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Melaku B, Gebremichael B, Negash B, Kitessa M, Kassa O, Dereje J, Kefelegn R, Firdisa D. Time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda, East Hararghe Zone, Eastern Ethiopia. Front Nutr 2024; 11:1369419. [PMID: 39171105 PMCID: PMC11335514 DOI: 10.3389/fnut.2024.1369419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 07/29/2024] [Indexed: 08/23/2024] Open
Abstract
Background Acute malnutrition is a major global public health problem, particularly in low-and middle-income countries. A targeted supplementary feeding program is an approach recommended to address moderate acute malnutrition in food-insecure settings. Preventing and treating moderate acute malnutrition requires identifying factors shown to affect the treatment outcome and duration of stay on treatment. This study aimed to determine the time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda East Hararghe Zone, Eastern Ethiopia, from January 1 to December 31, 2022. Methods A facility-based retrospective cohort study was conducted on 567 children with moderate acute malnutrition in Fedis Woreda, East Hararghe Zone, eastern Ethiopia. A multi-stage sampling technique was employed, and data was collected using a structured checklist. Data were extracted from randomly selected records after obtaining ethical clearance. Data were cleaned, coded, entered into EpiData 4.6, and analyzed using STATA/SE version 14. Descriptive statistics and analytic analysis schemes, including bivariable and multivariable Cox proportional hazards models, were conducted, and finally, statistical significance was considered at p < 0.05. Results The overall median time to recovery was 16 weeks. The major predicting factors for time to recovery among children aged 6-59 months were admission with a mid-upper arm circumference of 12.1-12.4 centimeters (AHR = 1.02, 95% CI: 1.01-1.19), access to transportation to facilities (AHR = 0.62, 95% CI: 0.36-0.81), children using specialized nutritious foods (RUSF; AHR = 1.96, 95% CI: 1.36-3.11), and children who had diarrhea (AHR = 0.4, 95% CI: 0.31-0.71). Conclusion The study found a median recovery time of 16 weeks for children with targeted supplementary feeding. Significant predictors included admission with a MUAC of 12.1-12.4 centimeters, transportation access, RUSF use, and the presence of diarrhea. These findings highlighted the importance of these factors in determining and improving recovery from moderate-acute malnutrition.
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Affiliation(s)
- Berhanu Melaku
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Berhe Gebremichael
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Belay Negash
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Monas Kitessa
- School of pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Obsan Kassa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Jerman Dereje
- Department of psychiatry, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Reta Kefelegn
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Dawit Firdisa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Tura DC, Belachew T, Tamiru D, Abate KH. Effects of blending ratio variation on macronutrient compositions and sensory acceptability of dabi teff-field pea-based novel composite complementary flours. Food Sci Nutr 2024; 12:2408-2425. [PMID: 38628205 PMCID: PMC11016380 DOI: 10.1002/fsn3.3925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 04/19/2024] Open
Abstract
The response of a mixed system is determined by the proportions of the various ingredients that add up to one, not by the combination's total amount. This research aimed at examining the effects of blending ratio variation on the macro-composition and sensory acceptability of dabi teff-field pea-based novel composite complementary flours. Standard methods (AOAC, 2016, Official Methods of Analysis of the Association of Official Analytical Chemists) were used to determine macronutrients. The sensory attributes were evaluated using a 5-point hedonic scale. The ingredients were constrained at 0%-30% for field pea, 20%-35% for dabi teff, and 5%-20% for maize, while the remaining were set constant at 5% linseed, 15% oats, and 25% barley. D-optimal was used to examine the effects of blending ratio variation on the responses. All the responses were significantly different (p < .05) among the blends except for fat content, ranging from 14.58% to 17.21% for protein, 4.22% to 5.59% fat, 2.01% to 2.60% ash, 2.68% to 3.96% fiber, 68.08% to 70.76% utilizable carbohydrate, and 378.82 to 386.9 kcal/100 g gross energy. The sensory acceptability score ranged from 3.4 to 4.4. The linear model was significant (p < .05) and adequate to describe variation in moisture, protein, and ash contents. An increase in the ratio of field pea significantly increased (p < .05) protein, ash, fiber, and energy. The interactive effect between dabi teff and field pea significantly increased the sensory acceptability of the blends. These findings showed that varied proportions of the ingredients had a significant effect on the responses, and were used to develop a wholesome product to combat protein-energy malnutrition among children.
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Affiliation(s)
- Diriba Chewaka Tura
- Department of Nutrition and DieteticsInstitute of Health, Jimma UniversityJimmaEthiopia
- Department of Human NutritionWollega UniversityNekemteEthiopia
| | - Tefera Belachew
- Department of Nutrition and DieteticsInstitute of Health, Jimma UniversityJimmaEthiopia
| | - Dessalegn Tamiru
- Department of Nutrition and DieteticsInstitute of Health, Jimma UniversityJimmaEthiopia
| | - Kalkidan Hassen Abate
- Department of Nutrition and DieteticsInstitute of Health, Jimma UniversityJimmaEthiopia
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Teshome MS, Lema TB, Abessa TG, Mingels S, Granitzer M, Rameckers E, Verbecque E. Current evidence on the effectiveness of Ready-to-Use Supplementary Foods in children with moderate acute malnutrition: a systematic review and meta-analysis. J Nutr Sci 2024; 12:e130. [PMID: 38179261 PMCID: PMC10765019 DOI: 10.1017/jns.2023.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/10/2023] [Accepted: 12/01/2023] [Indexed: 01/06/2024] Open
Abstract
Moderate acute malnutrition (MAM) is defined by a weight-for-height Z-score (WHZ) between -3 and -2 of the WHO reference or by a mid-upper arm circumference (MUAC) of ≥11⋅5 and <12⋅5 cm. This study aimed to synthesise the evidence for the effectiveness of Ready-to-Use Supplementary Food (RUSF) compared to other dietary interventions or no intervention on functioning at different levels of the International Classification of Functioning, Disability, and Health (ICF) among children with MAM between 2 and12 years old. Three databases (PubMed, Scopus, and Web of Science) were systematically searched (last update: 20 November 2022). Pooled estimates of effect were calculated using random-effects meta-analyses. The level of evidence was estimated with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method. Seven studies were included. RUSF had a significant small-sized better effect (pooled mean: 0⋅38; 95 % CI = [0⋅10, 0⋅67], P = 0⋅01, I² = 97 %) on different anthropometric measurements compared to other dietary interventions among MAM children (n 6476). Comparing RUSF with corn-soy blend Plus Plus (CSB++) showed that RUSF had a small-sized but significantly better effect on the children's anthropometric measures compared to children who received CSB++ (pooled mean: 0⋅16; 95 % CI = [0⋅05, 0⋅27], P = 0⋅01; I2 = 35 %). MAM children treated with RUSF had a better recovery rate compared to those treated with CSB++ (pooled risk difference: 0⋅11; 95 % CI = [0⋅06, 0⋅11], P < 0⋅001; I2 = 0 %). The RUSF intervention seems promising in improving MAM children's nutritional outcomes and recovery rate compared to other dietary interventions.
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Affiliation(s)
- Melese Sinaga Teshome
- Department of Nutrition and Dietetics, Faculty of Public Health, Health Institute, Jimma University, Jimma, Ethiopia
- Rehabilitation Research Centre (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, 3590Diepenbeek, Belgium
| | - Tefera Belachew Lema
- Department of Nutrition and Dietetics, Faculty of Public Health, Health Institute, Jimma University, Jimma, Ethiopia
| | - Teklu Gemechu Abessa
- Department of Special Needs and Inclusive Education, Jimma University, Jimma, Ethiopia
| | - Sarah Mingels
- Rehabilitation Research Centre (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, 3590Diepenbeek, Belgium
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Leuven University, Leuven 3000, Belgium
| | - Marita Granitzer
- Rehabilitation Research Centre (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, 3590Diepenbeek, Belgium
| | - Eugene Rameckers
- Rehabilitation Research Centre (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, 3590Diepenbeek, Belgium
- Research School CAPHRI, Department of Rehabilitation Medicine, Maastricht University, Maastricht, The Netherlands
- Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Evi Verbecque
- Rehabilitation Research Centre (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, 3590Diepenbeek, Belgium
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Akinmoladun OF, Bamidele OP, Jideani VA, Nesamvuni CN. Severe Acute Malnutrition: The Potential of Non-Peanut, Non-Milk Ready-to-Use Therapeutic Foods. Curr Nutr Rep 2023; 12:603-616. [PMID: 37897619 PMCID: PMC10766793 DOI: 10.1007/s13668-023-00505-9] [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] [Accepted: 10/04/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW This review provides information on the prospect and effectiveness of ready-to-use therapeutic foods (RUTFs) produced locally without the addition of milk and peanut. RECENT FINDINGS The foods used in fighting malnutrition in the past decades contributed little to the success of the alleviation program due to their non-effectiveness. Hence, RUTFs are introduced to fight malnutrition. The peanut allergies, the high cost of milk, and the high production cost of peanut RUTF have made its distribution, treatment spread, and accessibility very slow, especially in areas where it is highly needed. There is a need, therefore, for a low-cost RUTF that is acceptable and effective in treating severe acute malnutrition among under-5 children. This review shows both the success and failure of reported studies on the use of non-peanut and non-milk RUTF, including their cost of production as compared to the standard milk and peanut-based RUTF. It was hypothesised that replacing the milk ingredient component with legumes like soybeans can reduce the cost of production of RUTFs while also delivering an effective product in managing and treating severe acute malnutrition (SAM). Consumers generally accept them better because of their familiarity with the raw materials.
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Affiliation(s)
- Oluwaseun F Akinmoladun
- Department of Nutrition, Faculty of Health Sciences, University of Venda, Private Bag X5050, Thohoyandou, 0950, South Africa.
- Department of Nutrition and Dietetics, College of Agriculture, Food Science and Technology, Wesley University, PMB 507 Ondo, Ondo State, Nigeria.
