Kathryn Dewey and Mary Arimond discuss new research in PLOS Medicine that assesses the effect of blanket provision of ready-to-use supplementary food to children at high risk of malnutrition in Chad, and highlight some of the challenges of investigating the efficacy of supplementary foods for malnourished children

Arimond, Mary

Dewey, Kathryn G

PLoS Medicine

English

PubMed

Kathryn G Dewey

Mary Arimond

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Lipid-based nutrient supplements: how can they combat child malnutrition?

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UC DavisUC Davis Previously Published WorksTitleLipid-Based Nutrient Supplements: How Can They Combat Child Malnutrition?Permalinkhttps://escholarship.org/uc/item/652198cxJournalPLOS Medicine, 9(9)ISSN1549-1277AuthorsDewey, Kathryn GArimond, MaryPublication Date2012DOI10.1371/journal.pmed.1001314 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaPerspectiveLipid-Based Nutrient Supplements: How Can TheyCombat Child Malnutrition?Kathryn G. Dewey*, Mary ArimondUniversity of California, Davis, Davis, California, United States of AmericaInterest in the use of lipid-based foods tocombat child malnutrition has grown,accelerated by the success of ready-to-usetherapeutic foods (RUTF) for the treat-ment of severely malnourished children[1–3]. This has motivated the develop-ment of a range of lipid-based productsdesigned for different purposes, includingtreatment of moderate acute malnutrition(MAM) (wasting, or weight-for-heightbelow -2 SD of the standard) and preven-tion of wasting or stunting (low height-for-age). With more lipid-based productscomes a diversity of terminology, chal-lenges in comparisons across products, andconfusion about the appropriate use of theterm RUTF.Lipid-based products vary along anumber of dimensions but most notablyin energy dose and concentration ofmicronutrients. RUTFs are designed toachieve rapid nutritional recovery and arethus provided in large amounts (200–300 g/d), temporarily replacing most orall other foods aside from breast milk. Bycontrast, lipid-based nutrient supplements(LNS) designed for prevention of wastingor stunting are meant to be given in muchsmaller amounts (20–50 g/d), whichmeans that they are more concentratedin micronutrients and cost less. At the lowend of this range, ‘‘small-quantity’’ LNSsuch as Nutributter, which provide a dailyration of only 20 g (4 teaspoons), areconsidered suitable for ‘‘home-fortifica-tion’’ of local foods (with micronutrients,essential fatty acids and a small amount ofprotein) and leave more ‘‘room’’ for otherfoods in the diet. The term ‘‘ready-to-usesupplementary food’’ (RUSF) has beeninconsistently used, sometimes referringonly to products used for treatment ofMAM, and sometimes also to refer toproducts used for prevention of MAM.Efforts to standardize use of terminologyare underway.Unlike use of RUTF, which is currentlyrecommended for treatment of severeacute malnutrition [4], other lipid-basedproducts for different purposes are stillunder study—comparative effectivenessand cost-effectiveness are not yet estab-lished. In the meantime, and especially inemergencies, international agencies andother humanitarian actors must makechoices in the absence of robust evidence.These decisions are based on an analysis ofthe situation as well as the programmingand product options that are available andguidance is beginning to emerge [5,6].Vexing the field is ongoing concern andcontroversy about the role of lipid-basedproducts in the diet of infants andchildren, their potential to displace breastmilk or diverse local diets, whether andhow imported or processed foods shouldbe used to prevent or treat malnutrition,inappropriate commercial promotion ofinfant foods, and finally the cost of theproducts, which raises concerns bothabout sustainability and trade-offs/oppor-tunity costs. These issues are complex, andsome are more or less salient depending onthe daily ration size of the product, and onwhether products are distributed throughprogrammatic channels, through privatesector marketing, or some mix of the two.Research to date provides some evidencethat compared to local porridge, use of upto 50 g/d of LNS does not displace breastmilk [7,8]. We encourage continuedattention to these critical issues. Newresearch in this week’s PLOS Medicine [9]adds to the evidence base and ourunderstanding of the role of lipid-basedproducts in child malnutrition.Citation: Dewey KG, Arimond M (2012) Lipid-Based Nutrient Supplements: How Can They Combat ChildMalnutrition? PLoS Med 9(9): e1001314. doi:10.1371/journal.pmed.1001314Published September 18, 2012Copyright:  2012 Dewey, Arimond. This is an open-access article distributed under the terms of theCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in anymedium, provided the original author and source are credited.Funding: Neither author received any funding to write this piece.Competing Interests: Neither author has a competing financial interest. Kathryn Dewey is PrincipalInvestigator and Mary Arimond is Project Manager for the International Lipid-Based Nutrient SupplementsProject (http://www.iLiNS.org), an on-going series of efficacy trials using ‘‘small-quantity’’ LNS. The supplementsused in these trials were developed in collaboration with Nutriset and are purchased from Nutriset for the trials.A representative from Nutriset serves on the iLiNS Project Steering Committee, but the company had no role instudy design and will have no role in analysis of results. The iLiNS Project is funded by the Bill & Melinda GatesFoundation.Abbreviations: DRC, Democratic Republic of Congo; LNS, lipid-based nutrient supplements; MAM, moderateacute malnutrition; RUSF, ready-to-use supplementary food; RUTF, ready-to-use therapeutic foods* E-mail: kgdewey@ucdavis.eduProvenance: Commissioned; not externally peer reviewedLinked Research ArticleThis Perspective discusses the fol-lowing new study published inPLOS Medicine:Huybregts L, Houngbé F, SalpéteurC, Brown R, Roberfroid D, et al. (2012)The Effect of Adding Ready-to-UseSupplementary Food to a GeneralFood Distribution on Child Nutrition-al Status and Morbidity: A Cluster-Randomized Controlled Trial. PLoSMed 9(9): e1001313. doi:10.1371/journal.pmed.1001313Lieven Huybregts and colleaguesinvestigate how supplementing ageneral food distribution with afortified lipid-based spread duringa seasonal hunger gap in Chadaffects anthropometric and morbid-ity outcomes for children aged 6 to36 months.The Perspective section is for experts to discuss theclinical practice or public health implications of apublished study that is freely available online.PLOS Medicine | www.plosmedicine.org 1 September 2012 | Volume 9 | Issue 9 | e1001314A New Study in ChadOne approach that has been studied byseveral research groups is the blanketprovision of ‘‘medium-quantity’’ LNS (e.g.,,50 g/d) to children at high risk ofmalnutrition. In this issue of PLOS Medicine,Lieven Huybregts and colleagues describethe results of a cluster-randomized pragmat-ic trial conducted in Chad to evaluate thisstrategy in the context of a food distributionprogram [9]. In this case, the product(Plumpy’Doz, 46 g/d) was added to apackage of monthly household food rationsfor a period of 4 months and targeted tochildren 6–36 months of age (n = 1038). Thisintervention did not significantly reduce theincidence of the primary outcome, wasting,which is perhaps not surprising given thatthe control group also received the house-hold ration, designed to cover 86% of dailyenergy requirements. However, the inter-vention group exhibited greater growth inheight, lower prevalence of anemia, and lessmorbidity (29% reduction in incidence ofdiarrhea, 23% reduction in incidence offever) than the control group. Because thequantity of food (energy provided) waspresumably not limiting in either group, thisspeaks to the importance of dietary quality forinfants and young children.Three other trials have investigated theblanket provision of a similar quantity ofLNS to that used in Chad [10–12]. In allthree studies, two from Malawi and onefrom the Democratic Republic of Congo(DRC), infants were enrolled at 6 months ofage and were randomized to the interven-tion group(s) that received LNS or to acontrol group that received another type offood supplement intended to provide anequivalent amount of energy. These studieshave produced mixed results for weight andheight gain, and it seems likely that some ofthis variation may be explained by differ-ences across the trials in the foods providedto both the control and intervention groups.For example, control groups received foodthat was fortified with micronutrients (bothMalawi studies) [10,12] or enriched withfish powder (DRC) [11], which contrastswith the situation in Chad where the controlgroup received unfortified staple foods.Furthermore, in the first Malawi study[10] (as in Chad), the LNS included driedskim milk powder as a key ingredient,whereas in the second Malawi study [11]the LNS did not include any milk and in theDRC [12] the amount of milk was aboutone-fifth of the amount in the LNS used inthe other two studies. Other research hassuggested that milk products may increasechild growth by stimulating growth factorssuch as IGF-I [13,14]. The phytate contentof the products also differed, which canaffect the absorption of key nutrients such asiron and zinc.Where Next for ChildNutritional Supplements?These studies illustrate that conclusionsregarding the efficacy of various types of LNSmay depend on the target group (age range),baseline prevalence and type of undernutri-tion, study design (e.g., type of control group;duration of intervention), and ration size andcomposition of the products being evaluated.Large variability across these dimensions inthe small number of studies conducted todate makes it impossible to generalize.There is clearly a need for additionalresearch to understand the potentialgrowth-promoting effect of certain ingredi-ents in LNS (e.g., milk powder, essentialfatty acids). The new study by Huybregts etal. [9] is an important contribution to theevidence base. Meanwhile, programmaticexperience with the blanket provision ofboth ‘‘medium-quantity’’ and ‘‘small-quan-tity’’ LNS is growing, and in some cases isproviding further evidence regarding effec-tiveness for prevention of wasting andstunting [15]. While that evidence is not asrobust as the results of randomized con-trolled trials, careful attention to studydesign and data analysis should yieldinterpretable findings that are immediatelyrelevant to real-world settings. Program-matic studies are also essential for under-standing optimal ration size for the targetage group and how best to integrate theappropriate use of high-quality fortifiedproducts with the other essential compo-nents for improving infant and young childnutrition, such as promotion of continuedbreastfeeding, dietary diversity, responsivefeeding practices, and attention to hygieneand sanitation [5,6]. Finally, high-qualityprogrammatic studies can help provideurgently needed information on the costand comparative cost-effectiveness of differ-ent integrated strategies for filling nutrientgaps and promoting healthy growth.Author ContributionsWrote the first draft of the manuscript: KGD.Contributed to the writing of the manuscript:KGD MA. ICMJE criteria for authorship readand met: KGD MA. Agree with manuscriptresults and conclusions: KGD MA.References1. WHO (2007) Community-based management ofsevere acute malnutrition-a joint statement by theWorld Health Organization, the World FoodProgramme, the United Nations Standing Com-mittee on Nutrition and the United NationsChildren’s Fund. Geneva: UN Press.2. Briend A, Collins S (2010) Therapeutic nutrition forchildren with severe acute malnutrition summary ofAfrican experience. Indian Pediatr 47(8): 655–659.3. Tekeste A, Wondafrash M, Azene G, Deribe K (2012)Cost effectiveness of community-based and in-patienttherapeutic feeding programs to treat severe acutemalnutrition in Ethiopia. Cost Eff Resour Alloc 10: 4.4. WHO (2007) Community-based management ofsevere acute malnutrition: a joint statement by theWorld Health Organization, the World FoodProgramme, the United Nations System StandingCommittee on Nutrition and the United NationsChildren’s Fund. Geneva: WHO.5. UNICEF (2012)Programming guide on infantand young child feeding. New York: UNICEF.6. UNHCR (2011) UNHCR Operational Guidanceon the Use of Special Nutrition Products toReduce Micronutrient Deficiencies and Malnutri-tion in Refugee Populations. Geneva: UNHCR.7. Galpin L, Thakwalakwa C, Phuka J, Ashorn P,Maleta K, et al. (2007) Breast milk intake is notreduced more by the introduction of energy densecomplementary food than by typical infantporridge. J Nutr 137(7): 1828–1833.8. Owino VO, Bahwere P, Bisimwa G, Mwangi CM,Collins S (2011) Breast-milk intake of 9–10-mo-oldrural infants given a ready-to-use complementaryfood in South Kivu, Democratic Republic ofCongo. Am J Clin Nutr 93(6): 1300–1304.9. Houngbé F, Huybregts L, Salpéteur C, Brown R,Roberfroid D, et al. (2012) Adding ready-to-usesupplementary food to a general food distributionimproves anemia, length and morbidity: a clusterrandomized controlled trial. PLoS Med 9:e1001313. 10.1371/journal.pmed.100131310. Phuka JC, Maleta K, Thakwalakwa C, Cheung YB,Briend A, et al. (2008) Complementary feeding withfortified spread and incidence of severe stunting in 6-to 18-month-old rural Malawians. Arch PediatrAdolesc Med 162(7): 619–626.11. Lin CA, Manary MJ, Maleta K, Briend A,Ashorn P (2008) An energy-dense complementaryfood is associated with a modest increase inweight gain when compared with a fortifiedporridge in Malawian children aged 6–18months. J Nutr 138(3): 593–598.12. Bisimwa G, Owino VO, Bahwere P, Dramaix M,Donnen P, et al. (2012) Randomized controlled trialof the effectiveness of a soybean-maize-sorghum-based ready-to-use complementary food paste oninfant growth in South Kivu, Democratic Republicof Congo. Am J Clin Nutr 95(5): 1157–1164.13. Hoppe C, Molgaard C, Michaelsen KF (2006) Cow’smilk and linear growth in industrialized and deve-loping countries. Annu Rev Nutr 26: 131–173.14. Dror DK, Allen LH (2011) The importance ofmilk and other animal-source foods for children inlow-income countries. Food Nutr Bull 32(3): 227–243.15. Isanaka S, Roederer T, Djibo A, Luquero FJ,Nombela N, et al. (2010) Reducing wasting inyoung children with preventive supplementation: acohort study in Niger. Pediatrics 126(2): e442–e450.PLOS Medicine | www.plosmedicine.org 2 September 2012 | Volume 9 | Issue 9 | e1001314

