaction, p < 0.001). No effect of milk was found. Four children died, and no child developed an allergic reaction to supplements. The main limitation of this study was that only SC was available as a marker of status and was missing from a quarter of the children. CONCLUSIONS Low SC is prevalent among children with MAM and may contribute to impaired erythropoiesis and child development. The SC increase during supplementation was inadequate. The bioavailability and adequacy of cobalamin in food supplements should be reconsidered. TRIAL REGISTRATION ISRCTN Registry ISRCTN42569496.
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Thurstans S, Sessions N, Dolan C, Sadler K, Cichon B, Isanaka S, Roberfroid D, Stobaugh H, Webb P, Khara T. The relationship between wasting and stunting in young children: A systematic review. MATERNAL & CHILD NUTRITION 2022; 18:e13246. [PMID: 34486229 PMCID: PMC8710094 DOI: 10.1111/mcn.13246] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/26/2021] [Accepted: 06/22/2021] [Indexed: 11/27/2022]
Abstract
In 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low- and middle-income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near-term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid-upper-arm circumference combined with weight-for-age Z score might effectively identify children at most risk of near-term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.
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Affiliation(s)
- Susan Thurstans
- Department of Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited KingdomUK
- Emergency Nutrition NetworkOxfordUK
| | | | | | | | | | - Sheila Isanaka
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Department of ResearchEpicentreParisFrance
| | - Dominique Roberfroid
- Faculty of MedicineUniversity of NamurNamurBelgium
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
| | - Heather Stobaugh
- Action Against Hunger USANew YorkNew YorkUSA
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | - Patrick Webb
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
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17
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Gluning I, Kerac M, Bailey J, Bander A, Opondo C. The management of moderate acute malnutrition in children aged 6-59 months in low- and middle-income countries: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2021; 115:1317-1329. [PMID: 34535798 DOI: 10.1093/trstmh/trab137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/11/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malnutrition is a leading cause of morbidity and mortality in children aged <5 y, especially in low- and middle-income countries (LMICs). Unlike severe acute malnutrition, moderate acute malnutrition (MAM) affects greater numbers globally, and guidelines lack a robust evidence base. This systematic review and meta-analysis assessed the evidence for lipid-based nutrient supplements (LNSs), fortified blended flours (FBFs) and nutrition counselling, in the treatment of MAM. METHODS Four databases were systematically searched for studies conducted in LMICs that compared the effectiveness of food-based products with any comparator group in promoting recovery from MAM in children aged 6-59 mo. Where appropriate, pooled estimates of effect were estimated using random-effects meta-analyses. RESULTS A total of 13 trials were identified for inclusion. All used active controls. There was evidence of increased probability of recovery (gaining normal weight-for-height and/or mid-upper arm circumference) among children treated with LNSs compared with children treated with FBFs (risk ratio 1.05, 95% CI 1.01 to 1.09, p=0·009). CONCLUSION Based on a relatively small number of studies mainly from Africa, LNSs are superior to FBFs in improving anthropometric recovery from MAM. Current evidence for the use of food supplements in MAM treatment is based on comparisons with active controls. Future studies should assess a wider range of comparator groups, such as nutrition education/counselling alone, and outcomes, including body composition, morbidity and development.
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Affiliation(s)
- Imara Gluning
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Brighton and Sussex University Hospitals Trust, Brighton, BN2 5BE, UK
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Centre for MARCH (Maternal, Reproductive, Adolescent & Child Health Centre), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Jeanette Bailey
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,International Rescue Committee, New York, NY, 10168-1289, USA
| | - Amela Bander
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, OX3 7LF, UK
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18
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Wells JCK, Marphatia AA, Amable G, Siervo M, Friis H, Miranda JJ, Haisma HH, Raubenheimer D. The future of human malnutrition: rebalancing agency for better nutritional health. Global Health 2021; 17:119. [PMID: 34627303 PMCID: PMC8500827 DOI: 10.1186/s12992-021-00767-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 09/15/2021] [Indexed: 01/11/2023] Open
Abstract
The major threat to human societies posed by undernutrition has been recognised for millennia. Despite substantial economic development and scientific innovation, however, progress in addressing this global challenge has been inadequate. Paradoxically, the last half-century also saw the rapid emergence of obesity, first in high-income countries but now also in low- and middle-income countries. Traditionally, these problems were approached separately, but there is increasing recognition that they have common drivers and need integrated responses. The new nutrition reality comprises a global ‘double burden’ of malnutrition, where the challenges of food insecurity, nutritional deficiencies and undernutrition coexist and interact with obesity, sedentary behaviour, unhealthy diets and environments that foster unhealthy behaviour. Beyond immediate efforts to prevent and treat malnutrition, what must change in order to reduce the future burden? Here, we present a conceptual framework that focuses on the deeper structural drivers of malnutrition embedded in society, and their interaction with biological mechanisms of appetite regulation and physiological homeostasis. Building on a review of malnutrition in past societies, our framework brings to the fore the power dynamics that characterise contemporary human food systems at many levels. We focus on the concept of agency, the ability of individuals or organisations to pursue their goals. In globalized food systems, the agency of individuals is directly confronted by the agency of several other types of actor, including corporations, governments and supranational institutions. The intakes of energy and nutrients by individuals are powerfully shaped by this ‘competition of agency’, and we therefore argue that the greatest opportunities to reduce malnutrition lie in rebalancing agency across the competing actors. The effect of the COVID-19 pandemic on food systems and individuals illustrates our conceptual framework. Efforts to improve agency must both drive and respond to complementary efforts to promote and maintain equitable societies and planetary health.
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Affiliation(s)
- Jonathan C K Wells
- Childhood Nutrition Research Centre, Population Policy and Practice Research and Teaching Programme, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | | | - Gabriel Amable
- Department of Geography, University of Cambridge, Cambridge, UK
| | - Mario Siervo
- School of Life Sciences, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hinke H Haisma
- Population Research Centre, Department of Demography, University of Groningen, Groningen, the Netherlands
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19
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Kamugisha JGK, Lanyero B, Nabukeera-Barungi N, Ritz C, Mølgaard C, Michaelsen KF, Briend A, Mupere E, Friis H, Grenov B. Weight-for-Height Z-score Gain during Inpatient Treatment and Subsequent Linear Growth during Outpatient Treatment of Young Children with Severe Acute Malnutrition: A Prospective Study from Uganda. Curr Dev Nutr 2021; 5:nzab118. [PMID: 34712895 PMCID: PMC8546154 DOI: 10.1093/cdn/nzab118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/04/2021] [Accepted: 09/09/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Linear catch-up growth after treatment of severe acute malnutrition (SAM) is low, and little is known about the association between ponderal and subsequent linear growth. OBJECTIVE The study assessed the association of weight-for-height z-score (WHZ) gain with subsequent linear growth during SAM treatment and examined its modifiers. METHODS This was a prospective study, nested in a trial (ISRCTN16454889), among 6-59-mo-old children treated for SAM in Uganda. Weight, total length (TL), and knee-heel length (KHL) were measured at admission, weekly during inpatient therapeutic care (ITC), at discharge, and fortnightly during outpatient therapeutic care (OTC) for 8 wk. Linear regression was used to assess the association between WHZ gain during ITC and linear growth during OTC. RESULTS Of 400 children, 327 were discharged to OTC and 290 were followed up for 8 wk. Mean WHZ gains were 0.45 in ITC and 1.24 in OTC, whereas mean height-for-age z-score (HAZ) declined by 0.41 during ITC and increased by 0.14 during OTC. WHZ gain during ITC was positively associated with HAZ, TL, and KHL gains during OTC [regression coefficients (β) (95% CI): 0.12 (0.09, 0.15) z-score; 3.1 (2.4, 3.8) mm and 0.5 (0.1, 0.7) mm, respectively]. The regression coefficients were highest for the middle tertile of WHZ gain with respect to HAZ and TL. Admission diarrhea and low plasma citrulline reduced the association between WHZ gain during ITC and HAZ and TL gain during OTC (P < 0.001). In contrast, pneumonia (P = 0.051) and elevated plasma C-reactive protein (P < 0.001) increased the association with TL gain, but reduced the association with KHL gain (P < 0.001). CONCLUSIONS Among children admitted with SAM, considerable WHZ gain during ITC was followed by very modest linear catch-up growth during OTC, with no indication of a WHZ gain threshold, above which linear growth was higher. To optimize linear growth in these children, early treatment of infections and conditions affecting the gut may be necessary.
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Affiliation(s)
- Jolly G K Kamugisha
- Mwanamugimu Nutrition Unit, Department of Pediatrics, Mulago National Referral Hospital, Kampala, Uganda
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Betty Lanyero
- World Health Organization, Ethiopia Country Office, UNECA Compound, Addis Ababa, Ethiopia
| | | | - Christian Ritz
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - André Briend
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ezekiel Mupere
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Henrik Friis
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
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20
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Mwene-Batu P, Wells J, Maheshe G, Hermans MP, Kalumuna E, Ngaboyeka G, Chimanuka C, Owino VO, Macq J, Lukula M, Dramaix M, Donnen P, Bisimwa G. Body composition of adults with a history of severe acute malnutrition during childhood using the deuterium dilution method in eastern DR Congo: the Lwiro Cohort Study. Am J Clin Nutr 2021; 114:2052-2059. [PMID: 34582550 PMCID: PMC8634579 DOI: 10.1093/ajcn/nqab293] [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: 04/12/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Few studies have evaluated the body composition (BC) of adults who suffered from severe acute malnutrition (SAM) during childhood, a population at risk of long-term noncommunicable diseases. OBJECTIVE We performed an observational cohort study to evaluate BC in a group of young adults aged 11-30 y after nutritional rehabilitation for SAM, in the Democratic Republic of the Congo (DRC). METHODS We evaluated 151 adults in eastern DRC who were treated for SAM during childhood between 1988 and 2007. They were compared with 120 aged- and sex-matched control adults living in the same community who had not been exposed to malnutrition as children. The main variables of interest were the different compartments of adult BC (fat-free mass [FFM], fat mass [FM], and 2 indices of height-normalized BC: FFM index [FFMI] and FM index [FMI]) measured by deuterium dilution. RESULTS The mean age in both groups was 23 y, and females represented 49% and 56% of the exposed and nonexposed groups, respectively. SAM-exposed males had lower mean ± SD weight (53.6 ± 6.4 compared with 56.4 ± 7.9 kg, P = 0.029) and lower height (159.9 ± 6.6 compared with 163.6 ± 6.7 cm, P = 0.003) compared to unexposed males. SAM-exposed subjects had less FFM (-1.56 kg [-2.93, -0.20]; P = 0.024) but this observation was more marked in males (45.4 ± 5.4 compared with 48.2 ± 6.9 kg, P = 0.01) than in females. No differences in FM were noted between SAM-exposed and unexposed subjects. Adjusting for height, FFMI and FMI showed no difference between SAM-exposed and unexposed in either sex. CONCLUSION SAM during childhood is associated with reduced FFM in adulthood which is probably due to a shorter height.
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Affiliation(s)
| | - Jonathan Wells
- Childhood Nutrition Research Centre, Institute of Child Health, London, United Kingdom
| | - Ghislain Maheshe
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo,Hôpital Provincial General de Reference de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Michel P Hermans
- Division of Endocrinology & Nutrition, Cliniques universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Esther Kalumuna
- Hôpital Provincial General de Reference de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Gaylord Ngaboyeka
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Christine Chimanuka
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Victor O Owino
- Nutritional and Health Related Environmental Studies Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Jean Macq
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Melissa Lukula
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Michelle Dramaix
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Donnen
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Ghislain Bisimwa
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo,Nutritional department, Centre de Recherche en Sciences Naturelles
, Lwiro, Democratic Republic of the Congo
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21
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Arora C, Malhotra A, Ranjan P, Kumar A. Designing and Conducting Randomized Controlled Trials: Basic Concepts for Educating Early Researchers in the Field of Clinical Nutrition. Cureus 2021; 13:e17036. [PMID: 34522515 PMCID: PMC8425776 DOI: 10.7759/cureus.17036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 11/05/2022] Open
Abstract
Randomized controlled trials (RCTs) provide the best quality evidence to steer patient care in the field of clinical nutrition. However, designing and conducting an RCT, analyzing data, interpreting and reporting its findings is rather complex for young researchers working in the field of clinical nutrition. This review article attempts to educate early researchers by offering a simple step by step guide on planning the key aspects (randomization, allocation concealment, blinding, outcome measures) of a trial, and highlighting the practical considerations (ethical clearance, trial registry, patient recruitment, trial monitoring) to be kept in mind while conducting a trial contextualised to clinical nutrition settings.
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Affiliation(s)
- Charu Arora
- Food and Nutrition, University of Delhi, New Delhi, IND
| | - Anita Malhotra
- Food and Nutrition, Lakshmibai College, University of Delhi, New Delhi, IND
| | - Piyush Ranjan
- Medicine, All India Institute of Medical Sciences, New Delhi, IND
| | - Akshay Kumar
- Internal Medicine, All India Institute of Medical Sciences, New Delhi, IND
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22
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Kjaer TW, Grenov B, Yaméogo CW, Fabiansen C, Iuel-Brockdorff AS, Cichon B, Nielsen NS, Filteau S, Briend A, Wells JCK, Michaelsen KF, Friis H, Faurholt-Jepsen D, Christensen VB. Correlates of serum IGF-1 in young children with moderate acute malnutrition: a cross-sectional study in Burkina Faso. Am J Clin Nutr 2021; 114:965-972. [PMID: 33963730 DOI: 10.1093/ajcn/nqab120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Serum insulin-like growth factor 1 (sIGF-1) is an important growth factor in childhood. However, studies on sIGF-1 among children from low-income countries are few, and the role of body composition is unknown. OBJECTIVES To assess the associations of anthropometry, body composition, inflammation, and breastfeeding with sIGF-1 among children with moderate acute malnutrition (MAM). METHODS A cross-sectional study based on admission data from 6- to 23-mo-old children with MAM participating in a nutrition intervention trial (Treatfood) in Burkina Faso. Linear regression analysis was used to identify correlates of sIGF-1. RESULTS Among 1546 children, the median (IQR) sIGF-1 was 12 (8.2-18.3) ng/mL. sIGF-1 was highest at 6 mo, with a nadir ∼10-11 mo, and higher in girls than boys. Length-for-age z score (LAZ), weight-for-length z score (WLZ), and midupper arm circumference were positively associated with sIGF-1 (P ≤ 0.001). Fat-free mass (FFM) was also positively associated, as sIGF-1 increased 1.5 (95% CI: 0.5, 2.5) ng/mL for each 1-kg increase in FFM. However, the association disappeared after adjustment for height. Elevated serum C-reactive protein and α1-acid glycoprotein were negatively associated with sIGF-1 (P ≤ 0.001), as was fever (P < 0.001) but not a positive malaria test per se (P = 0.15). Children never breastfed had lower sIGF-1 (-5.1; 95% CI: -9.8, -0.3). CONCLUSIONS LAZ and WLZ were positively and inflammation negatively associated with sIGF-1. As all children were moderately malnourished and many had inflammation, this probably explains the very low median sIGF-1. The association of FFM with sIGF-1 was fully explained by height. There was a marked age pattern, with a nadir in late infancy, confirming findings from smaller studies from well-nourished populations. There is a need for prospective studies to disentangle the role of sIGF-1 in growth and health. This trial was registered at https://www.isrctn.com as ISRCTN42569496.
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Affiliation(s)
- Thora W Kjaer
- Department of Pediatrics and Adolescent Health, Rigshospitalet, Copenhagen, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Charles W Yaméogo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,Département Biomédical et Santé Publique, Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
| | - Christian Fabiansen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,The Pediatric Department, Holbæk Sygehus, Holbæk, Denmark
| | | | - Bernardette Cichon
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Nick S Nielsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,Department for International Health, University of Tampere, School of Medicine, Tampere, Finland
| | - Jonathan C K Wells
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Faurholt-Jepsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke B Christensen
- Department of Pediatrics and Adolescent Health, Rigshospitalet, Copenhagen, Denmark.,Médecins Sans Frontières-Denmark, Copenhagen, Denmark
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23
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Thymus size in children with moderate malnutrition: a cohort study from Burkina Faso. Pediatr Res 2021; 89:1732-1741. [PMID: 32688368 DOI: 10.1038/s41390-020-1057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 04/24/2020] [Accepted: 06/05/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Moderate acute malnutrition (MAM) affects millions of children, increasing their risk of dying from infections. Thymus atrophy may be a marker of malnutrition-associated immunodeficiency, but factors associated with thymus size in children with MAM are unknown, as is the effect of nutritional interventions on thymus size. METHODS Thymus size was measured by ultrasound in 279 children in Burkina Faso with MAM, diagnosed by low mid-upper arm circumference (MUAC) and/or low weight-for-length z-score (WLZ), who received 12 weeks treatment with different food supplements as part of a randomized trial. Correlates of thymus size and of changes in thymus size after treatment, and after another 12 weeks of follow-up were identified. RESULTS Thymus size correlated positively with age, anthropometry and blood haemoglobin, and was smaller in children with malaria. Children with malnutrition diagnosed using MUAC had a smaller thymus than children diagnosed based on WLZ. Thymus size increased during and after treatment, similarly across the different food supplement groups. CONCLUSIONS In children with MAM, the thymus is smaller in children with anaemia or malaria, and grows with recovery. Assuming that thymus size reflects vulnerability, low MUAC seems to identify more vulnerable children than low WLZ in children with MAM. IMPACT Thymus atrophy is known to be a marker of the immunodeficiency associated with malnutrition in children. In children with moderate malnutrition, we found the thymus to be smaller in children with anaemia or malaria. Assuming that thymus size reflects vulnerability, low MUAC seems to identify more vulnerable children than low weight for length. Thymus atrophy appears reversible with recovery from malnutrition, with similar growth seen in children randomized to treatment with different nutritional supplements.
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24
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Pesu H, Mutumba R, Mbabazi J, Olsen MF, Mølgaard C, Michaelsen KF, Ritz C, Filteau S, Briend A, Mupere E, Friis H, Grenov B. The Role of Milk Protein and Whey Permeate in Lipid-based Nutrient Supplements on the Growth and Development of Stunted Children in Uganda: A Randomized Trial Protocol (MAGNUS). Curr Dev Nutr 2021; 5:nzab067. [PMID: 34027295 PMCID: PMC8128719 DOI: 10.1093/cdn/nzab067] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/25/2021] [Accepted: 04/16/2021] [Indexed: 11/13/2022] Open
Abstract
Stunting is associated with cognitive impairment and later chronic disease. Previous trials to prevent stunting have had little effect, and no trials seem to have provided larger amounts of energy and high-quality proteins to already stunted children. We aimed to assess the effects of milk protein (MP) and whey permeate (WP) in large-quantity lipid-based nutrient supplements (LNS-LQ), among stunted children, on linear growth and child development. This was a randomized, double-blind, 2-by-2 factorial trial. Stunted children aged 12-59 mo from eastern Uganda (n = 750) were randomly assigned to receive 100 g LNS-LQ with or without MP and WP (n = 4 × 150) or no supplement (n = 150) for 3 mo. The primary outcomes were change in knee-heel and total length. Secondary outcomes included child development, body composition, anthropometry, and hemoglobin. Micronutrient status, intestinal function, and microbiota were also assessed. Our findings will contribute to an understanding of the role of milk ingredients and LNS in linear catch-up growth. This trial was registered at www.isrctn.com as ISRCTN13093195.
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Affiliation(s)
- Hannah Pesu
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Rolland Mutumba
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Paediatrics and Child Health, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Mbabazi
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Paediatrics and Child Health, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mette F Olsen
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian Ritz
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Suzanne Filteau
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - André Briend
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
- Tampere Centre for Child Health Research, Tampere University, Tampere, Finland
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | - Henrik Friis
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
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25
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Suri DJ, Potani I, Singh A, Griswold S, Wong WW, Langlois B, Shen Y, Chui KHK, Rosenberg IH, Webb P, Rogers BL. Body Composition Changes in Children during Treatment for Moderate Acute Malnutrition: Findings from a 4-Arm Cluster-Randomized Trial in Sierra Leone. J Nutr 2021; 151:2043-2050. [PMID: 33880554 PMCID: PMC8245884 DOI: 10.1093/jn/nxab080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/12/2021] [Accepted: 03/01/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Measures that better describe "healthy" and sustainable recovery during nutritional treatment of children with moderate acute malnutrition (MAM) are needed. OBJECTIVES We compared changes to body composition among children receiving 1 of 4 specialized nutritious food (SNFs) during treatment of MAM and by recovery and relapse outcomes. METHODS The study was nested within a prospective, cluster-randomized, community-based, cost-effectiveness trial assessing 4 SNFs to treat children aged 6-59 mo with MAM [midupper arm circumference (MUAC) ≥11.5 cm and <12.5 cm without bipedal edema] in Sierra Leone. Biweekly SNF rations (1 of 3 fortified-blended foods or a lipid-based nutrient supplement) were given until children recovered (MUAC ≥12.5 cm), or up to 7 rations (∼12 wk). Deuterium dilution was used to estimate fat-free mass (FFM) and fat mass (FM) at enrollment and after 4 wk of treatment to ensure similar treatment exposure among the participants. Another MUAC measurement was performed among recovered children 4 wk after program exit to determine whether recovery was sustained. ANOVA, paired t tests, and linear regression models were used to determine significant differences in changes from baseline to 4 wk. RESULTS Among 312 analyzed participants, mean baseline weight comprised ∼80% FFM; mean weight gained after 4 wk comprised ∼82% FFM. Changes in FM and FFM among 4 SNFs were similar. Children who recovered gained more weight (241%), FFM (179%), and weight-for-height z score (0.44 compared with 0) compared with those who did not recover; sustainers gained 150% more weight. FM gains were positive among recovered children and sustainers, as well as negative among those who did not recover or sustain recovery, but not significantly different. CONCLUSIONS Four SNFs had similar effects on body composition in children after 4 wk of treatment for MAM, showing a healthy pattern of weight gain, the majority being FFM. Differential responses to treatment underscore a need for further research to provide targets for healthy, sustainable recovery. This trial was registered at clinicaltrials.gov as NCT03146897.
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Affiliation(s)
- Devika J Suri
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | - Isabel Potani
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Akriti Singh
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | - Stacy Griswold
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | - William W Wong
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Breanne Langlois
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | - Ye Shen
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | | | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
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Heidkamp RA, Piwoz E, Gillespie S, Keats EC, D'Alimonte MR, Menon P, Das JK, Flory A, Clift JW, Ruel MT, Vosti S, Akuoku JK, Bhutta ZA. Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action. Lancet 2021; 397:1400-1418. [PMID: 33691095 DOI: 10.1016/s0140-6736(21)00568-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/28/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022]
Abstract
As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.
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Affiliation(s)
| | - Ellen Piwoz
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Stuart Gillespie
- International Food Policy Research Institute, Washington, DC, USA
| | - Emily C Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Purnima Menon
- International Food Policy Research Institute, Delhi, India
| | - Jai K Das
- Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | | | | | - Marie T Ruel
- International Food Policy Research Institute, Washington, DC, USA
| | - Stephen Vosti
- Department of Agricultural and Resource Economics, and Institute for Global Nutrition, University of California, Davis, CA, USA
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada; Centre of Excellence in Women and Child Health and Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan.
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Impact of food supplements on early child development in children with moderate acute malnutrition: A randomised 2 x 2 x 3 factorial trial in Burkina Faso. PLoS Med 2020; 17:e1003442. [PMID: 33362221 PMCID: PMC7757806 DOI: 10.1371/journal.pmed.1003442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lipid-based nutrient supplements (LNS) and corn-soy blends (CSBs) with varying soy and milk content are used in treatment of moderate acute malnutrition (MAM). We assessed the impact of these supplements on child development. METHODS AND FINDINGS We conducted a randomised 2 × 2 × 3 factorial trial to assess the effectiveness of 12 weeks' supplementation with LNS or CSB, with either soy isolate or dehulled soy, and either 0%, 20%, or 50% of protein from milk, on child development among 6-23-month-old children with MAM. Recruitment took place at 5 health centres in Province du Passoré, Burkina Faso between September 2013 and August 2014. The study was fully blinded with respect to soy quality and milk content, while study participants were not blinded with respect to matrix. This analysis presents secondary trial outcomes: Gross motor, fine motor, and language development were assessed using the Malawi Development Assessment Tool (MDAT). Of 1,609 children enrolled, 54.7% were girls, and median age was 11.3 months (interquartile range [IQR] 8.2-16.0). Twelve weeks follow-up was completed by 1,548 (96.2%), and 24 weeks follow-up was completed by 1,503 (93.4%); follow-up was similar between randomised groups. During the study, 4 children died, and 102 children developed severe acute malnutrition (SAM). There was no difference in adverse events between randomised groups. At 12 weeks, the mean MDAT z-scores in the whole cohort had increased by 0.33 (95% CI: 0.28, 0.37), p < 0.001 for gross motor; 0.26 (0.20, 0.31), p < 0.001 for fine motor; and 0.14 (0.09, 0.20), p < 0.001 for language development. Children had larger improvement in language z-scores if receiving supplements with milk (20%: 0.09 [-0.01, 0.19], p = 0.08 and 50%: 0.11 [0.01, 0.21], p = 0.02), although the difference only reached statistical significance for 50% milk. Post hoc analyses suggested that this effect was specific to boys (interaction p = 0.02). The fine motor z-scores were also improved in children receiving milk, but only when 20% milk was added to CSB (0.18 [0.03, 0.33], p = 0.02). Soy isolate over dehulled soy increased language z-scores by 0.07 (-0.01, 0.15), p = 0.10, although not statistically significant. Post hoc analyses suggested that LNS benefited gross motor development among boys more than did CSB (interaction p = 0.04). Differences between supplement groups did not persist at 24 weeks, but MDAT z-scores continued to increase post-supplementation. The lack of an unsupplemented control group limits us from determining the overall effects of nutritional supplementation for children with MAM. CONCLUSIONS In this study, we found that child development improved during and after supplementation for treatment of MAM. Milk protein was beneficial for language and fine motor development, while suggested benefits related to soy quality and supplement matrix merit further investigation. Supplement-specific effects were not found post-intervention, but z-scores continued to improve, suggesting a sustained overall effect of supplementation. TRIAL REGISTRATION ISRCTN42569496.
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28
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Kangas ST, Kaestel P, Salpéteur C, Nikièma V, Talley L, Briend A, Ritz C, Friis H, Wells JC. Body composition during outpatient treatment of severe acute malnutrition: Results from a randomised trial testing different doses of ready-to-use therapeutic foods. Clin Nutr 2020; 39:3426-3433. [DOI: 10.1016/j.clnu.2020.02.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/29/2020] [Accepted: 02/28/2020] [Indexed: 01/12/2023]
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Varkey A, Devi S, Mukhopadhyay A, Kamat NG, Pauline M, Dharmar M, Holt RR, Allen LH, Thomas T, Keen CL, Kurpad AV. Metabolome and microbiome alterations related to short-term feeding of a micronutrient-fortified, high-quality legume protein-based food product to stunted school age children: A randomized controlled pilot trial. Clin Nutr 2020; 39:3251-3261. [DOI: 10.1016/j.clnu.2020.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 05/18/2019] [Accepted: 02/14/2020] [Indexed: 11/30/2022]
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30
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Roediger R, Stein H, Callaghan‐Gillespie M, Blackman JK, Kohlmann K, Maleta K, Manary M. Protein quality in ready-to-use supplementary foods for moderate wasting. MATERNAL & CHILD NUTRITION 2020; 16:e13019. [PMID: 32426949 PMCID: PMC7507576 DOI: 10.1111/mcn.13019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 04/08/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022]
Abstract
There are no guidelines for the optimal protein quality of ready-to-supplementary food (RUSF) for moderate acute malnutrition (MAM). This randomized, controlled, double-blinded, clinical effectiveness trial evaluated two RUSFs in the treatment of MAM. Both foods contained greater than 7% dairy protein, but the protein-optimized RUSF had a calculated digestible indispensable amino acid score (DIAAS) of 95%, whereas the control RUSF had a calculated DIAAS of 63%. There were 1,737 rural Malawian children 6-59 months of age treated with 75 kcal/kg/day of either control or protein quality-optimized RUSF for up to 12 weeks. There was no difference in the proportion of children who recovered from MAM between the group that received protein-optimized RUSF (759/860, 88%) and the group that received control RUSF (766/877, 87%, difference 1%, 95% CI, -2.1 to 4.1, p = 0.61). There were no differences in time to recovery or average weight gain; nor were adverse effects reported. Both RUSFs showed indistinguishable clinical outcomes, with recovery rates higher than typically seen in treatment for MAM. The DIAAS of these two RUSFs was measured using a pig model. Unexpectedly, the protein quality of the optimized RUSF was inferior to the control RUSF: DIAAS = 82% for the protein quality optimized RUSF and 96% for control RUSF. The controlled conditions of this trial suggest that in supplementary food products for MAM, protein quality is not an independent predictor of clinical effectiveness.
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Affiliation(s)
- Rebecca Roediger
- Division of Gastroenterology, Department of MedicineWashington UniversitySt. LouisMissouriUSA
| | | | | | | | - Kristin Kohlmann
- Department of PediatricsWashington UniversitySt. LouisMissouriUSA
| | - Kenneth Maleta
- Department of Community Health, College of MedicineUniversity of MalawiBlantyreMalawi
| | - Mark Manary
- Department of PediatricsWashington UniversitySt. LouisMissouriUSA
- Department of Community Health, College of MedicineUniversity of MalawiBlantyreMalawi
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31
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Cliffer IR, Masters WA, Rogers BL. Fortified blended flour supplements displace plain cereals in feeding of young children. MATERNAL AND CHILD NUTRITION 2020; 17:e13089. [PMID: 32990388 PMCID: PMC7988859 DOI: 10.1111/mcn.13089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/13/2022]
Abstract
Lipid-based nutritional supplements (LNS) and fortified blended flours (FBF) are widely used to increase the nutrient density of children's diets and improve their health, but their effectiveness could be modified by displacement of other foods. We reanalysed data from a cost-effectiveness trial comparing impacts on anthropometry of three FBFs (Corn Soy Blend Plus [CSB+], Corn Soy Whey Blend [CSWB], SuperCereal Plus [SC+]) and one LNS (Ready-to-use Supplementary Food [RUSF]) among infants aged 7-23 months in Burkina Faso. Using dietary diversity data from a single 24-h recall period (n = 1,591 children, observed once over 18-month study period), we fit logistic regression models to estimate differences in intake of each food group making up the infant and young child minimum dietary diversity score and linear models to test for differences in dietary diversity score among children in each supplement arm. We tested for differences in breastfeeding time using the subsample for which breastfeeding was observed (n = 176). Children who consumed one of the three FBFs had lower odds of consuming household grains, roots and tubers compared with the LNS consumers (odds ratios [ORs] = 0.35-0.47; 95% confidence intervals [CIs]: 0.20-1.05). Consumption of other foods, dietary diversity and breastfeeding did not differ significantly at the 5% significance level. FBFs displaced the household's own cereals more than LNS, with no difference in the child's consumption of other more nutrient-rich family foods. Given limited stomach capacity and feeding time, providing fortified cereals may help improve children's overall diet quality in settings where children would otherwise be fed nutrient-poor root crops or cereal grains.
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Affiliation(s)
- Ilana R Cliffer
- Department of Food and Nutrition Policy and Programs, Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
| | - William A Masters
- Department of Food and Nutrition Policy and Programs, Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
| | - Beatrice L Rogers
- Department of Food and Nutrition Policy and Programs, Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
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32
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Stewart CP, de Pee S, Maleta K, Michaelsen KF, Dewey KG. The double burden of malnutrition-further perspective. Lancet 2020; 396:814-815. [PMID: 32950084 DOI: 10.1016/s0140-6736(20)31360-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 06/05/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Christine P Stewart
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA.
| | - Saskia de Pee
- Nutrition Division, World Food Programme, Rome, Italy
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Kathryn G Dewey
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA
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33
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Fabiansen C, Cichon B, Yaméogo CW, Iuel-Brockdorf AS, Phelan KPQ, Wells JC, Ritz C, Filteau S, Briend A, Christensen VB, Ashorn P, Michaelsen KF, Shepherd S, Friis H. Association between admission criteria and body composition among young children with moderate acute malnutrition, a cross-sectional study from Burkina Faso. Sci Rep 2020; 10:13266. [PMID: 32764545 PMCID: PMC7413376 DOI: 10.1038/s41598-020-69987-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 07/20/2020] [Indexed: 12/03/2022] Open
Abstract
Children with moderate acute malnutrition (MAM) are treated based on low weight-for-length z-score (WLZ), low mid-upper arm circumference (MUAC) or both. This study aimed to assess associations of admission criteria and body composition (BC), to improve treatment of MAM. We undertook a cross-sectional study among 6–23 months old Burkinabe children with MAM. Fat-free (FFM) and fat mass (FM) were determined by deuterium dilution and expressed as FFM (FFMI) and FM index (FMI). Of 1,489 children, 439 (29.5%) were recruited by low MUAC only (MUAC-O), 734 (49.3%) by low WLZ and low MUAC (WLZ-MUAC) and 316 (21.2%) by low WLZ only (WLZ-O). Thus, 1,173 (78.8%) were recruited by low MUAC, with or without low WLZ (ALL-MUAC). After adjustments, WLZ-O had 89 g (95% confidence interval (CI) 5; 172) lower FFM compared to MUAC-O. Similarly, WLZ-O had 0.89 kg/m2 (95% CI 0.77; 1.01) lower FFMI compared to MUAC-O, whereas there was no difference for FMI. However, boys included by WLZ-O compared to MUAC-O had 0.21 kg/m2 (95% CI 0.05; 0.38) higher FMI. In contrast, girls included by WLZ-O had 0.17 (95% CI 0.01; 0.33) kg/m2 lower FMI compared to MUAC-O (interaction, p = 0.002). We found that different criteria for admission into MAM treatment programmes select children with differences in BC, especially FFMI. Trial registration: ISRCTN42569496.