- Department of Health Science, University of the People, Pasadena, CA 91101, USA.
| | - Oluwaseun P Bamidele
- Department of Food Science and Technology, University of Venda, Private Bag X5050, Thohoyandou, 09590, South Africa
| | - Victoria A Jideani
- Department of Food Technology, Cape Peninsula University of Technology, P.O. Box 652, Cape Town, 8000, South Africa
| | - Cebisa N Nesamvuni
- Department of Nutrition, Faculty of Health Sciences, University of Venda, Private Bag X5050, Thohoyandou, 0950, South Africa
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Sarfraz A, Ahmed S, Muhammad S, Rehman N, Soomro SI, Qureshi K, Jakhro S, Umrani F, Greene A, Syed S, Moore SR, Ali SA. Standard RUTF vs. locally-made RUSF for acutely malnourished children: A quasi-experimental comparison of the impact on growth and compliance in a rural community of Pakistan. PLoS One 2023; 18:e0287962. [PMID: 37437065 PMCID: PMC10337979 DOI: 10.1371/journal.pone.0287962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/14/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND The reduction in severe and moderate acute malnutrition (SAM and MAM) rates in Pakistan has been sub-optimal compared to other low-and middle-income countries (LMICs). Specially-formulated products have been designed globally to manage SAM and MAM, such as ready-to-use therapeutic food (RUTF) and ready-to-use supplementary food (RUSF), with variable efficacies. RUTF is primarily produced and patented in industrialized countries, raising supply challenges in resource-constrained regions with a high burden of acute malnutrition. RUSF minimizes costs by using locally-available ingredients while providing similar nutritional value. In this study, we compared the efficacy, side effects, and compliance of two months of supplementation with either RUTF or RUSF. METHODS Children aged nine months in the rural district of Matiari, Pakistan, with a weight-for-height z-score (WHZ) <-2 received either RUTF (500 kcal sachet) for two months in 2015 or RUSF (520 kcal sachet) for two months in 2018. RESULTS The RUSF group had a higher height gain and mid-upper arm circumferences (MUAC) score. Higher compliance was noted with lower side effects in the RUSF group. A higher compliance rate did correlate with the growth parameters in respective groups. CONCLUSION Our study found that both RUTF and RUSF partially improve the anthropometric status of acutely malnourished children, with neither being superior to the other.
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Affiliation(s)
- Azza Sarfraz
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Muhammad
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeb Rehman
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sanam Iram Soomro
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Khaliq Qureshi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sadaf Jakhro
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fayaz Umrani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Adam Greene
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Sana Syed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Sean R. Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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6
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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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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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Odei Obeng‐Amoako GA, Stobaugh H, Wrottesley SV, Khara T, Binns P, Trehan I, Black RE, Webb P, Mwangome M, Bailey J, Bahwere P, Dolan C, Boyd E, Briend A, Myatt MA, Lelijveld N. How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies. MATERNAL & CHILD NUTRITION 2023; 19:e13434. [PMID: 36262055 PMCID: PMC9749592 DOI: 10.1111/mcn.13434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/13/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022]
Abstract
Children with weight-for-age z-score (WAZ) <-3 have a high risk of death, yet this indicator is not widely used in nutrition treatment programming. This pooled secondary data analysis of children aged 6-59 months aimed to examine the prevalence, treatment outcomes, and growth trajectories of children with WAZ <-3 versus children with WAZ ≥-3 receiving outpatient treatment for wasting and/or nutritional oedema, to inform future protocols. Binary treatment outcomes between WAZ <-3 and WAZ ≥-3 admissions were compared using logistic regression. Recovery was defined as attaining mid-upper-arm circumference ≥12.5 cm and weight-for-height z-score ≥-2, without oedema, within a period of 17 weeks of admission. Data from 24,829 children from 9 countries drawn from 13 datasets were included. 55% of wasted children had WAZ <-3. Children admitted with WAZ <-3 compared to those with WAZ ≥-3 had lower recovery rates (28.3% vs. 48.7%), higher risk of death (1.8% vs. 0.7%), and higher risk of transfer to inpatient care (6.2% vs. 3.8%). Growth trajectories showed that children with WAZ <-3 had markedly lower anthropometry at the start and end of care, however, their patterns of anthropometric gains were very similar to those with WAZ ≥-3. If moderately wasted children with WAZ <-3 were treated in therapeutic programmes alongside severely wasted children, we estimate caseloads would increase by 32%. Our findings suggest that wasted children with WAZ <-3 are an especially vulnerable group and those with moderate wasting and WAZ <-3 likely require a higher intensity of nutritional support than is currently recommended. Longer or improved treatment may be necessary, and the timeline and definition of recovery likely need review.
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Affiliation(s)
| | - Heather Stobaugh
- Action Against Hunger USANew York CityNew YorkUSA
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA
| | | | - Tanya Khara
- Emergency Nutrition Network (ENN)KidlingtonUK
| | | | - Indi Trehan
- Departments of Paediatrics, Global Health, and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Robert E. Black
- Institute for International ProgrammesJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA
- Emergency Nutrition Network (ENN)KidlingtonUK
| | - Martha Mwangome
- Kenya Medical Research Institute (KEMRI)Centre for Geographic Medicine Research‐CoastKilifiKenya
| | | | - Paluku Bahwere
- Center for Epidémiology, Biostatistics and Clinical Research (CR2), School of Public HealthUniversité Libre de BruxellesBrusselsBelgium
| | | | - Erin Boyd
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA
- USAID/BHAWashingtonDistrict of ColumbiaUSA
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of ScienceUniversity of CopenhagenFrederiksbergDenmark
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
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9
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Rashid MY, Kebira JY, Oljira L, Dheresa M. Time to Recovery From Moderate Acute Malnutrition and Its Predictors Among Children 6–59 Months of Age Enrolled in Targeted Supplementary Feeding Program in Darolebu District, Eastern Ethiopia: A Retrospective Cohort Study. Front Public Health 2022; 10:914837. [PMID: 35910899 PMCID: PMC9330372 DOI: 10.3389/fpubh.2022.914837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Acute malnutrition is a major global public health problem, particularly in low and middle-income countries. A targeted supplementary feeding program is an approach recommended to address moderate acute malnutrition in food insecure settings. Preventing and treating moderate acute malnutrition requires identifying factors shown to affect the treatment outcome and duration of stay on treatment. This study aimed to determine the treatment outcome and predictors of recovery time from moderate acute malnutrition among children 6–59 months of age in Darolebu district, Eastern Ethiopia. Methods A retrospective cohort study design was conducted on 540 children with moderate acute malnutrition. A Kaplan–Meier survival analysis was used to estimate the recovery time. Cox proportional hazard regression model was used to determine the association between the independent and the outcome variables. The proportional hazard assumption of the model was checked graphically and statistically. Any violation of the proportional hazard assumption of the model was also considered and adjusted in the analysis. Finally, a variable with a P-value <0.05 in the multivariate cox regression model was considered statistically significant. Results The overall recovery rate was 73% (95% CI 69.4–76.4%) with the median time to recovery of 16 weeks. Being between the ages of 24 and 59 months (AHR = 1.24, 95% CI: 1.01–1.54), having a mid-upper arm circumference (MUAC) at admission between 11.5 and 11.9 cm (AHR = 1.27, 95% CI: 1.34–2.61), walking for an hour or less to receive services (AHR = 1.2, 95% CI: 1.02–1.89), using ready-to-use supplementary food (AHR= 1.8, 95%CI: 1.38–2.39) were significant predictors of recovery time. Conclusion The recovery rate was slightly below the accepted minimum international standard, suggesting that further work is needed to improve the treatment outcomes and mortality and morbidity associated with moderate acute malnutrition.
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Affiliation(s)
| | - Jemal Yusuf Kebira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- *Correspondence: Jemal Yusuf Kebira
| | - Lemessa Oljira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Merga Dheresa
- School Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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10
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Udoh E, Nwazuluoke B, Bassey V, Motilewa O, Okorie O, Adesina S, Ejemot-Nwadiaro R, Meremikwu M. Comparison of standardised milk-based, standardised non-milk based and hospital-based formulations on the anthropometric indices of under-fives with moderate acute malnutrition: A randomised clinical trial. J Hum Nutr Diet 2021; 35:523-534. [PMID: 34843141 DOI: 10.1111/jhn.12960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Moderate acute malnutrition (MAM) causes impaired anthropometry, which can be reversed by supplementary feeding. The present study aimed to compare the effect of a standardised milk-based formulation (SMBF), standardised non-milk based formulation (SNMBF) and hospital-based formulation (HBF) on anthropometric indices of children aged <5 years with MAM. METHODS This was a randomised clinical trial during which eligible children aged 6-59 months with MAM received SMBF, SNMBF or HBF over 4 months. They were followed up on a biweekly basis during which their weight, mid upper arm circumference (MUAC) and length/height were measured. The effect of the formulations was determined at the end of the period by the change in their anthropometric indices using 'per protocol' analysis. p < 0.05 was considered statistically significant. RESULTS There were 157 evaluable participants of whom 54 received the SMBF, 57 received the SNMBF and 46 received the HBF. The overall result showed a significant improvement in the mean weight and MUAC of the children. Subgroup analysis showed a significant improvement in mean weight and MUAC among children aged 6-23 months (p = 0.013) and improvement in MUAC only among those aged 24-59 months (p = 0.03). CONCLUSIONS The formulations significantly improved the mean weight and MUAC of children with MAM.
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Affiliation(s)
- Ekong Udoh
- Paediatrics Department, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Blessing Nwazuluoke
- Dietetic Unit, Department of Internal Medicine, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Victor Bassey
- Nutrition Division, State Ministry of Health, Uyo, Akwa Ibom State, Nigeria
| | - Olugbemi Motilewa
- Community Health Department, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Obasi Okorie
- Paediatric Endocrine Unit, Endocrine and Diabetes Center, King Abdulaziz Specialist Hospital, Sakaka, Kingdom of Saudi Arabia
| | - Sunday Adesina
- Paediatrics Department, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Regina Ejemot-Nwadiaro
- Department of Public Health, Faculty of Allied Medical Sciences, University of Calabar, Calabar, Cross River State, Nigeria
| | - Martin Meremikwu
- Paediatrics Department, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria
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11
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Nane D, Hatløy A, Lindtjørn B. A local-ingredients-based supplement is an alternative to corn-soy blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: A randomized controlled non-inferiority trial in Wolaita, Southern Ethiopia. PLoS One 2021; 16:e0258715. [PMID: 34710105 PMCID: PMC8553037 DOI: 10.1371/journal.pone.0258715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Globally, moderate acute malnutrition (MAM) affects approximately 5% of children below five years of age. MAM is a persistent public health problem in Ethiopia. The current approach in Ethiopia for managing MAM is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. The objective of the study was to compare a local-ingredients-based supplement (LIBS) with the standard corn-soy blend plus (CSB+) in treating MAM among children aged 6 to 59 months to test the hypothesis that the recovery rate achieved with LIBS will not be more than 7% worse than that achieved with CSB+. METHODS AND FINDINGS We used an individual randomized controlled non-inferiority trial design with two arms, involving 324 children with MAM aged 6 to 59 months in Wolaita, Southern Ethiopia. One hundred and sixty-two children were randomly assigned to each of the two arms. In the first arm, 125.2 g of LIBS with 8 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. In the second arm, 150 g of CSB+ with 16 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. Each child was provided with a daily ration of either LIBS or CSB+ for 12 weeks. Both intention-to-treat (ITT) and per-protocol (PP) analyses were done. ITT and PP analyses showed non-inferiority of LIBS compared with CSB+ for recovery rate [ITT risk difference = 4.9% (95% CI: -4.70, 14.50); PP risk difference = 3.7% (95% CI: -5.91, 13.31)]; average weight gain [ITT risk difference = 0.10 g (95% CI: -0.33 g, 0.53 g); PP risk difference = 0.04 g (95% CI: -0.38 g, 0.47 g)]; and recovery time [ITT risk difference = -2.64 days (95% CI: -8.40 days, 3.13 days); PP difference -2.17 days (95% CI: -7.97 days, 3.64 days]. Non-inferiority in MUAC gain and length/height gain was also observed in the LIBS group compared with the CSB+ group. CONCLUSIONS LIBS can be used as an alternative to the standard CSB+ for the treatment of MAM. Thus, the potential of scaling up the use of LIBS should be promoted. TRIAL REGISTRATION Pan-African Clinical Trial Registration number: PACTR201809662822990.
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Affiliation(s)
- Debritu Nane
- School of Public and Environmental Health, Hawassa University, Awassa, Ethiopia
- Centre for International Health, University of Bergen, Bergen, Norway
- Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Anne Hatløy
- Centre for International Health, University of Bergen, Bergen, Norway
- Fafo Institute for Labour and Social Research, Oslo, Norway
| | - Bernt Lindtjørn
- School of Public and Environmental Health, Hawassa University, Awassa, Ethiopia
- Centre for International Health, University of Bergen, Bergen, Norway
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12
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Ickes SB, Craig C, Heidkamp R. Design Factors for Food Supplementation and Nutrition Education Interventions That Limit Conclusions about Effectiveness for Wasting Prevention: A Scoping Review of Peer-Reviewed Literature. Adv Nutr 2021; 13:328-341. [PMID: 34666351 PMCID: PMC8803494 DOI: 10.1093/advances/nmab107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/04/2021] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
We conducted a scoping review to characterize the evidence base for the effectiveness of food supplementation (FS), nutrition education (NE), or FS/NE interventions to prevent wasting among children aged 6 to 59 mo. We aimed to identify gaps in peer-reviewed literature and to develop recommendations for strengthening study designs. We identified 56 unique studies (FS = 21, NE = 19, FS/NE = 16) for which we assessed intervention design factors, implementation context, evaluation methods, and wasting impact. Compared with studies focused on stunting, fewer wasting-focused studies reported weight-for-height z score (WHZ). Midupper arm circumference (MUAC) was more commonly reported in wasting-focused studies (71.4%) than those focused on stunting (36.8%) or wasting and stunting (30.4%). FS studies measured anthropometry (mean, 95% CI) more frequently at every 11.3 (7.8, 14.8) wk than NE interventions at 36.3 (8.8, 62.1) wk (P = 0.036), but not FS/NE interventions at 25.8 (5.6, 49.1) wk (P = 0.138). NE interventions tended to be of longer duration than FS or FS/NE interventions. Only 6 studies followed and measured children after the intervention period ended. Across all studies, 45% reported a significant effect on wasting; these included FS, NE, and FS/NE interventions. The lack of comparability across studies limits conclusions about the effectiveness of specific types of interventions. To build a more unified evidence base for wasting prevention we recommend that future studies 1) report on a consistent set of metrics, including MUAC; 2) attempt to measure change in wasting incidence using more frequent measures; 3) measure wasting prevalence among the general population; 4) follow children postintervention to assess relapse; 5) measure food insecurity and diet quality; and 6) use harmonized protocols across multiple settings. Such efforts to improve study comparability will strengthen the evidence base, may help unite divergent professional communities, and ultimately accelerate progress toward eliminating child undernutrition.
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Affiliation(s)
| | | | - Rebecca Heidkamp
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Patterson GT, Manthi D, Osuna F, Muia A, Olack B, Mbuchi M, Saldarriaga OA, Ouma L, Inziani M, Yu X, Otieno P, Melby PC. Environmental, Metabolic, and Inflammatory Factors Converge in the Pathogenesis of Moderate Acute Malnutrition in Children: An Observational Cohort Study. Am J Trop Med Hyg 2021; 104:1877-1888. [PMID: 33755580 PMCID: PMC8103470 DOI: 10.4269/ajtmh.20-0963] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/07/2021] [Indexed: 01/04/2023] Open
Abstract
Acute malnutrition affects more than 50 million children worldwide. These children are at an increased risk of morbidity and mortality from infectious disease. However, the pathogenesis of acute malnutrition and mechanisms underlying the increased risk and poor outcomes from infection are not well understood. Our objective was to identify differences in inflammation and inflammatory responses between children with moderate acute malnutrition (MAM) and healthy controls (HCs), and search for environmental, pathophysiological, and metabolic factors that may influence this response. Sixteen children with MAM and 16 HCs aged 18-36 months were studied in Nairobi, Kenya. None of the children had symptoms of an infectious disease (fever, diarrhea, or cough) in the 2 weeks before enrollment and sample collection. Demographic and health data were provided by their primary caregivers. Blood samples were collected to measure various biomarkers and the response to an inflammatory stimulus. Children with MAM were more frequently from households with contaminated water, crowding, and unstable income sources. They also had increases in basal inflammation, circulating bacterial lipopolysaccharide (LPS), markers of intestinal damage, and an exaggerated whole blood inflammatory response to LPS. Metabolic changes in children with MAM led to increased plasma levels of long-chain fatty acids, which were found to contribute to the pro-inflammatory state. These exploratory findings suggest convergence of multiple factors to promote dysregulated inflammatory responses and prompt several mechanistic hypotheses that can be pursued to better understand the pathogenesis of MAM.
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Affiliation(s)
- Grace T. Patterson
- Department of Internal Medicine and Infectious Disease, University of Texas Medical Branch, Galveston, Texas
| | - Dennis Manthi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Finnley Osuna
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Alfred Muia
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Beatrice Olack
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Margaret Mbuchi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Omar A. Saldarriaga
- Department of Internal Medicine and Infectious Disease, University of Texas Medical Branch, Galveston, Texas
| | - Linet Ouma
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Mary Inziani
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Xiaoying Yu
- Department of Preventative Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas
| | - Phelgona Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya;,Address correspondence to Phelgona Otieno, Kenya Medical Research Institute, Mbagathi Road, Nairobi, Kenya, E-mail: or Peter C. Melby, Department of Internal Medicine and Infectious Disease, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77550, E-mail:
| | - Peter C. Melby
- Department of Internal Medicine and Infectious Disease, University of Texas Medical Branch, Galveston, Texas;,Address correspondence to Phelgona Otieno, Kenya Medical Research Institute, Mbagathi Road, Nairobi, Kenya, E-mail: or Peter C. Melby, Department of Internal Medicine and Infectious Disease, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77550, E-mail:
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14
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Nane D, Hatløy A, Lindtjørn B. Development and nutritional evaluation of local ingredients-based supplements to treat moderate acute malnutrition among children aged below five years: A descriptive study from rural Wolaita, Southern Ethiopia. Food Sci Nutr 2020; 8:6287-6295. [PMID: 33282278 PMCID: PMC7684584 DOI: 10.1002/fsn3.1927] [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: 06/23/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 11/07/2022] Open
Abstract
In Ethiopia, moderate acute malnutrition (MAM) is a persistent public health problem. The current management approaches for MAM among children are counseling in food-secure settings and food supplementation in chronically food-insecure areas. The objective of this study was to develop a local ingredients-based supplement (LIBS) for treating MAM among children. Collection of food ingredients (pumpkin seed, amaranth grain, flaxseed, peanut, and emmer wheat) was made. Sorting, soaking, drying, roasting, and milling of ingredients were done. Nutrient analysis was done using triplicate measurements of each nutrient. One-way ANOVA was used to analyze differences in means with ± standard deviation of nutrient measurements among the supplements. The nutrient content of four developed LIBS ranged from 20.3 g to 22.5 g for protein, 29.3 g to 33.5 g for fat, 509.5 kcal to 570.0 for kcal, 6.0 g to 8.5 g for fiber, 2.8 g to 3.7 g for moisture, and 2.1 g to 4.3 g for ash. The mineral and antinutrient components ranged from 75.6 mg to 115.6 mg for calcium, 473.1 mg to 570.2 mg for potassium, 79.3 mg to 114.4 mg for sodium, 4.1 mg to 5.6 mg for zinc, 8.2 mg to 10.2 mg for iron, 442.6 mg to 470.4 mg for phosphorous, and 2.1 mg to 4.3 mg for phytate. The LIBS with the highest portion of pumpkin seed had significantly highest amounts of protein, fat, calories, iron, zinc, and potassium. The results found were within the recommended range of required nutrients for the treatment of children with MAM. Therefore, LIBS may be used for the management of children with MAM.
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Affiliation(s)
- Debritu Nane
- School of Public and Environmental HealthHawassa UniversityHawassaEthiopia
- Centre for International HealthUniversity of BergenBergenNorway
| | - Anne Hatløy
- Centre for International HealthUniversity of BergenBergenNorway
- Fafo Institute for Labour and Social ResearchOsloNorway
| | - Bernt Lindtjørn
- School of Public and Environmental HealthHawassa UniversityHawassaEthiopia
- Centre for International HealthUniversity of BergenBergenNorway
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15
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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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16
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Azimi F, Esmaillzadeh A, Alipoor E, Moslemi M, Yaseri M, Hosseinzadeh-Attar MJ. Effect of a newly developed ready-to-use supplementary food on growth indicators in children with mild to moderate malnutrition. Public Health 2020; 185:290-297. [PMID: 32712460 DOI: 10.1016/j.puhe.2020.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Malnutrition is one of the leading causes of death among children younger than five years. In this study, we aimed to formulate a ready-to-use supplementary food (RUSF), based on local food products, and investigate its efficacy on growth indicators in children with mild to moderate malnutrition. STUDY DESIGN This is a randomized controlled clinical trial. METHODS This study was performed in six health centers in Shahr-e-Rey, Tehran, Iran, between April and October 2017. One hundred children, aged 24-59 months, with mild to moderate malnutrition (weight-for-height Z-score [WHZ] between -3 and -1) were randomly assigned to two groups to receive either 1-3 sachets of RUSF or normal diet for 8 weeks. All mothers and caregivers received nutrition education. Growth indicators including weight and height, WHZ, and body mass index (BMI), along with clinical outcomes, were assessed. RESULTS Children who received RUSF had a significant increase in weight (1.44 ± 0.38 vs 0.7 ± 0.32 kg, respectively, P < 0.001), and BMI (1.2 ± 0.47 vs 0.35 ± 0.33 kg/m2, respectively, P < 0.001) compared with the control group. There was a greater daily weight gain during the first 4 weeks (P < 0.001) and throughout the study (P = 0.013) in the RUSF group. Daily height gain was considerably higher in the RUSF group during the first 4 weeks (P = 0.027). Children in the RUSF group had more improvement in WHZ (1.18 ± 0.41 vs 0.41 ± 0.31, P < 0.001) after supplementation. Besides, 92% of the RUSF and 12% of the control group reached to WHZ > -1 at the end of the study (P < 0.001). There was lower prevalence of diarrhea (12% vs 28.6%, respectively, P = 0.01) and marginally lower fever (16% vs 36.7%, respectively, P = 0.05) in the intervention than in the control group. CONCLUSIONS A newly developed RUSF improved growth indicators and clinical outcomes in children with mild to moderate malnutrition. CLINICAL TRIAL REGISTRY NUMBER IRCT2017021315536N6 (registered at www.irct.ir).
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Affiliation(s)
- F Azimi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - A Esmaillzadeh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - E Alipoor
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - M Moslemi
- Food and Drug Laboratories Research Center, Food and Drug Administration, Ministry of Health and Medical Education, Tehran, Iran
| | - M Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - M J Hosseinzadeh-Attar
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center (CPPRC), Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
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17
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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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Langlois BK, Cliffer IR, Nikiema L, Suri DJ, Garanet F, Shen Y, Zeba AN, Walton SM, Lanou HB, Webb P, Rogers BL. Factors that May Influence the Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso. Curr Dev Nutr 2020; 4:nzaa002. [PMID: 31998858 PMCID: PMC6981338 DOI: 10.1093/cdn/nzaa002] [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: 09/17/2019] [Revised: 12/06/2019] [Accepted: 01/02/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A trial in Burkina Faso compared the cost-effectiveness of 4 specialized nutritious foods (SNFs) used to prevent stunting and wasting in children aged 6-23 mo. OBJECTIVES This article explores differences in SNF use that may have influenced effectiveness, specifically in relation to consumption by the recipient child and by any other person (i.e., sharing), other diversion from the recipient child, preparation, storage, and hygiene. METHODS Subsamples from a geographically clustered, longitudinal trial with random assignment to Corn Soy Blend Plus with oil (CSB+ w/oil), Corn Soy Whey Blend with oil (CSWB w/oil), Super Cereal Plus (SC+), or ready-to-use supplementary food (RUSF) were selected for in-depth interviews, in-home observations, and focus group discussions. RESULTS Sharing was common in all arms, with the highest reported in SC+ (73%) and highest observed in CSWB w/oil (36%). Some reported giving the ration away (highest in SC+ at 17%) or using it for other purposes (highest in CSWB w/oil at 17%). The recipient child was observed consuming the ration in 49% of households on average (38-60% by arm in CSB+ w/oil and RUSF, respectively). Qualitative reports of bitterness and spoilage emerged in the CSWB w/oil arm. Most observed households (excluding RUSF) did not prepare porridge daily as instructed (35-46% by arm). Household water samples showed either high-risk or unsafe contamination with Escherichia coli (72-78% by arm). Low percentages were observed handwashing (both child and server) before consuming the porridge. CONCLUSIONS The SNFs were not prepared or served as intended and diversion from the recipient was common. Storage conditions may have resulted in spoilage of the ration containing whey before reaching recipients. This article provides context about factors that may have influenced the effectiveness of these SNFs. Programming and household use of SNFs are as important as their nutrient composition. This trial was registered at clinicaltrials.gov as NCT02071563.
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Affiliation(s)
- Breanne K Langlois
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ilana R Cliffer
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Laetitia Nikiema
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Devika J Suri
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Franck Garanet
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Ye Shen
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Augustin N Zeba
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Shelley M Walton
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Hermann B Lanou
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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Das JK, Salam RA, Saeed M, Kazmi FA, Bhutta ZA. Effectiveness of Interventions for Managing Acute Malnutrition in Children under Five Years of Age in Low-Income and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients 2020; 12:nu12010116. [PMID: 31906272 PMCID: PMC7019612 DOI: 10.3390/nu12010116] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [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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Nane D, Hatløy A, Tadesse E, Lindtjørn B. Research protocol local ingredients-based supplementary food as an alternative to corn-soya blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: a randomized controlled non-inferiority trial in Wolaita. BMC Public Health 2019; 19:1689. [PMID: 31842852 PMCID: PMC6916533 DOI: 10.1186/s12889-019-8031-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 12/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Ethiopia, 12.5% of children below 5 years are wasted, and 9.7% are moderately wasted. The present strategy for the management of moderate acute malnutrition (MAM) is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. This randomized controlled non-inferiority trial examines if Local ingredients-based supplement (LIBS) is as effective as corn-soya blends plus (CSB+) in treating moderate acute malnutrition among children aged 6-59 months. METHODS A randomized controlled non-inferiority trial will be conducted with moderately wasted children aged 6 to 59 months in Wolaita, Ethiopia. The calculated sample size is 324 (i.e. with 162 children in each of two arms, to be assigned by randomization). The daily ration will be: 100 g of LIBS plus 25.2 g of sugar with 8 ml oil in the intervention group, and 150 g of CSB+ with 16 ml of oil in the control group. These interventions will be provided for a maximum period of 12 weeks, with follow-up performed on a weekly basis. Data analysis will be done using SPSS and STATA software. Both intention-to-treat and per protocol analyses will be done. Hazard ratio and Kaplan-Meier (log rank) curves of survival analysis will be done to predict the probability of recovery rate. Logistic regression will be used to test for interactions between independent and dependent variables. Analysis of variances, t-tests, fisher's exact test and chi-square tests will be used to assess baseline characteristics. CONCLUSIONS This paper will introduce to the existing research locally available nutritious foods which have the potential to enhance recovery from moderate acute malnutrition and to reduce the burden of malnutrition. The perceptions of mothers on feeding children with local ingredient-based supplementary food to assist recovery from moderate acute malnutrition will be the focus of in a qualitative study to follow; this will provide a further contribution in an evolving area of research. TRIAL REGISTRATION Pan-African Clinical Trial Registration number: PACTR201809662822990, retrospectively registered on 11/09/2018.
