The selection of articles below is biased. It is intended to draw attention to a sample (27) of publications that encouraged us to think that it was possible to go beyond existing responses to nutritional crises. We have also included articles published by Epicentre and MSF (marked *).

Articles are divided in 4 sections:

I. Foods
II. Diagnosis
III.Epidemiology
IV. Treatment

I. Foods

I.1. Presented in the workshop “History of Food and Nutrition in Emergency Relief” given at the Experimental Biology 2001 Meeting, in Orlando, Florida on April 3, 2001, sponsored by the American Society for Nutritional Sciences.

‘The development of concepts of malnutrition’

MICHAEL H. N. GOLDEN

Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, United Kingdom Pr. M. Golden gives an overview of key evolutions of concepts in nutrition, over a century.

I.2. Presentation to an internal meeting at MSF Paris. 2008.

‘The response to nutrient deficiency / Type 1 and type 2 responses’

MICHAEL H. N. GOLDEN

Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, United Kingdom A child responds to a deficiency of an essential nutrient in one of two quite different ways. First, he can continue growing, consume the body stores and then have a reduction in the specific bodily functions that depend upon the deficient nutrient. Or, second, he can stop growing, avidly conserve the nutrient in the body and, if necessary, loose weight to make the nutrient internally available and thus maintain the concentration of the nutrient in the tissues. The difference between these two responses is fundamental and can be seen in experimental and farm animals, bacteria and even in plants grown on soils that have the same nutrient deficiencies.

I.3. Journal of Nutrition. 133: 3932S–3935S, 2003.

‘Animal Source Foods to Improve Micronutrient Nutrition and Human Function in Developing Countries. Nutritional Importance of Animal Source Foods’

SUZANNE P. MURPHY AND LINDSAY H. ALLEN

Cancer Research Center of Hawaii, University of Hawaii, Honolulu, HI 96813 and Department of Nutrition, University of California, Davis, CA 95616

ABSTRACT. Animal source foods can provide a variety of micronutrients that are difficult to obtain in adequate quantities from plant source foods alone. In the 1980s, the Nutrition Collaborative Research Support Program identified six micronutrients that were particularly low in the primarily vegetarian diets of schoolchildren in rural Egypt, Kenya and Mexico: vitamin A, vitamin B-12, riboflavin, calcium, iron and zinc. Negative health outcomes associated with inadequate intake of these nutrients include anemia, poor growth, rickets, impaired cognitive performance, blindness, neuromuscular deficits and eventually, death. