Is the inclusion of animal source foods in fortified blended foods justified?

A fermented milk drink with Umbu (Spondias tuberosa) pulp and whey is effective for weight gain and re-nutrition in malnourished: An in vivo study in mice and children

Malnutrition is considered one of the major public health problems worldwide and negatively affects the growth, development and learning of schoolchildren. This study developed and evaluated a fermented milk drink with added Umbu (Spondias tuberosa) pulp in the weight gain and renutrition of mice submitted to malnutrition by calorie restriction, and in malnourished children. The supplementation with this fermented milk drink contributed to an increase of 7.2 % in body weight, and 64.3 % in albumin, and a reduction of 35 % in cholesterol in malnourished mice. In humans, a group of nine malnourished children consumed a daily 200 mL serving of the milk drink (for 60 days). For humans, the fermented milk drink allowed an increase of 16.5 % in body weight, and 20.9 % in body mass index in malnourished children. In conclusion, fermented milk drink has a positive effect on the re-nutrition of malnourished mice and helps to improve the nutritional status of malnourished children.

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

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.

The Role of Food Insecurity and Dietary Diversity on Recovery from Wasting among Hospitalized Children Aged 6-23 Months in Sub-Saharan Africa and South Asia

Background: Current guidelines for the management of childhood wasting primarily focus on the provision of therapeutic foods and the treatment of medical complications. However, many children with wasting live in food-secure households, and multiple studies have demonstrated that the etiology of wasting is complex, including social, nutritional, and biological causes. We evaluated the contribution of household food insecurity, dietary diversity, and the consumption of specific food groups to the time to recovery from wasting after hospital discharge. Methods: We conducted a secondary analysis of the Childhood Acute Illness Network (CHAIN) cohort, a multicenter prospective study conducted in six low- or lower-middle-income countries. We included children aged 6−23 months with wasting (mid-upper arm circumference [MUAC] ≤ 12.5 cm) or kwashiorkor (bipedal edema) at the time of hospital discharge. The primary outcome was time to nutritional recovery, defined as a MUAC > 12.5 cm without edema. Using Cox proportional hazards models adjusted for age, sex, study site, HIV status, duration of hospitalization, enrollment MUAC, referral to a nutritional program, caregiver education, caregiver depression, the season of enrollment, residence, and household wealth status, we evaluated the role of reported food insecurity, dietary diversity, and specific food groups prior to hospitalization on time to recovery from wasting during the 6 months of posthospital discharge. Findings: Of 1286 included children, most participants (806, 63%) came from food-insecure households, including 170 (13%) with severe food insecurity, and 664 (52%) participants had insufficient dietary diversity. The median time to recovery was 96 days (18/100 child-months (95% CI: 17.0, 19.0)). Moderate (aHR 1.17 [0.96, 1.43]) and severe food insecurity (aHR 1.14 [0.88, 1.48]), and insufficient dietary diversity (aHR 1.07 [0.91, 1.25]) were not significantly associated with time to recovery. Children who had consumed legumes and nuts prior to diagnosis had a quicker recovery than those who did not (adjusted hazard ratio (aHR): 1.21 [1.01,1.44]). Consumption of dairy products (aHR 1.13 [0.96, 1.34], p = 0.14) and meat (aHR 1.11 [0.93, 1.33]), p = 0.23) were not statistically significantly associated with time to recovery. Consumption of fruits and vegetables (aHR 0.78 [0.65,0.94]) and breastfeeding (aHR 0.84 [0.71, 0.99]) before diagnosis were associated with longer time to recovery. Conclusion: Among wasted children discharged from hospital and managed in compliance with wasting guidelines, food insecurity and dietary diversity were not major determinants of recovery.

Soy Protein is an Efficacious Alternative to Whey Protein in Sorghum–Soy Fortified Blended Foods in Rats

Background

Previously we found that extruded corn–soy blend (CSB) and sorghum–soy blend (SSB) fortified blended foods (FBFs) containing whey protein concentrate (WPC) were equally nutritious food aid products. WPC provides high-quality protein; however, it is the most expensive ingredient in these FBFs.

Objectives

The primary objective of this study was to determine if soy protein can serve as an alternative to WPC and the secondary objective was to evaluate different sucrose amounts in the FBFs.

Methods

Nine extruded FBFs were formulated: 1 CSB and 1 SSB, both containing 9.5% WPC and 15% sucrose, served as comparison FBFs. Three additional CSB and 4 SSB FBFs were formulated containing no WPC, but with increased soy flour to meet protein requirements and varying sucrose concentrations. The sucrose content ranged from 0% to 10% for the CSBs and 0% to 15% for the SSBs. Male weanling Sprague Dawley rats were individually housed and divided into 10 diet groups (n = 9–10) which consumed either AIN-93G or a dry FBF for 28 d. At study conclusion, blood, livers, and body composition data were collected. Results were analyzed using 1-factor ANOVA with Tukey's test.

Results

Outcomes were not significantly different between the SSB groups, with the exception of significantly higher protein efficiency for the WPC-containing group. Among the CSB groups, caloric and protein efficiencies were significantly higher for the WPC-containing CSB group. There were no significant differences in hemoglobin or hepatic iron concentrations between FBF groups, but hepatic iron concentrations were significantly higher in all FBF groups than in the AIN-93G group. Groups consuming diets with ≤10% sucrose had significantly higher bone mineral density than groups consuming diets with 15% sucrose.

Conclusions

These results suggest that extruded SSB, but not necessarily CSB, FBFs with soy protein and 5%–10% added sucrose are efficacious and cost-effective alternatives to WPC-containing FBFs.

Nutrient Cost-Effectiveness of Fortified Blended Food Aid Products

BACKGROUND

Sorghum-Soy Blend (SSB) and Sorghum-Cowpea Blend (SCB) fortified blended food aid porridge products were developed as alternatives to Corn-Soy Blend Plus (CSB+) and Super Cereal Plus (SC+), the most widely used fortified blended food aid products. However, the cost and nutrient cost-effectiveness of these products procured from different geographical areas have not been determined.

OBJECTIVE

The objective of this study is to determine the nutrient cost-effectiveness of SSB and SCB compared to existing fortified blended foods.

METHODS

Nutritional data as well as ingredient, processing, and transportation cost for SSB, SCB, and existing fortified blended foods were compiled. Using the omega value, the ratio of the fortified blended food's Nutrient Value Score to the total cost of the fortified blended food divided by an identical ratio of a different fortified blended food or the same fortified blended food produced in a different country and the nutrient cost-effectiveness of each of the fortified blended foods procured in the United States and several African countries were determined.

RESULTS

Both CSB+ and SC+ are less expensive than SSB and SCB, but they also have lower Nutrient Value Scores of 7.7 and 8.6, respectively. However, the omega values of CSB+ and SC+ are all above 1 when compared to SSB and SCB, suggesting that the existing fortified blended foods are more nutrient cost-effective.

CONCLUSIONS

Comparing the nutrient cost-effectiveness of various food aid products could provide valuable information to food aid agencies prior to making procurement decisions.

Novel Formulated Fortified Blended Foods Result in Improved Protein Efficiency and Hepatic Iron Concentrations Compared with Corn-Soy Blend Plus in Broiler Chickens

BACKGROUND

Corn- and soybean-based fortified blended foods (FBFs) have been the primary food aid product provided by the United States. Sorghum and cowpea have been suggested as alternative FBF commodities because they are drought-tolerant, grown in food aid-receiving areas, and not genetically modified. Extrusion processing has also been suggested to improve the quality of these FBFs.

OBJECTIVES

The aim of this study was to determine the protein quality and iron and vitamin A bioavailability of novel FBFs in broiler chickens.

METHODS

Whey protein concentrate (WPC)-containing FBFs corn-soy blend 14, sorghum-soy, and sorghum-cowpea (SC); a soy protein isolate (SPI)-containing SC FBF (SC+SPI); 2 reformulated, overprocessed SC FBFs (O-SC+WPC, O-SC+SPI); and a nonextruded WPC-containing SC FBF were developed. Nonextruded corn-soy blend plus (CSB+), a currently used FBF, and a gamebird starter/grower diet were used as comparison diets. In the prepared FBF study, 9 groups of 8-d-old broiler chicks (n = 10) consumed prepared FBFs for 21 d. In the dry study, 8 groups of 4-d-old broiler chicks (n = 24; control: n = 23) consumed dry FBFs for 14 d. Results were analyzed by 1-factor ANOVA with least-significant-difference test.

RESULTS

In the prepared study, novel formulated FBFs significantly increased caloric and protein efficiency and nonsignificantly increased body weight gain, despite similar food intake compared with CSB+. In the dry study, novel formulated FBFs, except for O-SC+SPI, significantly increased food intake, caloric efficiency, and protein efficiency and nonsignificantly increased body-weight gain compared with CSB+. Novel formulated FBFs nonsignificantly and significantly increased hepatic iron concentrations compared with all FBFs in the prepared and dry studies, respectively.

CONCLUSION

Novel formulated FBFs, apart from O-SC+SPI, resulted in improved protein efficiencies and hepatic iron concentrations compared with CSB+, suggesting that they are of higher nutritional quality.

Maximizing Recovery and Growth When Treating Moderate Acute Malnutrition with Whey-Containing Supplements

BACKGROUND

Much debate exists about the utility of dairy ingredients in the supplementary foods used to treat childhood moderate acute malnutrition (MAM).

OBJECTIVE

To review the evidence regarding the effectiveness of dairy-containing supplements, particularly specially formulated foods containing whey permeate and whey protein concentrate, in treating children with MAM.

METHODS

A summary of a conference presentation regarding an overview of current evidence behind the use of whey in supplementary foods, including results of a randomized double-blinded clinical effectiveness trial involving 2259 Malawian children treated for MAM using either a soy ready-to-use supplementary food (RUSF) or a novel whey RUSF treatment.

RESULTS

While the majority of the evidence base only suggests potential benefits of including whey in supplementary foods to treat MAM, a recent study specifically demonstrates that a whey RUSF produced superior recovery and growth outcomes in treating children with MAM when compared with a soy RUSF.

CONCLUSIONS

The use of whey ingredients has been shown to improve outcomes in the treatment of MAM; however, further research is needed to identify the ideal amount and type of dairy protein required to produce the best outcomes for the lowest cost.

Milk products in the dietary management of childhood undernutrition - a historical review

The present narrative review outlines the use of milk products in infant and young child feeding from early history until today and illustrates how research findings and technical innovations contributed to the evolution of milk-based strategies to combat undernutrition in children below the age of 5 years. From the onset of social welfare initiatives, dairy products were provided by maternal and child health services to improve nutrition. During the last century, a number of aetiological theories on oedematous forms of undernutrition were developed and until the 1970s the dogma of protein deficiency was dominant. Thereafter, a multifactorial concept gained acceptance and protein quality was emphasised. During the last decades, research findings demonstrated that the inclusion of dairy products in the management of severe acute malnutrition is most effective. For children suffering from moderate acute malnutrition the evidence for the superiority of milk-based diets is less clear. There is an unmet need for evaluating locally produced milk-free alternatives at lower cost, especially in countries that rely on imported dairy products. New strategies for the dietary management of childhood undernutrition need to be developed on the basis of research findings, current child feeding practices, socio-cultural conditions and local resources. Exclusive and continued breast-feeding supported by community-based nutrition programmes using optimal combinations of locally available complementary foods should be compared with milk product-based interventions.

Newly formulated, protein quality-enhanced, extruded sorghum-, cowpea-, corn-, soya-, sugar- and oil-containing fortified-blended foods lead to adequate vitamin A and iron outcomes and improved growth compared with non-extruded CSB+ in rats

Corn and soyabean micronutrient-fortified-blended foods (FBF) are commonly used for food aid. Sorghum and cowpeas have been suggested as alternative commodities because they are drought tolerant, can be grown in many localities, and are not genetically modified. Change in formulation of blends may improve protein quality, vitamin A and Fe availability of FBF. The primary objective of this study was to compare protein efficiency, Fe and vitamin A availability of newly formulated extruded sorghum-, cowpea-, soya- and corn-based FBF, along with a current, non-extruded United States Agency for International Development (USAID) corn and soya blend FBF (CSB+). A second objective was to compare protein efficiency of whey protein concentrate (WPC) and soya protein isolate (SPI) containing FBF to determine whether WPC inclusion improved outcomes. Eight groups of growing rats (n 10) consumed two white and one red sorghum–cowpea (WSC1 + WPC, WSC2 + WPC, RSC + WPC), white sorghum–soya (WSS + WPC) and corn–soya (CSB14 + WPC) extruded WPC-containing FBF, an extruded white sorghum–cowpea with SPI (WSC1 + SPI), non-extruded CSB+, and American Institute of Nutrition (AIN)-93G, a weanling rat diet, for 4 weeks. There were no significant differences in protein efficiency, Fe or vitamin A outcomes between WPC FBF groups. The CSB+ group consumed significantly less food, gained significantly less weight, and had significantly lower energy efficiency, protein efficiency and length, compared with all other groups. Compared with WSC1 + WPC, the WSC1 + SPI FBF group had significantly lower energy efficiency, protein efficiency and weight gain. These results suggest that a variety of commodities can be used in the formulation of FBF, and that newly formulated extruded FBF are of better nutritional quality than non-extruded CSB+.