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Affiliation(s)
- Debritu Nane
- Hawassa University, School of Public and Environmental Health, PO Box 5, Hawassa, Ethiopia
- Centre for International Health, University of Bergen, PO Box 7800, 5020 Bergen, Norway
| | - Anne Hatløy
- Centre for International Health, University of Bergen, PO Box 7800, 5020 Bergen, Norway
- Fafo Institute for Labour and Social Research, PO Box 2947, 0608 Oslo, Norway
| | - Elazar Tadesse
- Kotebe Metropolitan University, PO Box 31228, Addis Ababa, Ethiopia
| | - Bernt Lindtjørn
- Centre for International Health, University of Bergen, PO Box 7800, 5020 Bergen, Norway
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21
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Isanaka S, Barnhart DA, McDonald CM, Ackatia-Armah RS, Kupka R, Doumbia S, Brown KH, Menzies NA. Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali. BMJ Glob Health 2019; 4:e001227. [PMID: 31139441 PMCID: PMC6509694 DOI: 10.1136/bmjgh-2018-001227] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/21/2018] [Accepted: 01/12/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Moderate acute malnutrition (MAM) causes substantial child morbidity and mortality, accounting for 4.4% of deaths and 6.0% of disability-adjusted life years (DALY) lost among children under 5 each year. There is growing consensus on the need to provide appropriate treatment of MAM, both to reduce associated morbidity and mortality and to halt its progression to severe acute malnutrition. We estimated health outcomes, costs and cost-effectiveness of four dietary supplements for MAM treatment in children 6–35 months of age in Mali. Methods We conducted a cluster-randomised MAM treatment trial to describe nutritional outcomes of four dietary supplements for the management of MAM: ready-to-use supplementary foods (RUSF; PlumpySup); a specially formulated corn–soy blend (CSB) containing dehulled soybean flour, maize flour, dried skimmed milk, soy oil and a micronutrient pre-mix (CSB++; Super Cereal Plus); Misola, a locally produced, micronutrient-fortified, cereal–legume blend (MI); and locally milled flour (LMF), a mixture of millet, beans, oil and sugar, with a separate micronutrient powder. We used a decision tree model to estimate long-term outcomes and calculated incremental cost-effectiveness ratios (ICERs) comparing the health and economic outcomes of each strategy. Results Compared to no MAM treatment, MAM treatment with RUSF, CSB++, MI and LMF reduced the risk of death by 15.4%, 12.7%, 11.9% and 10.3%, respectively. The ICER was US$9821 per death averted (2015 USD) and US$347 per DALY averted for RUSF compared with no MAM treatment. Conclusion MAM treatment with RUSF is cost-effective across a wide range of willingness-to-pay thresholds. Trial registration NCT01015950.
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Affiliation(s)
- Sheila Isanaka
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Dale A Barnhart
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Robert S Ackatia-Armah
- Department of Nutrition and Program in International and Community Nutrition, University of California, Davis, CA, USA
| | - Roland Kupka
- United Nations Children's Fund, Nutrition Section, New York, NY, USA
| | - Seydou Doumbia
- Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technology of Bamako, Bamako, Mali
| | - Kenneth H Brown
- Department of Nutrition and Program in International and Community Nutrition, University of California, Davis, CA, USA
| | - Nicolas A Menzies
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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22
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Das JK, Salam RA, Saeed M, Bilal H, Bhutta ZA. PROTOCOL: Effectiveness of interventions to manage acute malnutrition in children under five years of age in low- and middle-income countries: a systematic review. CAMPBELL SYSTEMATIC REVIEWS 2018; 14:1-26. [PMID: 37131390 PMCID: PMC8428063 DOI: 10.1002/cl2.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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23
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Stobaugh H. Maximizing Recovery and Growth When Treating Moderate Acute Malnutrition with Whey-Containing Supplements. Food Nutr Bull 2018; 39:S30-S34. [PMID: 30238798 DOI: 10.1177/0379572118774492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Moramarco S, Amerio G, Kasengele Chipoma J, Nielsen-Saines K, Palombi L, Buonomo E. Filling the Gaps for Enhancing the Effectiveness of Community-Based Programs Combining Treatment and Prevention of Child Malnutrition: Results from the Rainbow Project 2015⁻17 in Zambia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15091807. [PMID: 30131480 PMCID: PMC6164199 DOI: 10.3390/ijerph15091807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/10/2018] [Accepted: 08/12/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Child malnutrition, in all its forms, is a public health priority in Zambia. After implementations based on a previous evaluation in 2012⁻14 were made, the efficacy of the Rainbow Project Supplementary Feeding Programs (SFPs) for the integrated management of severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and underweight was reassessed in 2015⁻17. METHODS The outcomes were compared with International Standards and with those of 2012⁻14. Cox proportional risk regression analysis was performed to identify predictors of mortality and defaulting. RESULTS The data for 900 under-five year-old malnourished children were analyzed. Rainbow's 2015⁻17 outcomes met International Standards, for total and also when stratified for different type of malnutrition. A better performance than 2012⁻14 was noted in the main areas previously identified as critical: mortality rates were halved (5.6% vs. 3.1%, p = 0.01); significant improvements in average weight gain and mean length of stay were registered for recovered children (p < 0.001). HIV infection (5.5; 1.9⁻15.9), WAZ <⁻3 (4.6; 1.3⁻16.1), and kwashiorkor (3.5; 1.2⁻9.5) remained the major predictors of mortality. Secondly, training community volunteers consistently increased the awareness of a child's HIV status (+30%; p < 0.001). CONCLUSION Rainbow SFPs provide an integrated community-based approach for the treatment and prevention of child malnutrition in Zambia, with its effectiveness significantly enhanced after the gaps in activities were filled.
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Affiliation(s)
- Stefania Moramarco
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, via Montpellier, Rome 00133, Italy.
- Rainbow Project Association Pope John 23rd, 5656 Chinika Road, Ndola 10101, Zambia.
| | - Giulia Amerio
- Rainbow Project Association Pope John 23rd, 5656 Chinika Road, Ndola 10101, Zambia.
| | | | - Karin Nielsen-Saines
- Department of Pediatrics, David Geffen UCLA School of Medicine School of Medicine, Los Angeles, CA 90095, USA.
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, via Montpellier, Rome 00133, Italy.
| | - Ersilia Buonomo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, via Montpellier, Rome 00133, Italy.
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Ghodsi D, Omidvar N, Rashidian A, Eini-Zinab H, Raghfar H, Aghayan M. Effectiveness of the national food supplementary program on children growth and nutritional status in Iran. MATERNAL AND CHILD NUTRITION 2018; 14:e12591. [PMID: 29573559 DOI: 10.1111/mcn.12591] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/19/2017] [Accepted: 01/04/2018] [Indexed: 11/29/2022]
Abstract
This study aimed to evaluate the effectiveness of the national food distribution program on the growth and nutritional status of malnourished or growth-retarded children in 2 provinces of Iran. A quasi-experimental design was used for the effectiveness evaluation. Qualitative data were gathered to explain the results. An intervention group consisted of 362 children aged 6-72 months who were under coverage of the program. These children received monthly food as foodstuff, food vouchers, or cash. A comparison group included 409 children aged 6-72 months who were selected from those covered by the Primary Health Care system. Children anthropometric indices were measured at the baseline and also 6 months later. Twelve focus group discussions were held with mothers who had at least 1 child under the coverage of the program. At the end of the study, the mean weight-for-age Z scores, height-for-age Z scores, and weight-for-height Z scores increased compared with the baselines in both groups (p < .001). The differences between 2 groups in weight-for-age Z scores, height-for-age Z scores, and weight-for-height Z scores were not significant at the end of the study (p = .62, p = .91, and p = .94, respectively). According to the mothers' reports, factors affected the program outcome, that is, children anthropometric indices were low income, intrahousehold food sharing, irregular distribution, quantity and quality of the distributed food, and insufficient training. Providing foods for the malnourished children living in low-income families helped to prevent a worsening of their nutritional status; however, it has not been effective in solving the problem, probably due to the weak implementation and lack of empowerment strategies.
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Affiliation(s)
- Delaram Ghodsi
- Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasrin Omidvar
- Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Eini-Zinab
- Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Maryam Aghayan
- Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Javan R, Kooshki A, Afzalaghaee M, Aldaghi M, Yousefi M. Effectiveness of supplementary blended flour based on chickpea and cereals for the treatment of infants with moderate acute malnutrition in Iran: A randomized clinical trial. Electron Physician 2018; 9:6078-6086. [PMID: 29560163 PMCID: PMC5843437 DOI: 10.19082/6078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/24/2017] [Indexed: 11/20/2022] Open
Abstract
Background Despite the decreasing rate of under nutrition children in recent years overall, the negative affect in growth and development make it as a main concern in the world. Applying an available and appropriate supplementary food is a major approach in treating children with Moderate Acute Malnutrition (MAM). Objective To compare the effectiveness of a new supplementary blended flour (containing chickpea, rice, wheat and barley, named Shadameen) in combination with multivitamin/mineral supplement and nutritional counseling versus multivitamin/mineral supplement and nutritional counseling alone, in the treatment of children with MAM. Methods This randomized controlled trial study was conducted at Heshmatiyeh Hospital in Sabzevar city in Iran, from January 2016 to December 2016. Seventy infants, aged 9 to 24 months with MAM who were referred from urban health centers to the hospital clinic were included. They were randomly assigned to receive, for about 3 months, either multivitamin / mineral supplement and nutritional counseling alone or in combination with an extra supplementary blended food. We analyzed weight, length, weight for length Z score (WLZ), weight for age Z score (WAZ) and length for weight Z score (LAZ), along with recovery rate and adverse events among the two groups. The data were analyzed using SPSS version 16. We used statistics, Chi-square, independent t-test, and Fisher’s exact test for the analyses of primary and secondary outcomes. Results The food supplementation infant’s mean weight and WLZ and WAZ were greater compared with the other group (0.81±0.29 gr and 0.55±0.33 gr, p=0.002), (0.36±0.36 and 0.02±0.52, p=0.003), (0.40±0.33 and 0.09±0.37, p=0.001). The recovery rate in the food supplemented group was significantly higher than the other group (68.4%, 31.6%, p=0.001). No adverse reactions were observed. There were no significant differences in LAZ at the end of the study between the two groups (p=0.53). Conclusion This study showed that Shadameen in combination with multivitamin/mineral and counselling therapy can be more effective in decreasing the wasting rate of children with MAM than vitamin/mineral and counseling therapy alone. Trial registration The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2015040921670N1. Funding This study was financially supported by the vice chancellor for research office, Mashhad University of Medical Sciences.