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Affiliation(s)
- Christian Fabiansen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark. .,Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark.
| | - Bernardette Cichon
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark
| | - Charles W Yaméogo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Département Biomédical et Santé Publique, Institut de Recherche en Sciences de la Santé, Ouagadougou 03, BP 7047, Bobo-Dioulasso, Burkina Faso
| | - Ann-Sophie Iuel-Brockdorf
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark
| | | | - Jonathan C Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark
| | - Suzanne Filteau
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, Keppel Street, London, WC1E 7HT, UK
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Center for Child Health Research, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Lääkärinkatu 1, 33014, Tampere, Finland
| | - Vibeke B Christensen
- Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark.,Department of Paediatrics and Adolenscent Medicine, Blegdamsvej 9, 2100, RighospitaletCopenhagen, Denmark
| | - Per Ashorn
- Center for Child Health Research, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Lääkärinkatu 1, 33014, Tampere, Finland
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark
| | - Susan Shepherd
- ALIMA, Route de l'Aéroport, Rue NG 96, BP 15530, Dakar, Sénégal
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark
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Shaikh S, Campbell RK, Mehra S, Kabir A, Schulze KJ, Wu L, Ali H, Shamim AA, West KP, Christian P. Supplementation with Fortified Lipid-Based and Blended Complementary Foods has Variable Impact on Body Composition Among Rural Bangladeshi Children: A Cluster-Randomized Controlled Trial. J Nutr 2020; 150:1924-1932. [PMID: 32240304 PMCID: PMC7330466 DOI: 10.1093/jn/nxaa061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/26/2019] [Accepted: 02/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Complementary food supplementation enhances linear growth and may affect body composition in children. OBJECTIVE We aimed to determine the effect of complementary food supplements provided from the age of 6 to 18 mo on fat-free mass (FFM) and fat mass (FM) gain among children in rural Bangladesh. METHODS In an unblinded, cluster-randomized, controlled trial we tested the effects of 4 complementary food supplements for 1 y [chickpea, rice lentil, Plumpy'doz, and wheat-soy-blend++ (WSB++)] compared with no supplements on linear growth. Body composition was estimated using weight-length-based, age- and sex-specific equations at 6, 9, 12, 15, and 18 mo and postintervention aged 24 mo. Generalized estimating equations (GEEs) were applied to estimate the effect of each complementary food on mean FFM and FM from 9 to 18 and 24 mo compared with the control, adjusting for baseline measures. Sex interactions were also explored. RESULTS In total, 3592 (65.9% of enrolled) children completed all anthropometric assessments. Estimated FFM and FM (mean ± SD) were 5.3 ± 0.6 kg and 1.4 ± 0.4 kg, respectively, at the age of 6 mo. Mean ± SE FFM and FM from 9 to 18 mo were 75.4 ± 14.0 g and 32.9 ± 7.1 g, and 61.0 ± 16.6 g and 30.0 ± 8.4 g, higher with Plumpy'doz and chickpea foods, respectively, than the control (P < 0.001). Estimated FFM was 41.5 ± 16.6 g higher in rice-lentil-fed versus control (P < 0.05) children. WSB++ had no impact on FFM or FM. A group-sex interaction (P < 0.1) was apparent with Plumpy'doz and rice-lentil foods, with girls involved in the intervention having higher estimated FFM and FM than control girls compared with no significant effect in boys. At 24 mo, FFM and FM remained higher only in girls eating Plumpy'doz compared with the controls (P < 0.01). CONCLUSIONS In this randomized trial, supplementation effected small shifts in apparent body composition in rural Bangladeshi children. Where seen, FFM increments were twice that of FM, in proportion to these compartments, and more pronounced in girls. FFM increased in line with reported improvements in length. This trial was registered at clinicaltrials.gov as NCT01562379.
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Affiliation(s)
| | - Rebecca K Campbell
- Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sucheta Mehra
- Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alamgir Kabir
- International Centre for Diarrhoeal Disease Research, Bangladesh, Mohakhali, Dhaka, Bangladesh
| | - Kerry J Schulze
- Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lee Wu
- Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hasmot Ali
- The JiVitA Project of Johns Hopkins University, Bangladesh, Gaibandha, Bangladesh,Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Abu Ahmed Shamim
- James P Grant School of Public Health, Bangladesh Rural Advancement Committee (BRAC), University, Dhaka, Bangladesh
| | - Keith P West
- Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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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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Isanaka S, Andersen CT, Hanson KE, Berthé F, Grais RF, Briend A. Energy needs in the treatment of uncomplicated severe acute malnutrition: Secondary analysis to optimize delivery of ready-to-use therapeutic foods. MATERNAL AND CHILD NUTRITION 2020; 16:e12989. [PMID: 32144946 PMCID: PMC7507348 DOI: 10.1111/mcn.12989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/24/2020] [Accepted: 02/18/2020] [Indexed: 11/28/2022]
Abstract
Outpatient therapeutic feeding protocols for the treatment of uncomplicated severe acute malnutrition in children were initially based on weight gain data from inpatient settings and expert knowledge of the physiological requirements during recovery. However, weight gain and energy requirements from historic inpatient settings may differ from modern outpatient settings and therefore may not be appropriate to guide current therapeutic feeding protocols. We calculated the weight gain and average estimated total daily energy requirement of children successfully treated for uncomplicated severe acute malnutrition as outpatients in Niger (n = 790). Mean energy provided by six therapeutic feeding protocols was calculated and compared with average estimated energy requirements in the study population. Overall weight gain was 5.5 g·kg-1 ·day-1 among recovered children. Average energy requirements ranged from 92 to 110 kcal·kg-1 ·day-1 depending on the estimation approach. Two current therapeutic feeding protocols were found to provide an excess of energy after the first week of treatment in our study population, whereas four research protocols tended to provide less energy than the estimated requirement after the first week of treatment. Alternative feeding protocols have the potential to simplify and lead to important savings for programmes but should be evaluated to show adequacy to meet the energy needs of children under treatment, as well as feasibility and cost efficiency. Our findings rely on theoretical calculations based on several assumptions and should be confirmed in field studies.
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Affiliation(s)
- Sheila Isanaka
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Epicentre, Paris, France
| | - Christopher T Andersen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kerstin E Hanson
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | | | | | - André Briend
- Center for Child Health Research, University of Tampere School of Medicine, Tampere, Finland.,Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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37
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Wells JC, Sawaya AL, Wibaek R, Mwangome M, Poullas MS, Yajnik CS, Demaio A. The double burden of malnutrition: aetiological pathways and consequences for health. Lancet 2020; 395:75-88. [PMID: 31852605 PMCID: PMC7613491 DOI: 10.1016/s0140-6736(19)32472-9] [Citation(s) in RCA: 380] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/24/2019] [Accepted: 08/07/2019] [Indexed: 12/29/2022]
Abstract
Malnutrition has historically been researched and addressed within two distinct silos, focusing either on undernutrition, food insecurity, and micronutrient deficiencies, or on overweight, obesity, and dietary excess. However, through rapid global nutrition transition, an increasing proportion of individuals are exposed to different forms of malnutrition during the life course and have the double burden of malnutrition (DBM) directly. Long-lasting effects of malnutrition in early life can be attributed to interconnected biological pathways, involving imbalance of the gut microbiome, inflammation, metabolic dysregulation, and impaired insulin signalling. Life-course exposure to early undernutrition followed by later overweight increases the risk of non-communicable disease, by imposing a high metabolic load on a depleted capacity for homoeostasis, and in women increases the risk of childbirth complications. These life-course trajectories are shaped both by societal driving factors-ie, rapidly changing diets, norms of eating, and physical activity patterns-and by broader ecological factors such as pathogen burden and extrinsic mortality risk. Mitigation of the DBM will require major societal shifts regarding nutrition and public health, to implement comprehensive change that is sustained over decades, and scaled up into the entire global food system.
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Affiliation(s)
- Jonathan C Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Ana Lydia Sawaya
- Department of Physiology, Federal University of São Paulo, São Paulo, Brazil
| | - Rasmus Wibaek
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark; Clinical Epidemiology, Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Martha Mwangome
- Kenya Medical Research Institute Wellcome Trust Research Program, Kilifi, Kenya
| | - Marios S Poullas
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Alessandro Demaio
- School of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; EAT Foundation, Oslo, Norway; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; VicHealth, Melbourne, VIC, Australia
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38
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Wells JCK, Stock JT. Life History Transitions at the Origins of Agriculture: A Model for Understanding How Niche Construction Impacts Human Growth, Demography and Health. Front Endocrinol (Lausanne) 2020; 11:325. [PMID: 32508752 PMCID: PMC7253633 DOI: 10.3389/fendo.2020.00325] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/27/2020] [Indexed: 12/18/2022] Open
Abstract
Over recent millennia, human populations have regularly reconstructed their subsistence niches, changing both how they obtain food and the conditions in which they live. For example, over the last 12,000 years the vast majority of human populations shifted from foraging to practicing different forms of agriculture. The shift to farming is widely understood to have impacted several aspects of human demography and biology, including mortality risk, population growth, adult body size, and physical markers of health. However, these trends have not been integrated within an over-arching conceptual framework, and there is poor understanding of why populations tended to increase in population size during periods when markers of health deteriorated. Here, we offer a novel conceptual approach based on evolutionary life history theory. This theory assumes that energy availability is finite and must be allocated in competition between the functions of maintenance, growth, reproduction, and defence. In any given environment, and at any given stage during the life-course, natural selection favours energy allocation strategies that maximise fitness. We argue that the origins of agriculture involved profound transformations in human life history strategies, impacting both the availability of energy and the way that it was allocated between life history functions in the body. Although overall energy supply increased, the diet composition changed, while sedentary populations were challenged by new infectious burdens. We propose that this composite new ecological niche favoured increased energy allocation to defence (immune function) and reproduction, thus reducing the allocation to growth and maintenance. We review evidence in support of this hypothesis and highlight how further work could address both heterogeneity and specific aspects of the origins of agriculture in more detail. Our approach can be applied to many other transformations of the human subsistence niche, and can shed new light on the way that health, height, life expectancy, and fertility patterns are changing in association with globalization and nutrition transition.
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Affiliation(s)
- Jonathan C. K. Wells
- Childhood Nutrition Research Centre, Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- *Correspondence: Jonathan C. K. Wells
| | - Jay T. Stock
- Department of Anthropology, University of Western Ontario, London, ON, Canada
- Department of Archaeology, Max Planck Institute for the Science of Human History, Jena, Germany
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39
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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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40
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Olsen MF, Iuel-Brockdorff AS, Yaméogo CW, Cichon B, Fabiansen C, Filteau S, Phelan K, Ouédraogo A, Wells JC, Briend A, Michaelsen KF, Lauritzen L, Ritz C, Ashorn P, Christensen VB, Gladstone M, Friis H. Early development in children with moderate acute malnutrition: A cross-sectional study in Burkina Faso. MATERNAL AND CHILD NUTRITION 2019; 16:e12928. [PMID: 31823490 PMCID: PMC7083399 DOI: 10.1111/mcn.12928] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/06/2019] [Accepted: 11/14/2019] [Indexed: 12/30/2022]
Abstract
Malnutrition impairs cognitive, communication, and motor development, but it is not known how nutrition and health are associated with development in children with moderate acute malnutrition (MAM). We aimed to describe motor and language development of children with MAM and explore its nutrition and health-related correlates. This cross-sectional study used baseline data from a nutritional trial in children with MAM aged 6-23 months in Burkina Faso. Motor and language skills were assessed using the Malawi Development Assessment Tool (MDAT). Linear mixed models were used to explore potential correlates of MDAT including socio-economic status, anthropometry, body composition, whole-blood polyunsaturated fatty acids (PUFA), haemoglobin (Hb), iron status, and morbidity. We also assessed child and caregiver participation during MDAT procedures and their associations with correlates and development. MDAT data were available for 1.608 children. Mean (95% CI) MDAT z-scores were -0.39 (-0.45, -0.34) for gross motor, 0.54 (0.48, 0.59) for fine motor, and -0.91 (-0.96, -0.86) for language skills. Children with higher mid-upper arm circumference, weight-for-height, height-for-age, fat-free mass, n-3 PUFAs, Hb, and iron status had better MDAT z-scores, whereas children with more fat mass index, anaemia, illness, and inflammation had poorer z-scores. In addition, children living in larger households or with an unmarried mother had poorer MDAT z-scores. Associations between morbidity and z-scores were largely explained by children's poorer participation during MDAT assessment. The identified factors associated with child development may inform interventions needed to stimulate development during or after management of MAM.
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Affiliation(s)
- Mette F Olsen
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | | | - Charles W Yaméogo
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark.,Département Biomédical et Santé Publique, Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
| | - Bernardette Cichon
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - Christian Fabiansen
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | | | - Jonathan C Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK
| | - André Briend
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - Lotte Lauritzen
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - Per Ashorn
- Centre for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Vibeke B Christensen
- Department of Pediatrics and Adolescent Health, Rigshospitalet, Copenhagen, Denmark.,Medicins Sans Frontieres - Denmark, Copenhagen, Denmark
| | - Melissa Gladstone
- Department of Women and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen, Copenhagen, Denmark
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41
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Fabiansen C, Friis H, Wells J. Fat Mass in Young Malian Children with Moderate Acute Malnutrition: A Concern Regarding the Use of Correction Factors. J Nutr 2019; 149:2265. [PMID: 31792543 DOI: 10.1093/jn/nxz195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Christian Fabiansen
- From the Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- From the Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Jonathan Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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42
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McDonald CM, Ackatia-Armah RS, Doumbia S, Brown KH. Reply to C Fabiansen et al. J Nutr 2019. [DOI: 10.1093/jn/nxz196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Seydou Doumbia
- Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, CA, USA
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43
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Wells JCK. Body composition of children with moderate and severe undernutrition and after treatment: a narrative review. BMC Med 2019; 17:215. [PMID: 31767002 PMCID: PMC6878632 DOI: 10.1186/s12916-019-1465-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Until recently, undernourished children were usually assessed using simple anthropometric measurements, which provide global assessments of nutritional status. There is increasing interest in obtaining more direct data on body composition to assess the effects of undernutrition on fat-free mass (FFM) and its constituents, such as muscle and organs, and on fat mass (FM) and its regional distribution. MAIN TEXT Recent studies show that severe-acute undernutrition, categorised as 'wasting', is associated with major deficits in both FFM and FM that may persist in the long-term. Fat distribution appears more central, but this is more associated with the loss of peripheral fat than with the elevation of central fat. Chronic undernutrition, categorised as 'stunting', is associated with deficits in FFM and in specific components, such as organ size. However, the magnitude of these deficits is reduced, or - in some cases - disappears, after adjustment for height. This suggests that FFM is largely reduced in proportion to linear growth. Stunted children vary in their FM - in some cases remaining thin throughout childhood, but in other cases developing higher levels of FM. The causes of this heterogeneity remain unclear. Several different pathways may underlie longitudinal associations between early stunting and later body composition. Importantly, recent studies suggest that short children are not at risk of excess fat deposition in the short term when given nutritional supplementation. CONCLUSION The short- and long-term functional significance of FFM and FM for survival, physical capacity and non-communicable disease risk means that both tissues merit further attention in research on child undernutrition.
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Affiliation(s)
- Jonathan C K Wells
- Childhood Nutrition Research Centre, Population, Policy and Practice Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
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44
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Wells JCK, Briend A, Boyd EM, Berkely JA, Hall A, Isanaka S, Webb P, Khara T, Dolan C. Beyond wasted and stunted-a major shift to fight child undernutrition. THE LANCET. CHILD & ADOLESCENT HEALTH 2019; 3:831-834. [PMID: 31521500 DOI: 10.1016/s2352-4642(19)30244-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 06/08/2019] [Accepted: 06/28/2019] [Indexed: 12/30/2022]
Abstract
Child undernutrition refers broadly to the condition in which food intake is inadequate to meet a child's needs for physiological function, growth, and the capacity to respond to illness. Since the 1970s, nutritionists have categorised undernutrition in two major ways, either as wasted (ie, low weight for height, or small mid-upper arm circumference) or stunted (ie, low height for age). This approach, although useful for identifying populations at risk of undernutrition, creates several problems: the focus is on children who have already become undernourished, and this approach draws an artificial distinction between two idealised types of undernourished children that are widely interpreted as indicative of either acute or chronic undernutrition. This distinction in turn has led to the separation of programmatic approaches to prevent and treat child undernutrition. In the past 3 years, research has shown that individual children are at risk of both conditions, might be born with both, pass from one state to the other over time, and accumulate risks to their health and life through their combined effects. The current emphasis on identifying children who are already wasted or stunted detracts attention from the larger number of children undergoing the process of becoming undernourished. We call for a major shift in thinking regarding how we assess child undernutrition, and how prevention and treatment programmes can best address the diverse causes and dynamic biological processes that underlie undernutrition.
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Affiliation(s)
- Jonathan C K Wells
- Childhood Nutrition Research Centre, Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK.
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark; Centre for Child Health Research, Faculty of Medicine and Medical Technology, Tampere University, Tampere, Finland
| | - Erin M Boyd
- US Agency for International Development's Office of US Foreign Disaster Assistance, Washington, DC, USA
| | - James A Berkely
- Kenya Medical Research Institute, Wellcome Trust Research Programme, Kilifi, Kenya; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK; The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | | | - Sheila Isanaka
- Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Research Department, Epicentre, Paris, France
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | | | - Carmel Dolan
- Childhood Nutrition Research Centre, Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
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45
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Lelijveld N, Beedle A, Farhikhtah A, Elrayah EE, Bourdaire J, Aburto N. Systematic review of the treatment of moderate acute malnutrition using food products. MATERNAL AND CHILD NUTRITION 2019; 16:e12898. [PMID: 31667981 PMCID: PMC7038867 DOI: 10.1111/mcn.12898] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/02/2019] [Accepted: 09/25/2019] [Indexed: 01/05/2023]
Abstract
There is currently a lack of international guidance on the most appropriate treatment for moderate acute malnutrition (MAM), and discrepancies in national treatment guidelines exist. We aimed to explore whether food interventions are effective for MAM children 6–59 months old and whether they result in better outcomes compared with no treatment or management with nutrition counselling. A systematic literature search was conducted in October 2018, identifying studies that compared treating MAM children with food products versus management with counselling or no intervention. A total of 673 abstracts were screened, 101 full texts were read, and one study was identified that met our inclusion criteria. After broadening the criteria to include micronutrients in the control group and enrolment based on out‐dated anthropometric criteria, 11 studies were identified for inclusion. Seven of these found food products to be superior for anthropometric outcomes compared with counselling and/or micronutrient supplementation; two of the studies found no significant benefit of a food product intervention; and two studies were inconclusive. Hence, the majority of studies in this review found that food products resulted in greater anthropometric gains than counselling or micronutrient interventions. This was especially true if the supplementary food provided was of suitable quality and provided for an adequate duration. Improving quality of and adherence to counselling may improve its effectiveness, particularly in food secure contexts. There is currently a paucity of comparable studies on this topic as well as a lack of studies that include important functional outcomes beyond anthropometric proxies.
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Affiliation(s)
- Natasha Lelijveld
- School of Human Development and Health, University of Southampton, Southampton, UK
| | - Alexandra Beedle
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Nancy Aburto
- United National World Food Programme, Rome, Italy
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Kangas ST, Salpéteur C, Nikièma V, Talley L, Ritz C, Friis H, Briend A, Kaestel P. Impact of reduced dose of ready-to-use therapeutic foods in children with uncomplicated severe acute malnutrition: A randomised non-inferiority trial in Burkina Faso. PLoS Med 2019; 16:e1002887. [PMID: 31454351 PMCID: PMC6711495 DOI: 10.1371/journal.pmed.1002887] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/23/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children with uncomplicated severe acute malnutrition (SAM) are treated at home with ready-to-use therapeutic foods (RUTFs). The current RUTF dose is prescribed according to the weight of the child to fulfil 100% of their nutritional needs until discharge. However, there is doubt concerning the dose, as it seems to be shared, resulting in suboptimal cost-efficiency of SAM treatment. We investigated the efficacy of a reduced RUTF dose in community-based treatment of uncomplicated SAM. METHODS AND FINDINGS We undertook a randomised trial testing the non-inferiority of weight gain velocity of children with SAM receiving (a) a standard RUTF dose for two weeks, followed by a reduced dose thereafter (reduced), compared with (b) a standard RUTF dose throughout the treatment (standard). A mean difference of 0.0 g/kg/day was expected, with a non-inferiority margin fixed at -0.5 g/kg/day. Linear and logistic mixed regression analyses were performed, with study site and team as random effects. Between October 2016 and July 2018, 801 children with uncomplicated SAM aged 6-59 months were enrolled from 10 community health centres in Burkina Faso. At admission, the mean age (± standard deviation [SD]) was 13.4 months (±8.7), 49% were male, and the mean weight was 6.2 kg (±1.3). The mean weight gain velocity from admission to discharge was 3.4 g/kg/day and did not differ between study arms (Δ 0.0 g/kg/day; 95% CI -0.4 to 0.4; p = 0.92) confirming non-inferiority (p = 0.013). However, after two weeks, the weight gain velocity was significantly lower in the reduced dose with a mean of 2.3 g/kg/day compared with 2.7 g/kg/day in the standard dose (Δ -0.4 g/kg/day; 95% CI -0.8 to -0.02; p = 0.041). The length of stay (LoS) was not different (p = 0.73) between groups with a median of 56 days (interquartile range [IQR] 35-91) in both arms. No differences were found between reduced and standard arm in recovery (52.7% and 55.4%; p = 0.45), referral (19.2% and 20.1%; p = 0.80), defaulter (12.2% and 8.5%; p = 0.088), non-response (12.7% and 12.5%; p = 0.95), and relapse (2.4% and 1.8%; p = 0.69) rates, respectively. However, the reduced RUTF dose had a small 0.2 mm/week (95% CI 0.04 to 0.4; p = 0.015) negative effect on height gain velocity with a mean height gain of 2.6 mm/week with reduced and 2.8 mm/week with standard RUTF dose. The impact was more pronounced in children under 12 months of age (interaction, p = 0.019) who gained 2.8 mm/week with reduced and 3.1 mm/week with standard dose (Δ -0.4 mm/week; 95% CI -0.6 to -0.2; p < 0.001). Limitations include not blinding participants to the RUTF dose received and excluding all children with negative appetite test. The results are generalisable for relatively food secure contexts with a young SAM population. CONCLUSIONS Reducing the RUTF dose provided to children with SAM after two weeks of treatment did not reduce overall weight or mid-upper arm circumference (MUAC) gain velocity nor affect recovery or lengthen treatment time. However, it led to a small but significant negative effect on linear growth, especially among the youngest. The potential effect of reducing the RUTF dose in a routine program on treatment outcomes should be evaluated before scaling up. TRIAL REGISTRATION ISRCTN registry ISRCTN50039021.