Lipid-Based Nutrient Supplements: How Can They Combat Child Malnutrition?

(2012)Randomizedcontrolled trial of the effectiveness of a soybean-maize-sorghumbased ready-to-use complementary food paste on infant growth in South Kivu, Democratic Republic of Congo.

Adding ready-to-use supplementary food to a general food distribution improves anemia, length and morbidity: a cluster randomized controlled trial. PLoS Med 9:

An energy-dense complementary food is associated with a modest increase in weight gain when compared with a fortified porridge in Malawian children aged 6–18 months.

Breast milk intake is not reduced more by the introduction of energy dense complementary food than by typical infant porridge.

Breast-milk intake of 9–10-mo-old rural infants given a ready-to-use complementary food in South Kivu, Democratic Republic of Congo.

Community-based management of severe acute malnutrition-a joint statement by the World Health Organization, the World Food Programme, the United Nations Standing Committee on Nutrition and the United Nations Children’s Fund.

Community-based management of severe acute malnutrition: a joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund.

Complementary feeding with fortified spread and incidence of severe stunting in 6-to 18-month-old rural Malawians. Arch Pediatr Adolesc Med

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

Molgaard C,Michaelsen KF

Reducing wasting in young children with preventive supplementation: a cohort study

The importance of milk and other animal-source foods for children in low-income countries.

Therapeutic nutrition for children with severe acute malnutrition summary of African experience.

UNHCR Operational Guidance on the Use of Special Nutrition Products to Reduce Micronutrient Deficiencies and Malnutrition in Refugee Populations.

UNICEF (2012)Programming guide on infant and young child feeding.

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Lipid-based nutrient supplements: how can they combat child malnutrition?

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