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Affiliation(s)
- Roghayeh Javan
- MD-PhD of Persian Medicine, Assistant Professor, Traditional and Complementary Medicine Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran.,Student Research Committee, Department of Persian Medicine, Faculty of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Akram Kooshki
- Ph.D. of Nutrition, Associate Professor, Department of Nutrition & Biochemistry, Faculty Member of Medicine School, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Monavvar Afzalaghaee
- MD, Social Medicine Specialist, Assistant Professor, School of Health, Management and Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mitra Aldaghi
- MD, Pediatrics Gastroenterologist, Assistant Professor, Department of Pediatrics, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Mahdi Yousefi
- MD-PhD of Persian Medicine, Assistant Professor, Department of Persian Medicine, Faculty of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Clark LF. Policy conflicts in global food assistance strategies: balancing local procurement and harmonization. Food Secur 2018. [DOI: 10.1007/s12571-017-0758-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Cichon B, Fabiansen C, Iuel-Brockdorf AS, Yaméogo CW, Ritz C, Christensen VB, Filteau S, Briend A, Michaelsen KF, Friis H. Impact of food supplements on hemoglobin, iron status, and inflammation in children with moderate acute malnutrition: a 2 × 2 × 3 factorial randomized trial in Burkina Faso. Am J Clin Nutr 2018; 107:278-286. [PMID: 29529160 DOI: 10.1093/ajcn/nqx050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/29/2017] [Indexed: 11/14/2022] Open
Abstract
Background Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplements (LNSs) or corn-soy blends (CSBs) but little is known about the impact of these supplements on hemoglobin, iron status, and inflammation. Objective The objective of this study was to investigate the impact of supplementary foods for treatment of MAM on hemoglobin, iron status, inflammation, and malaria. Design A randomized 2 × 2 × 3 factorial trial was conducted in Burkina Faso. Children aged 6-23 mo with MAM received 500 kcal/d as LNS or CSB, containing either dehulled soy (DS) or soy isolate (SI) and different quantities of dry skimmed milk (0%, 20% or 50% of total protein) for 12 wk. The trial was double-blind with regard to quality of soy and quantity of milk, but not matrix (CSB compared to LNS). Hemoglobin, serum ferritin (SF), serum soluble transferrin receptor (sTfR), serum C-reactive protein (CRP), serum α1-acid glycoprotein (AGP), and malaria antigens were measured at inclusion and after supplementation. Results Between September 2013 and August 2014, 1609 children were enrolled. Among these, 61 (3.8%) were lost to follow-up. During the 12-wk supplementation period, prevalence of anemia, low SF adjusted for inflammation (SFAI), elevated sTfR, and iron-deficiency anemia decreased by 16.9, 8.7, 12.6 and 10.5 percentage points. Children who received LNS compared to CSB had higher hemoglobin (2 g/L; 95% CI: 1, 4 g/L), SFAI (4.2 µg/L; 95% CI: 2.9, 5.5 µg/L), and CRP (0.8 mg/L; 95% CI: 0.4, 1.2 mg/L) and lower sTfR (-0.9 mg/L, 95% CI: -1.3, -0.6 mg/L) after the intervention. Replacing DS with SI or increasing milk content did not affect hemoglobin, SFAI, sTfR, or CRP. Conclusion Supplementation with LNS compared to CSB led to better hemoglobin and iron status, but overall prevalence of anemia remained high. The higher concentrations of acute-phase proteins in children who received LNSs requires further investigation. This trial was registered at www.controlled-trials.com as ISRCTN42569496.
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Affiliation(s)
- Bernardette Cichon
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Doctors Without Borders, Denmark, Copenhagen, Denmark
| | - Christian Fabiansen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Doctors Without Borders, Denmark, Copenhagen, Denmark
| | - Ann-Sophie Iuel-Brockdorf
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Doctors Without Borders, Denmark, Copenhagen, Denmark
| | - Charles W Yaméogo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Department of Biomedical and Public Health, Research Institute for Health Sciences, Ouagadougou, Burkina Faso
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Vibeke B Christensen
- Doctors Without Borders, Denmark, Copenhagen, Denmark.,Department of Pediatrics, Righospitalet, Copenhagen, Denmark
| | - Suzanne Filteau
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, University of Tampere, Tampere, Finland
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
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Abstract
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.
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Gera T, Pena-Rosas JP, Boy-Mena E, Sachdev HS. Lipid based nutrient supplements (LNS) for treatment of children (6 months to 59 months) with moderate acute malnutrition (MAM): A systematic review. PLoS One 2017; 12:e0182096. [PMID: 28934235 PMCID: PMC5608196 DOI: 10.1371/journal.pone.0182096] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 07/12/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Moderate acute malnutrition is a major public health problem affecting children from low- and middle-income countries. Lipid nutrient supplements have been proposed as a nutritional intervention for its treatment. OBJECTIVES To evaluate the effectiveness and safety of LNS for the treatment of MAM in infants and children 6 to 59 months of age. STUDY DESIGN Systematic review of randomized-controlled trials and controlled before-after studies. RESULTS Data from nine trials showed that use of LNS, in comparison to specially formulated foods, improved the recovery rate (RR 1.08; 95% CI 1.02-1.14, 8 RCTs, 8934 participants, low quality evidence); decreased the chances of no recovery (RR 0.70; 95% CI 0.58-0.85, 7 RCTs, 8364 participants, low quality evidence) and the risk of deterioration into severe acute malnutrition (RR 0.87; 95% CI 0.73-1.03, 6 RCTs, 6788 participants, low quality evidence). There was little impact on mortality (RR 0.94, 95% CI 0.54-1.52, 8 RCTs, 8364 participants, very-low- quality evidence) or default rate (RR 1.32; 95% CI 0.73-2.4, 7 studies, 7570 participants, low quality evidence). There was improvement in weight gain, weight-for-height z-scores, height-for-age z-scores and mid-upper arm circumference. Subset analyses suggested higher recovery rates with greater amount of calories provided and with ready-to-use therapeutic foods, in comparison to ready-to-use supplementary foods. One study comparing LNS with nutritional counselling (very low quality evidence) showed higher chance of recovery, lower risk of deteriorating into severe acute malnutrition and lower default rate, with no impact on mortality, and no recovery. CONCLUSIONS Evidence restricted to the African regions suggests that LNS may be slightly more effective than specially formulated fortified foods or nutritional counselling in recovery from MAM, lowering the risk of deterioration into SAM, and improving weight gain with little impact on mortality or default rate.
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Affiliation(s)
- Tarun Gera
- Department of Pediatrics, SL Jain Hospital, Delhi, India
| | - Juan Pablo Pena-Rosas
- Evidence and Programme Guidance, Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
| | - Evelyn Boy-Mena
- Evidence and Programme Guidance, Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
| | - Harshpal S. Sachdev
- Department of Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi, India
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Fabiansen C, Yaméogo CW, Iuel-Brockdorf AS, Cichon B, Rytter MJH, Kurpad A, Wells JC, Ritz C, Ashorn P, Filteau S, Briend A, Shepherd S, Christensen VB, Michaelsen KF, Friis H. Effectiveness of food supplements in increasing fat-free tissue accretion in children with moderate acute malnutrition: A randomised 2 × 2 × 3 factorial trial in Burkina Faso. PLoS Med 2017; 14:e1002387. [PMID: 28892496 PMCID: PMC5593178 DOI: 10.1371/journal.pmed.1002387] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 08/09/2017] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplement (LNS) or corn-soy blend (CSB). We assessed the effectiveness of (a) matrix, i.e., LNS or CSB, (b) soy quality, i.e., soy isolate (SI) or dehulled soy (DS), and (c) percentage of total protein from dry skimmed milk, i.e., 0%, 20%, or 50%, in increasing fat-free tissue accretion. METHODS AND FINDINGS Between September 9, 2013, and August 29, 2014, a randomised 2 × 2 × 3 factorial trial recruited 6- to 23-month-old children with MAM in Burkina Faso. The intervention comprised 12 weeks of food supplementation providing 500 kcal/day as LNS or CSB, each containing SI or DS, and 0%, 20%, or 50% of protein from milk. Fat-free mass (FFM) was assessed by deuterium dilution technique. By dividing FFM by length squared, the primary outcome was expressed independent of length as FFM index (FFMI) accretion over 12 weeks. Other outcomes comprised recovery rate and additional anthropometric measures. Of 1,609 children, 4 died, 61 were lost to follow-up, and 119 were transferred out due to supplementation being switched to non-experimental products. No children developed allergic reaction. At inclusion, 95% were breastfed, mean (SD) weight was 6.91 kg (0.93), with 83.5% (5.5) FFM. In the whole cohort, weight increased 0.90 kg (95% CI 0.88, 0.93; p < 0.01) comprising 93.5% (95% CI 89.5, 97.3) FFM. As compared to children who received CSB, FFMI accretion was increased by 0.083 kg/m2 (95% CI 0.003, 0.163; p = 0.042) in those who received LNS. In contrast, SI did not increase FFMI compared to DS (mean difference 0.038 kg/m2; 95% CI -0.041, 0.118; p = 0.35), irrespective of matrix. Having 20% milk protein was associated with 0.097 kg/m2 (95% CI -0.002, 0.196) greater FFMI accretion than having 0% milk protein, although this difference was not significant (p = 0.055), and there was no effect of 50% milk protein (0.049 kg/m2; 95% CI -0.047, 0.146; p = 0.32). There was no effect modification by season, admission criteria, or baseline FFMI, stunting, inflammation, or breastfeeding (p > 0.05). LNS compared to CSB resulted in 128 g (95% CI 67, 190; p < 0.01) greater weight gain if both contained SI, but there was no difference between LNS and CSB if both contained DS (mean difference 22 g; 95% CI -40, 84; p = 0.49) (interaction p = 0.017). Accordingly, SI compared to DS increased weight by 89 g (95% CI 27, 150; p = 0.005) when combined with LNS, but not when combined with CSB. A limitation of this and other food supplementation trials is that it is not possible to collect reliable data on individual adherence. CONCLUSIONS Based on this study, children with MAM mainly gain fat-free tissue when rehabilitated. Nevertheless, LNS yields more fat-free tissue and higher recovery rates than CSB. Moreover, current LNSs with DS may be improved by shifting to SI. The role of milk relative to soy merits further research. TRIAL REGISTRATION ISRCTN registry ISRCTN42569496.