Delivering Improved Nutrition: Dairy Ingredients in Food Aid Products

The United States has a long history of food assistance for humanitarian need. The Food for Peace Act of 1954 established the United States' permanent food assistance program which has fed over 3 billion people in 150 countries worldwide through thousands of partner organizations. In 60 years, the program has evolved and will continue to do so. Recently, the program has gone from a focus on quantity of food shipped to quality food assistance from improved products, programs, and processes to effectively meet the needs of different vulnerable groups. The current debate focuses on the appropriateness of using fortified blended foods to prevent and treat malnutrition during the first 1000 days of life. Dairy ingredients have been at the center of this debate; they were included initially in fortified blended, removed in the 1980s, and now reincorporated into fortified therapeutic and supplemental foods. Improved quality food baskets and effective nutrition programming to prevent and treat malnutrition were developed through multisectoral collaboration between government and nongovernment organizations. The US Agency for International Development has focused on improving nutrition through development programs often tied to health, education, and agriculture. The years since 2008 have been a particularly intense period for improvement. The Food Aid Quality Review was established to update current food aid programming products, program implementation, cost-effectiveness, and interagency processes. Trials are underway to harmonize the areas of multisectoral nutrition programming and gather more evidence on the effects of dairy ingredients in food aid products.

The Role of Dairy in Effectiveness and Cost of Treatment of Children With Moderate Acute Malnutrition: A Narrative Review

BACKGROUND

Dairy is recommended in specially formulated supplementary foods to treat children with moderate acute malnutrition (MAM) but with limited evidence and added cost.

OBJECTIVE

Review studies of ready-to-use foods (RUFs) versus fortified blended foods (FBFs) to determine whether inclusion of dairy modifies the comparative effectiveness and cost.

METHODS

We reviewed literature comparing FBF and RUF in treatment of MAM among children younger than 5 years in developing countries. Outcomes of recovery from MAM, weight, and length gain were compared among treatment categories: FBF with dairy (FBF+), FBF without dairy (FBF-), RUF with dairy (RUF+), and RUF without dairy (RUF-). Supplement cost was compared per 500 kcal.

RESULTS

Eight studies were included. Rations were heterogeneous in energy and type of dairy. Overall, RUF+, RUF-, and FBF+ performed similarly, with higher recovery and weight gain compared with FBF-. RUF+ had higher recovery (in 5 of 6 comparisons), weight gain (4 of 4), and length gain (1 of 4) versus FBF-. The RUF+ had higher recovery (1 of 2) versus FBF+, with no other differences. The RUF- versus FBF+ had no differences (0 of 2). The RUF- had higher recovery (1 of 2), weight gain (2 of 2) versus FBF-. Four studies reported supplement costs, which averaged US$0.15 (FBF-), US$0.18 (FBF+), US$0.18 (RUF-), and US$0.37 (RUF+) per 500 kcal.

CONCLUSIONS

There is a consistent benefit of FBF that include dairy in treatment of children with MAM. Benefits of dairy in RUF require further investigation. Evidence from rigorous quantitative analysis of existing data, cost-effectiveness, and prospective trials will be essential in determining policy on treatment for children with MAM.

Including whey protein and whey permeate in ready-to-use supplementary food improves recovery rates in children with moderate acute malnutrition: a randomized, double-blind clinical trial

BACKGROUND

The utility of dairy ingredients in the supplementary foods used in the treatment of childhood moderate acute malnutrition (MAM) remains unsettled.

OBJECTIVE

We evaluated the effectiveness of a peanut-based ready-to-use supplementary food (RUSF) with soy protein compared with a novel RUSF containing dairy ingredients in the form of whey permeate and whey protein concentrate in the treatment of children with MAM.

DESIGN

We conducted a randomized, double-blind clinical effectiveness trial involving rural Malawian and Mozambican children 6-59 mo of age with MAM treated with either soy RUSF or a novel whey RUSF treatment of ~75 kcal · kg(-1) · d(-1) for up to 12 wk.

RESULTS

The proportion of children that recovered from MAM was significantly higher in the group that received whey RUSF (960 of 1144; 83.9%) than in the group that received soy RUSF (874 of 1086; 80.5%; P < 0.04; risk difference 3.4%, 95% CI: 0.3%, 6.6%). Children who consumed whey RUSF also demonstrated better growth markers, with a higher mean midupper arm circumference (MUAC) at the time of discharge (P < 0.009), greater MUAC gain during the course of treatment (P < 0.003), higher mean weight-for-height z score at discharge (P < 0.008), and greater weight gain (P < 0.05). No significant differences were identified in length gain or time to recovery between the 2 groups.

CONCLUSION

This study highlights the importance of milk protein in the treatment of MAM, because the use of a novel whey RUSF resulted in higher recovery rates and improved growth than did soy RUSF, although the whey RUSF supplement provided less total protein and energy than the soy RUSF. This study was registered at clinicaltrials.gov as NCT01790048.