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Affiliation(s)
- Suvi T. Kangas
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
- * E-mail:
| | - Cécile Salpéteur
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
| | - Victor Nikièma
- Nutrition and Health Department, Action Against Hunger (ACF) mission, Ouagadougou, Burkina Faso
| | - Leisel Talley
- Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Center for Child Health Research, University of Tampere School of Medicine, Tampere University, Tampere, Finland
| | - Pernille Kaestel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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Pimpin L, Kranz S, Liu E, Shulkin M, Karageorgou D, Miller V, Fawzi W, Duggan C, Webb P, Mozaffarian D. Effects of animal protein supplementation of mothers, preterm infants, and term infants on growth outcomes in childhood: a systematic review and meta-analysis of randomized trials. Am J Clin Nutr 2019; 110:410-429. [PMID: 31175810 PMCID: PMC6669064 DOI: 10.1093/ajcn/nqy348] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 11/07/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Child stunting is a major public health problem, afflicting 155 million people worldwide. Lack of animal-source protein has been identified as a risk, but effects of animal protein supplementation are not well established. OBJECTIVE The aim of this study was to investigate effects of animal protein supplementation in mothers, preterm infants, and term infants/children on birth and growth outcomes. METHODS PubMed, EMBASE, Cochrane library, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature were searched for randomized controlled trials of animal protein supplementation in mothers or infants and children (≤age 5 y), evaluating measures of anthropometry (≤age 18 y). Main outcomes included birth weight, low birth weight, small for gestational age at birth; height, height-for-age, weight, weight-for-age, weight-for-length, stunting, and wasting ≤18 y of age. Data were extracted independently in duplicate, and findings pooled using inverse variance meta-analysis. Heterogeneity was explored using I2, stratified analysis, and meta-regression, and publication bias by funnel plots, Egger's test, and fill/trim methods. RESULTS Of 6808 unique abstracts and 357 full-text articles, 62 trials were included. The 62 trials comprised over 30,000 participants across 5 continents, including formula-based supplementation in infants and food-based supplementation in pregnancy and childhood. Maternal supplementation increased birth weight by 0.06 kg, and both formula and food-based supplementation in term infants/young children increased weight by ≤0.14 kg. Neither formula nor food-based supplementation for term infants/young children increased height, whereas the height-for-age z-score was increased in the food-based (+0.06 z-score) but not formula-based (-0.11 z-score) trials reporting this outcome. In term infants, the weight-for-length z-score was increased in trials of formula (+0.24 z-score) and food supplementation (+0.06 z-score), whereas food supplementation was also associated with reduced odds of stunting (-13%). CONCLUSIONS Supplementation of protein from animal-source foods generally increased weight and weight-for-length in children, but with more limited effects on other growth outcomes such as attained height.
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Affiliation(s)
- Laura Pimpin
- Friedman School of Nutrition & Science Policy, Tufts University, Boston, MA
| | - Sarah Kranz
- Friedman School of Nutrition & Science Policy, Tufts University, Boston, MA
| | - Enju Liu
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Masha Shulkin
- Friedman School of Nutrition & Science Policy, Tufts University, Boston, MA
| | | | - Victoria Miller
- Friedman School of Nutrition & Science Policy, Tufts University, Boston, MA
| | - Wafaie Fawzi
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Christopher Duggan
- Harvard T.H. Chan School of Public Health, Boston, MA
- Boston Children's Hospital, Boston, MA
| | - Patrick Webb
- Friedman School of Nutrition & Science Policy, Tufts University, Boston, MA
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Owino VO, Murphy‐Alford AJ, Kerac M, Bahwere P, Friis H, Berkley JA, Jackson AA. Measuring growth and medium- and longer-term outcomes in malnourished children. MATERNAL & CHILD NUTRITION 2019; 15:e12790. [PMID: 30690903 PMCID: PMC7199054 DOI: 10.1111/mcn.12790] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/13/2018] [Accepted: 12/12/2018] [Indexed: 12/26/2022]
Abstract
Severe and moderate acute malnutrition are among the leading causes of mortality among children in low- and middle-income countries. There is strong evidence that growth assessed anthropometrically from conception to 2 years of age marks later risk of ill health. This is central to the concept of the developmental origins of adult disease and is presumed to be related to modification of developmental processes during critical "window(s)" of vulnerability. Interventions to treat acute malnutrition have resulted in dramatic increase in the number of affected children surviving. Ensuring that these children thrive to fulfil their full physical and cognitive potential is a new challenge. Integral to this challenge is the need to be able to measure how earlier insults relate to the ability to survive and thrive to productive adulthood. Despite its obvious value, routine anthropometry does not adequately indicate how earlier adverse exposures affect more refined aspects of growth. Anthropometry is inadequate for predicting how disruption of healthy growth might modulate risk of disease or any subsequent interventions that correct this risk. A clear characterisation of healthy child growth is needed for determining which component best predicts later outcomes. The extent to which postnatal acute malnutrition is a consequence of maternal factors acting preconception or in utero and their relationship to postnatal health and long-term risk of non-communicable diseases is not clear. Body-composition measurement has significant untapped potential allowing us to translate and better understand the relationship between early insults and interventions on early growth in the short-term and long-term health outcomes.
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Affiliation(s)
- Victor O. Owino
- Nutritional and Health Related Environmental Studies Section, Division of HealthInternational Atomic Energy AgencyViennaAustria
| | - Alexia J. Murphy‐Alford
- Nutritional and Health Related Environmental Studies Section, Division of HealthInternational Atomic Energy AgencyViennaAustria
| | - Marko Kerac
- Department of Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Paluku Bahwere
- Valid InternationalOxfordUK
- Research Centre in Epidemiology, Biostatistics and Clinical Research, School of Public HealthFree University of BrusselsBrusselsBelgium
| | - Henrik Friis
- Department of Nutrition, Exercise and SportsUniversity of CopenhagenFrederiksbergDenmark
| | - James A. Berkley
- DirectorThe Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
| | - Alan A. Jackson
- Human Nutrition, International Malnutrition Task ForceSouthampton General HospitalSouthamptonUK
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McDonald CM, Ackatia-Armah RS, Doumbia S, Kupka R, Duggan CP, Brown KH. Percent Fat Mass Increases with Recovery, But Does Not Vary According to Dietary Therapy in Young Malian Children Treated for Moderate Acute Malnutrition. J Nutr 2019; 149:1089-1096. [PMID: 30968123 PMCID: PMC6543204 DOI: 10.1093/jn/nxz037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/29/2018] [Accepted: 02/20/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Moderate acute malnutrition (MAM) affects 34.1 million children globally. Treatment effectiveness is generally determined by the amount and rate of weight gain. Body composition (BC) assessment provides more detailed information on nutritional stores and the type of tissue accrual than traditional weight measurements alone. OBJECTIVE The aim of this study was to compare the change in percentage fat mass (%FM) and other BC parameters among young Malian children with MAM according to receipt of 1 of 4 dietary supplements, and recovery status at the end of the 12-wk intervention period. METHODS BC was assessed using the deuterium oxide dilution method in a subgroup of 286 children aged 6-35 mo who participated in a 12-wk community-based, cluster-randomized effectiveness trial of 4 dietary supplements for the treatment of MAM: 1) lipid-based, ready-to-use supplementary food (RUSF); 2) special corn-soy blend "plus plus" (CSB++); 3) locally processed, fortified flour (MI); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). Multivariate linear regression modeling was used to evaluate change in BC parameters by treatment group and recovery status. RESULTS Mean ± SD %FM at baseline was 28.6% ± 5.32%. Change in %FM did not vary between groups. Children who received RUSF vs. MI gained more (mean; 95% CI) weight (1.43; 1.13, 1.74 kg compared with 0.84; 0.66, 1.03 kg; P = 0.02), FM (0.70; 0.45, 0.96 kg compared with 0.20; 0.05, 0.36 kg; P = 0.01), and weight-for-length z score (1.23; 0.79, 1.54 compared with 0.49; 0.34, 0.71; P = 0.03). Children who recovered from MAM exhibited greater increases in all BC parameters, including %FM, than children who did not recover. CONCLUSIONS In this study population, children had higher than expected %FM at baseline. There were no differences in %FM change between groups. International BC reference data are needed to assess the utility of BC assessment in community-based management of acute malnutrition programs. This trial was registered at clinicaltrials.gov as NCT01015950.
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Affiliation(s)
- Christine M McDonald
- Children's Hospital Oakland Research Institute, Oakland, CA,Address correspondence to CMM (e-mail: )
| | | | - Seydou Doumbia
- Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali
| | | | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA,Departments of Nutrition, and Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA
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O'Callaghan YC, Shevade AV, Guinee TP, O'Connor TP, O'Brien NM. Comparison of the nutritional composition of experimental fermented milk:wheat bulgur blends and commercially available kishk and tarhana products. Food Chem 2019; 278:110-118. [DOI: 10.1016/j.foodchem.2018.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/18/2018] [Accepted: 11/05/2018] [Indexed: 12/12/2022]
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