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Affiliation(s)
- Christian Fabiansen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Médecins Sans Frontières–Denmark, 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
| | - Ann-Sophie Iuel-Brockdorf
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Médecins Sans Frontières–Denmark, Copenhagen, Denmark
| | - Bernardette Cichon
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Médecins Sans Frontières–Denmark, Copenhagen, Denmark
| | - Maren J. H. Rytter
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Anura Kurpad
- Division of Nutrition, St John’s Research Institute, Bangalore, India
| | - Jonathan C. Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Per Ashorn
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal
| | - Vibeke B. Christensen
- Médecins Sans Frontières–Denmark, Copenhagen, Denmark
- Department of Paediatrics, Righospitalet, Copenhagen, Denmark
| | - 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
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Community-Based Management of Child Malnutrition in Zambia: HIV/AIDS Infection and Other Risk Factors on Child Survival. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13070666. [PMID: 27376317 PMCID: PMC4962207 DOI: 10.3390/ijerph13070666] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 11/17/2022]
Abstract
(1) BACKGROUND: Supplementary feeding programs (SFPs) are effective in the community-based treatment of moderate acute malnutrition (MAM) and prevention of severe acute malnutrition (SAM); (2) METHODS: A retrospective study was conducted on a sample of 1266 Zambian malnourished children assisted from 2012 to 2014 in the Rainbow Project SFPs. Nutritional status was evaluated according to WHO/Unicef methodology. We performed univariate and multivariate Cox proportional risk regression to identify the main predictors of mortality. In addition, a time-to event analysis was performed to identify predictors of failure and time to cure events; (3) RESULTS: The analysis included 858 malnourished children (19 months ± 9.4; 49.9% males). Program outcomes met international standards with a better performance for MAM compared to SAM. Cox regression identified SAM (3.8; 2.1-6.8), HIV infection (3.1; 1.7-5.5), and WAZ <-3 (3.1; 1.6-5.7) as predictors of death. Time to event showed 80% of children recovered by SAM/MAM at 24 weeks. (4) CONCLUSIONS: Preventing deterioration of malnutrition, coupled to early detection of HIV/AIDS with adequate antiretroviral treatment, and extending the duration of feeding supplementation, could be crucial elements for ensuring full recovery and improve child survival in malnourished Zambian children.
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James P, Sadler K, Wondafrash M, Argaw A, Luo H, Geleta B, Kedir K, Getnet Y, Belachew T, Bahwere P. Children with Moderate Acute Malnutrition with No Access to Supplementary Feeding Programmes Experience High Rates of Deterioration and No Improvement: Results from a Prospective Cohort Study in Rural Ethiopia. PLoS One 2016; 11:e0153530. [PMID: 27100177 PMCID: PMC4839581 DOI: 10.1371/journal.pone.0153530] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 03/30/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children with moderate acute malnutrition (MAM) have an increased risk of mortality, infections and impaired physical and cognitive development compared to well-nourished children. In parts of Ethiopia not considered chronically food insecure there are no supplementary feeding programmes (SFPs) for treating MAM. The short-term outcomes of children who have MAM in such areas are not currently described, and there remains an urgent need for evidence-based policy recommendations. METHODS We defined MAM as mid-upper arm circumference (MUAC) of ≥11.0 cm and <12.5 cm with no bilateral pitting oedema to include Ethiopian government and World Health Organisation cut-offs. We prospectively surveyed 884 children aged 6-59 months living with MAM in a rural area of Ethiopia not eligible for a supplementary feeding programme. Weekly home visits were made for seven months (28 weeks), covering the end of peak malnutrition through to the post-harvest period (the most food secure window), collecting anthropometric, socio-demographic and food security data. RESULTS By the end of the study follow up, 32.5% (287/884) remained with MAM, 9.3% (82/884) experienced at least one episode of SAM (MUAC <11 cm and/or bilateral pitting oedema), and 0.9% (8/884) died. Only 54.2% of the children recovered with no episode of SAM by the end of the study. Of those who developed SAM half still had MAM at the end of the follow up period. The median (interquartile range) time to recovery was 9 (4-15) weeks. Children with the lowest MUAC at enrolment had a significantly higher risk of remaining with MAM and a lower chance of recovering. CONCLUSIONS Children with MAM during the post-harvest season in an area not eligible for SFP experience an extremely high incidence of SAM and a low recovery rate. Not having a targeted nutrition-specific intervention to address MAM in this context places children with MAM at excessive risk of adverse outcomes. Further preventive and curative approaches should urgently be considered.
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Affiliation(s)
| | | | - Mekitie Wondafrash
- Population and Family Health Department, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
- Department of Food Safety and Food Quality, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Alemayehu Argaw
- Population and Family Health Department, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
- Department of Food Safety and Food Quality, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Hanqi Luo
- Valid International, Oxford, United Kingdom
| | - Benti Geleta
- Save the Children International, Addis Ababa, Ethiopia
| | - Kiya Kedir
- Save the Children International, Addis Ababa, Ethiopia
| | - Yilak Getnet
- Save the Children International, Addis Ababa, Ethiopia
| | - Tefera Belachew
- Population and Family Health Department, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
| | - Paluku Bahwere
- Valid International, Oxford, United Kingdom
- Research Center in Epidemiology, Biostatistics and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
- * E-mail:
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Suri DJ, Moorthy D, Rosenberg IH. The Role of Dairy in Effectiveness and Cost of Treatment of Children With Moderate Acute Malnutrition: A Narrative Review. Food Nutr Bull 2016; 37:176-85. [PMID: 26936209 DOI: 10.1177/0379572116633327] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Devika J Suri
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA Department of Nutritional Sciences, University of Wisconsin, Madison, WI, USA
| | - Denish Moorthy
- Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING) Project, Arlington, VA, USA
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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Medoua GN, Ntsama PM, Ndzana ACA, Essa’a VJ, Tsafack JJT, Dimodi HT. Recovery rate of children with moderate acute malnutrition treated with ready-to-use supplementary food (RUSF) or improved corn-soya blend (CSB+): a randomized controlled trial. Public Health Nutr 2016; 19:363-70. [PMID: 25939394 PMCID: PMC10270795 DOI: 10.1017/s1368980015001238] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 01/27/2015] [Accepted: 03/13/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare an improved corn-soya blend (CSB+) with a ready-to-use supplementary food (RUSF) to test the hypothesis that satisfactory recovery rate will be achieved with CSB+ or RUSF when these foods provide 50 % of the child's energy requirement, the 50 % remaining coming from usual diet. DESIGN A comparative efficacy trial study was conducted with moderately wasted children, using a controlled randomized design, with parallel assignment for RUSF or CSB+. Every child received a daily ration of 167 kJ (40 kcal)/kg body weight during 56 d with a follow-up performed every 14 d. Every caregiver received nutrition counselling at enrolment and at each follow-up visit. SETTING Health districts of Mvog-Beti and Evodoula in the Centre region of Cameroon. SUBJECTS Eight hundred and thirty-three children aged 6-59 months were screened and eighty-one malnourished children (weight-for-height Z-score between -3 and -2) aged 25-59 months were selected. RESULTS Of children treated with CSB+ and RUSF, 73 % (95 % CI 59 %, 87 %) and 85 % (95 % CI 73 %, 97 %), respectively, recovered from moderate acute malnutrition, with no significant difference between groups. The mean duration of treatment required to achieve recovery was 44 d in the RUSF group and 51 d in the CSB+ group (log-rank test, P=0·0048). CONCLUSIONS There was no significant difference in recovery rate between the groups. Both CSB+ and RUSF were relatively successful for the treatment of moderate acute malnutrition in children. Despite the relatively low ration size provided, the recovery rates observed for both groups were comparable to or higher than those reported in previous studies, a probable effect of nutrition education.
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Affiliation(s)
- Gabriel Nama Medoua
- Centre for Food and Nutrition Research, Institute of Medical Research and Medicinal Plants Studies (IMPM), PO Box 6163, Yaoundé, Cameroon
| | - Patricia M Ntsama
- Centre for Food and Nutrition Research, Institute of Medical Research and Medicinal Plants Studies (IMPM), PO Box 6163, Yaoundé, Cameroon
| | - Anne Christine A Ndzana
- Centre for Food and Nutrition Research, Institute of Medical Research and Medicinal Plants Studies (IMPM), PO Box 6163, Yaoundé, Cameroon
| | - Véronique J Essa’a
- Centre for Food and Nutrition Research, Institute of Medical Research and Medicinal Plants Studies (IMPM), PO Box 6163, Yaoundé, Cameroon
| | - Julie Judith T Tsafack
- Centre for Food and Nutrition Research, Institute of Medical Research and Medicinal Plants Studies (IMPM), PO Box 6163, Yaoundé, Cameroon
| | - Henriette T Dimodi
- Centre for Food and Nutrition Research, Institute of Medical Research and Medicinal Plants Studies (IMPM), PO Box 6163, Yaoundé, Cameroon
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Karakochuk CD, van den Briel T, Stephens D, Zlotkin S. Food Sharing Practices in Households Receiving Supplemental Foods for the Treatment of Moderate Acute Malnutrition in Ethiopian Children. JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITION 2015. [DOI: 10.1080/19320248.2014.962772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ackatia-Armah RS, McDonald CM, Doumbia S, Erhardt JG, Hamer DH, Brown KH. Malian children with moderate acute malnutrition who are treated with lipid-based dietary supplements have greater weight gains and recovery rates than those treated with locally produced cereal-legume products: a community-based, cluster-randomized trial. Am J Clin Nutr 2015; 101:632-45. [PMID: 25733649 DOI: 10.3945/ajcn.113.069807] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Moderate acute malnutrition (MAM), defined as weight-for-length z score between -3 and -2 or midupper arm circumference between 11.5 and 12.5 cm, affects ∼33 million children aged <5 y worldwide. OBJECTIVE The objective was to compare the effects of 4 dietary supplements for the treatment of MAM. DESIGN Twelve community health centers in rural Mali were randomly assigned to provide to 1264 MAM children aged 6-35 mo one of 4 dietary supplements containing ∼500 kcal/d for 12 wk: 1) ready-to-use, lipid-based supplementary food (RUSF); 2) special corn-soy blend (CSB++); 3) locally processed, fortified flour (Misola); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). RESULTS In total, 1178 children (93.2%) completed the study. The adjusted mean (95% CI) change in weight (kg) from baseline was greater with RUSF than with the locally processed blends and was intermediate with CSB++ [1.16 (1.08, 1.24) for RUSF, 1.04 (0.96, 1.13) for CSB++, 0.91 (0.82, 0.99) for Misola, and 0.83 (0.74, 0.92) for LMF; P < 0.001]. For length change, RUSF and CSB++ differed significantly from LMF. Sustained recovery rates were higher with RUSF (73%) than with Misola (61%) and LMF (58%), P < 0.0001; CSB++ recovery rates (68%) did not differ from any of the other groups. CONCLUSIONS RUSF was more effective, but more costly, than other dietary supplements for the treatment of MAM; CSB++ yielded intermediate results. The benefits of treatment should be considered in relation to product costs and availability.
