evidence-based blog of Filippo Dibari

Posts Tagged ‘acute malnutrition’

Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial

In Under-nutrition on July 7, 2013 at 12:33 pm

by Irena AH, Bahwere P, Owino VO, Diop EI, Bachmann MO, Mbwili-Muleya C, Dibari F, Sadler K, Collins S.

Matern Child Nutr. 2013 Jun 18.


Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto.

This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome.

The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group.

In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.

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International Conference: A Decade Of Community-based Treatment of Severe Acute Malnutrition

In Under-nutrition on June 3, 2013 at 8:57 pm

by Coverage Monitoring Network

Action Against Hunger (ACF International) and the Coverage Monitoring Network are pleased to invite you to a unique, two-day Conference titled “What We Know Now: a Decade of Community-based Treatment of Severe Acute Malnutrition”. The two day conference will bring together technical experts, field practitioners and policy makers to help identify priority areas for research and action. The event will review available evidence and emerging performance data of community-based SAM treatment.

SAVE THE DATE: October 17th – 18th  2013  London, UK

Field practitioners, academics and nutrition organisations are invited to submit proposals for presentations.  Abstracts should be sent to: Sophie Woodhead [s.woodhead@actionagainsthunger.org.uk] by Friday August 2nd 2013.

For more info click here.

State of the art of Ready-to-Use Therapeutic Food: A tool for nutraceuticals addition to foodstuff

In Under-nutrition on June 1, 2013 at 8:25 am

by Santini A, Novellino E, Armini V, Ritieni A.

Food Chem. 2013 Oct 15;140(4):843-9


Therapeutic foodstuff are a challenge for the use of food and functional food ingredients in the therapy of different pathologies. Ready-to-Use Therapeutic Food (RUTF) are a mixture of nutrients designed and primarily addressed to the therapy of the severe acute malnutrition. The main ingredients of the formulation are powdered milk, peanuts butter, vegetal oil, sugar, and a mix of vitamins, salts, and minerals. The potential of this food are the low percentage of free water and the high energy and nutritional density. The high cost of the powdered milk, and the food safety problems connected to the onset of toxigenic moulds on the peanuts butter, slowed down considerably the widespread and homogenous diffusion of this product. This paper presents the state of the art of RUTF, reviews the different proposed recipes, suggests some possible new formulations as an alternative of novel recipes for this promising food.

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Is mid-upper arm circumference alone sufficient for deciding admission to a nutritional programme for childhood severe acute malnutrition in Bangladesh?

In Under-nutrition on April 13, 2013 at 8:03 am

Engy Alia, Rony Zachariaha, Zubair Shamsb, Lieven Vernaeveb, Petra Aldersc, Flavio Saliob,  Marcel Manzia, Malik Allaounac, Bertrand Draguezc, Pascale Delchevaleriec and Anthony D. Harries

Trans R Soc Trop Med Hyg (2013)


Objectives Mid-upper arm circumference (MUAC) and weight-for-height Z-score (WHZ) identify different populations of children with severe acute malnutrition (SAM) with only some degree of overlap. In an urban slum in Bangladesh, we conducted a prospective cohort study on children assessed as being severely malnourished by WHZ (<–3) but not by MUAC (>115 mm), to: 1. Assess their nutritional outcomes, and 2. Report on morbidity and mortality.

Methods Children underwent 2-weekly prospective follow-up home visits for 3 months and their anthropometric evolution, morbidity and mortality were monitored.

Results Of 158 children, 21 did not complete follow-up (six were lost to follow-up and 15 changed residence). Of the remaining 137 children, nine (7%) required admission to the nutrition programme because of: MUAC dropping to <115 mm (5/9 children), weight loss ≥10% (1/9 children) and severe medical complications (3/9 children, of whom one died). Of the remaining 128 children who completed follow-up, 91 (66%) improved in nutritional status while 37 (27%) maintained a WHZ of <–3. Cough was less frequent among those whose nutritional status improved.

Conclusions It seems acceptable to rely on MUAC as a single assessment tool for case finding and for admission of children with SAM to nutritional programmes.

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Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia

In Under-nutrition on October 25, 2012 at 8:50 am

Tekeste AWondafrash MAzene GDeribe K.

Cost Eff Resour Alloc. 2012 Mar 19;10:4




This study estimated the cost effectiveness of community-based therapeutic care (CTC) for children with severe acute malnutrition (SAM) in Sidama Zone, Ethiopia compared to facility based therapeutic feeding center (TFC).


A cost effectiveness analysis comparing costs and outcomes of two treatment programmes was conducted. The societal perspective, which considers costs to all sectors of the society, was employed. Outcomes and health service costs of CTC and TFC were obtained from Save the Children USA (SC/USA) CTC and TFC programme, government health services and UNICEF(in kind supplies) cost estimates of unit costs. Parental costs were estimated through interviewing 306 caretakers. Cost categories were compared and a single cost effectiveness ratio of costs to treat a child with SAM in each program (regardless of outcome) was computed and compared.


A total of 328 patient cards/records of children treated in the programs were reviewed; out of which 306 (157 CTC and 149 TFC) were traced back to their households to interview their caretakers. The cure rate in TFC was 95.36% compared to 94.30% in CTC. The death rate in TFC was 0% and in CTC 1.2%. The mean cost per child treated was $284.56 in TFC and $134.88 in CTC. The institutional cost per child treated was $262.62 in TFC and $128.58 in CTC. Out of these institutional costs in TFC 46.6% was personnel cost. In contrast, majority (43.2%) of the institutional costs in CTC went to ready to use therapeutic food (RUTF). The opportunity cost per caretaker in the TFC was $21.01 whereas it was $5.87 in CTC. The result of this study shows that community based CTC was two times more cost effective than TFC.


CTC was found to be relatively more cost effective than TFC in this setting. This indicates that CTC is a viable approach on just economic grounds in addition to other benefits such improved access, sustainability and appropriateness documented elsewhere. If costs of RUTF can be reduced such as through local production the CTC costs per child can be further reduced as RUTF constitutes the highest cost in these study settings.


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WHO: Supplementary foods for the management of moderate acute malnutrition

In Under-nutrition on October 12, 2012 at 12:34 pm

Original title: Supplementary foods  for the management of moderate acute malnutrition in infants and children 6–59 months of age (Technical note)

by WHO (2012)

(download here a brief version of the document)

This document proposes the nutrient composition of supplementary foods to manage moderate acute malnutrition (MAM) in children under 5 years of age.

Experimental data were used to inform the estimates, taking into consideration the effect of different levels of nutrients and their bio-availability.

The document also lists the principles of nutritional management of children with MAM and reports the assumptions considered to set up the proposed recommendations, suggesting  which uses the latter can be applied for and topics for further research in this area.

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The Effect of Adding Ready-to-Use Supplementary Food to a General Food Distribution on Child Nutritional Status and Morbidity: A Cluster-Randomized Controlled Trial

In Under-nutrition on October 10, 2012 at 3:07 pm

by Lieven Huybregts, Freddy Houngbe´, Cecile Salpeteur, Rebecca Brown, Dominique Roberfroid, Myriam Ait-Aissa, Patrick Kolsteren

PLoS Med. 2012 Sep;9(9)

(download the entire paper)



Recently, operational organizations active in child nutrition in developing countries have suggested that blanket feeding strategies be adopted to enable the prevention of child wasting. A new range of nutritional supplements is now available, with claims that they can prevent wasting in populations at risk of periodic food shortages. Evidence is lacking as to the effectiveness of such preventive interventions. This study examined the effect of a ready-to-use supplementary food (RUSF) on the prevention of wasting in 6- to 36-mo-old children within the framework of a general
food distribution program.

Methods and Findings

We conducted a two-arm cluster-randomized controlled pragmatic intervention study in a sample of 1,038 children aged 6 to 36 mo in the city of Abeche, Chad. Both arms were included in a general food distribution program providing staple foods. The intervention group was given a daily 46 g of RUSF for 4 mo. Anthropometric measurements and morbidity were recorded monthly. Adding RUSF to a package of monthly household food rations for
households containing a child assigned to the intervention group did not result in a reduction in cumulative incidence of wasting (incidence risk ratio: 0.86; 95% CI: 0.67, 1.11; p = 0.25). However, the intervention group had a modestly higher gain in height-for-age (+0.03 Z-score/mo; 95% CI: 0.01, 0.04; p,0.001). In addition, children in the intervention group had a significantly higher hemoglobin concentration at the end of the study than children in the control group (+3.8 g/l; 95% CI:0.6, 7.0; p = 0.02), thereby reducing the odds of anemia (odds ratio: 0.52; 95% CI: 0.34, 0.82; p = 0.004). Adding RUSF also resulted in a significantly lower risk of self-reported diarrhea (229.3%; 95% CI: 20.5, 37.2; p,0.001) and fever episodes (222.5%; 95% CI: 14.0, 30.2; p,0.001). Limitations of this study include that the projected sample size was not fully attained and that significantly fewer children from the control group were present at follow-up sessions.


Providing RUSF as part of a general food distribution resulted in improvements in hemoglobin status and small improvements in linear growth, accompanied by an apparent reduction in morbidity.

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London: HUNGER TALKS (Fri, 19th Oct 2012) – open to public

In Under-nutrition on October 1, 2012 at 8:42 am

From the Conference Brochure:

Action Against Hunger and Birkbeck University are pleased to welcome you to HUNGER TALKS, a one day event that we hope will become a regular feature in the nutrition calendar.

“The aim of HUNGER TALKS is to bring together leading voices from the frontlines of the fight against hunger.

“In this first instalment, HUNGER TALKS will look at hunger from a broad perspective; not only from a Nutrition or Food Security & Livelihoods perspective, but by exploring ways in which these two come together.

“This year’s HUNGER TALKS will focus on what it means to integrate Nutrition and Food Security & Livelihoods in the 21st century, where the opportunities lie and where the challenges may lie.

“To do so, we have invited a panel of fi very experienced and innovative speakers:

Saul Guerrero – Chair man

Abigail Perry – DFID

Stephen Spratt – Research Fellow, IDS

Mark Davies – Programme Manager Social Protection, IDS

Filippo Dibari – Valid International/UCL (Institute of Global Health)

Leena Camadoo – TWIN

Click here  for the bio of the speakers, the programme details and the location.

The participation is OPEN to anybody interested.

Nutrition Barometer – Measuring What Matters

In Under-nutrition on September 26, 2012 at 5:43 pm

from 2000 days web site:

“Recently, Save the Children and World Vision joined forces to launch a ground-breaking Nutrition Barometer that examines the progress being made to improve nutrition in the 36 countries that are home to 90% of the world’s malnourished children.

“The Nutrition Barometer measures the political and financial commitments made by governments to tackle malnutrition, and looks at progress in transforming these commitments into real improvements for mothers and children.

“Of the countries profiled, Guatemala, Malawi and Peru –all SUN countries– are making the greatest strides against malnutrition, while the Democratic Republic of Congo, India and Yemen show the weakest performance, with frail commitments and poor outcomes for children.

“The Nutrition Barometer stresses the need to hold governments accountable for sustaining nutrition investments over the long-term in order to reverse the “unacceptably high levels” of chronic malnutrition and child mortality.”

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Where Hunger and Thirst Meet

In Under-nutrition on September 22, 2012 at 7:50 am

by Barbara Frost – Chief Executive of WaterAid

(reblogged from the Huffingtonpost – 31/08/2012)

The key theme at this year’s Stockholm World Water Week is water and food security: how do we meet the ever developing needs of a growing population with an increasing demand for resources?

At WaterAid, we believe the answer lies in providing water and sanitation for basic human needs, and that targeting the poorest communities will have the greatest impact on overcoming poverty and achieving global water and food security.

The figures shared at this annual event are concerning. In the past 100 years, global population has increased 3.6 times, while the amount of water withdrawn has increased 6.8 times. This reflects a shift in diet as we consume more water-intensive food, highlighting that it’s not just about population; it’s about trends.

Meanwhile, today, more than 900 million people suffer from hunger while 783 million people have no access to a clean, safe water source.

WaterAid/GMB Akash/PanosBut there is a positive message here; we have made a lot of progress – over 2billion people have accessed drinking water in the last two decades – showing that we should be capable of making the necessary changes to manage future growth more equitably.

The global population is set to reach nine billion by 2050 and demand for food willincrease by 70%, placing yet more pressures on water supplies. So the challenge is how to meet those demands.

As explained in our new Water security framework, launched at the global water event, clean water, improved toilets, and hygiene have a considerable impact on livelihoods, the environment and agriculture. Consequently, there is little hope of achieving food security and overall wellbeing without ensuring water security at a local level.

Dirty water and poor sanitation have serious implications on health – according to the UN half the hospital beds in developing countries are filled with people suffering from diseases caused by poor water, sanitation and hygiene. This affects people’s ability to farm and work, with a knock-on effect on both the availability of food and the ability to buy it. Similarly, relieving women and girls of the burden of water collection allows time for them to have an education and earn a living, leading to greater economic freedom and prosperity.

Improved water sources close to the home can be used to irrigate household kitchen gardens, providing additional nutrition in times of food shortages, while the bi-products of ecological sanitation can greatly enhance soil fertility and crop yields.

By improving access to clean, safe water and adequate toilets at a community level, the wider impacts will in turn spread to water and food security on a national and international level.

However, the majority of the money dedicated to improving access to water and sanitation in the developing world is currently spent in middle-income countries, meaning some of the poorest communities are being overlooked.

In fact, water and sanitation aid provided to sub-Saharan Africa amounts to less than the price of a cup of coffee per person – just $2.39 a year, according to another of our new reports: Addressing the shortfall. As a result, many of these least developed countries in the region become trapped in a vicious cycle of poverty.

Through thorough analysis of donor aid, our report shows that water and sanitation aid is not well targeted. Between 2008 and 2010, the 27 countries accounting for 90% of diarrhoeal deaths (primarily caused by dirty water, inadequate sanitation and poor hygiene), received only 39% of water and sanitation aid. The 28 countries accounting for 90% of the world’s population without basic sanitation received just less than half of the aid.

The analysis is clear; developing countries and their development partners need to significantly increase their investments and target those investments better if the world’s poorest people are to gain access to safe water to drink and adequate sanitation.

Furthermore, as covered through the many discussions and sessions in Stockholm, strong leadership, good governance, increased capacity, and effective monitoring are vital if we are to achieve sustainable change and turn promises into action.

With diarrhoea claiming the lives of more children every year than AIDS, malaria and measles combined, all governments need to take urgent action to ensure sufficient funding gets to the one person in every ten lacking safe water in this world and the two in five without access to adequate sanitation.

There is enough food and water to feed the world’s population. Now we must work together to ensure everyone has access to it as we strive for water and sanitation for all.

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