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Affiliation(s)
- Robert S Ackatia-Armah
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Christine M McDonald
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Seydou Doumbia
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Juergen G Erhardt
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Davidson H Hamer
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Kenneth H Brown
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
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Nikièma L, Huybregts L, Kolsteren P, Lanou H, Tiendrebeogo S, Bouckaert K, Kouanda S, Sondo B, Roberfroid D. Treating moderate acute malnutrition in first-line health services: an effectiveness cluster-randomized trial in Burkina Faso. Am J Clin Nutr 2014; 100:241-9. [PMID: 24808482 DOI: 10.3945/ajcn.113.072538] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Management of moderate acute malnutrition (MAM) is, currently, focused on food supplementation approaches. However, the sustainability of these strategies remains weak in low- and middle-income countries. In food-secure settings, an educational/behavioral intervention could be an alternative for improving MAM management. OBJECTIVE This study compared the effectiveness of weekly context-appropriate child-centered counseling (CCC), with an improved corn-soy blend [corn-soy blend with added micronutrients (CSB++)] or a locally produced ready-to-use supplementary food (RUSF), in treating MAM through first-line rural health services. DESIGN We used a cluster randomized controlled trial design with 3 arms, involving 18 rural health centers (6 by arm) and children aged 6-24 mo with uncomplicated MAM. In the first arm (CCC), trained health workers provided weekly personalized counseling to caretakers. In the 2 other arms, children received weekly either 455 g CSB++ or 350 g locally produced soy-based RUSF. Both food supplements provided ∼250 kcal/d. RESULTS The recovery rate after 3 mo of treatment was significantly lower with CCC (57.8%) than with CSB++ (74.5%) and RUSF (74.2%) (P < 0001). Mothers' attendance at health facilities was also substantially lower in the CCC arm (P < 0001); this arm had a high defaulter rate (P < 0.003). When the analysis was adjusted for attendance, we did not find a significant difference between the 3 arms, with incidence rate ratios of 1.14 (95% CI: 0.99, 1.31) and 1.13 (95% CI: 0.98, 1.30) for the CSB++ and RUSF arms, respectively, compared with the CCC arm. CONCLUSION Whereas supplement-based treatment of MAM was found to be more effective than the provision of CCC, we hypothesize that appropriate and specific nutrition counseling centered on children's needs, through primary health facilities, might be an alternative strategy for MAM treatment in rural food-secure areas, provided that attendance at counseling sessions by the caregiver is ensured. This trial was registered at clinicaltrials.gov as NCT01115647.
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Affiliation(s)
- Laetitia Nikièma
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Lieven Huybregts
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Patrick Kolsteren
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Hermann Lanou
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Simon Tiendrebeogo
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Kimberley Bouckaert
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Séni Kouanda
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Blaise Sondo
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
| | - Dominique Roberfroid
- From the Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso (LN, HL, ST, SK, and BS); the Child Health and Nutrition Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (DR, LH, and PK); and the Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium (LH, KB, and PK)
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Puett C, Salpéteur C, Lacroix E, Houngbé F, Aït-Aïssa M, Israël AD. Protecting child health and nutrition status with ready-to-use food in addition to food assistance in urban Chad: a cost-effectiveness analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2013; 11:27. [PMID: 24210058 PMCID: PMC4176497 DOI: 10.1186/1478-7547-11-27] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 10/31/2013] [Indexed: 11/18/2022] Open
Abstract
Background Despite growing interest in use of lipid nutrient supplements for preventing child malnutrition and morbidity, there is inconclusive evidence on the effectiveness, and no evidence on the cost-effectiveness of this strategy. Methods A cost effectiveness analysis was conducted comparing costs and outcomes of two arms of a cluster randomized controlled trial implemented in eastern Chad during the 2010 hunger gap by Action contre la Faim France and Ghent University. This trial assessed the effect on child malnutrition and morbidity of a 5-month general distribution of staple rations, or staple rations plus a ready-to-use supplementary food (RUSF). RUSF was distributed to households with a child aged 6–36 months who was not acutely malnourished (weight-for-height > = 80% of the NCHS reference median, and absence of bilateral pitting edema), to prevent acute malnutrition in these children. While the addition of RUSF to a staple ration did not result in significant reduction in wasting rates, cost-effectiveness was assessed using successful secondary outcomes of cases of diarrhea and anemia (hemoglobin <110 g/L) averted among children receiving RUSF. Total costs of the program and incremental costs of RUSF and related management and logistics were estimated using accounting records and key informant interviews, and include costs to institutions and communities. An activity-based costing methodology was applied and incremental costs were calculated per episode of diarrhea and case of anemia averted. Results Adding RUSF to a general food distribution increased total costs by 23%, resulting in an additional cost per child of 374 EUR, and an incremental cost per episode of diarrhea averted of 1,083 EUR and per case of anemia averted of 3,627 EUR. Conclusions Adding RUSF to a staple ration was less cost-effective than other standard intervention options for averting diarrhea and anemia. This strategy holds potential to address a broad array of health and nutrition outcomes in emergency settings where infrastructure is weak and other intervention options are infeasible in the short-term. However, further research is needed to establish the contexts in which RUSF is most effective and cost-effective in preventing acute malnutrition and morbidity among vulnerable children, compared to other options.
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Affiliation(s)
- Chloe Puett
- Action Against Hunger, 247 West 37th Street, New York, NY 10018, USA.
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Lenters LM, Wazny K, Webb P, Ahmed T, Bhutta ZA. Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health 2013; 13 Suppl 3:S23. [PMID: 24564235 PMCID: PMC3847503 DOI: 10.1186/1471-2458-13-s3-s23] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Globally, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) affect approximately 52 million children under five. This systematic review evaluates the effectiveness of interventions for SAM including the World Health Organization (WHO) protocol for inpatient management and community-based management with ready-to-use-therapeutic food (RUTF), as well as interventions for MAM in children under five years in low- and middle-income countries. METHODS We systematically searched the literature and included 14 studies in the meta-analysis. Study quality was assessed using CHERG adaptation of GRADE criteria. A Delphi process was undertaken to complement the systematic review in estimating case fatality and recovery rates that were necessary for modelling in the Lives Saved Tool (LiST). RESULTS Case fatality rates for inpatient treatment of SAM using the WHO protocol ranged from 3.4% to 35%. For community-based treatment of SAM, children given RUTF were 51% more likely to achieve nutritional recovery than the standard care group. For the treatment of MAM, children in the RUSF group were significantly more likely to recover and less likely to be non-responders than in the CSB group. In both meta-analyses, weight gain in the intervention group was higher, and although statistically significant, these differences were small. Overall limitations in our analysis include considerable heterogeneity in many outcomes and an inability to evaluate intervention effects separate from commodity effect. The Delphi process indicated that adherence to standardized protocols for the treatment of SAM and MAM should have a marked positive impact on mortality and recovery rates; yet, true consensus was not achieved. CONCLUSIONS Gaps in our ability to estimate effectiveness of overall treatment approaches for SAM and MAM persist. In addition to further impact studies conducted in a wider range of settings, more high quality program evaluations need to be conducted and the results disseminated.
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Affiliation(s)
- Lindsey M Lenters
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kerri Wazny
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Tahmeed Ahmed
- Centre for Nutrition and Food Security, ICDDR,B, Dhaka, Bangladesh
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Woman and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
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Lazzerini M, Rubert L, Pani P. Specially formulated foods for treating children with moderate acute malnutrition in low- and middle-income countries. Cochrane Database Syst Rev 2013:CD009584. [PMID: 23794237 DOI: 10.1002/14651858.cd009584.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low- and middle-income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid-based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. OBJECTIVES To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low- and middle-income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. SEARCH METHODS In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition-related organisations and researchers in this field. SELECTION CRITERIA We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low- and middle-income countries. DATA COLLECTION AND ANALYSIS Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses using the random-effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. MAIN RESULTS Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care - the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight-for-height (MD 0.20 z-score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid-based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses - there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid-based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non-recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight-for-height, and mid-upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid-based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses - no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid-based nutrient supplements versus specific types of blended foods - a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods - in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet - no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. AUTHORS' CONCLUSIONS In conclusion, there is moderate to high quality evidence that both lipid-based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid-based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short-term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.
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Affiliation(s)
- Marzia Lazzerini
- Unit for Health Services Research and International Health, WHO Collaborating Centre for Maternal and Child Health, Institutefor Maternal and Child Health, Trieste, Italy.
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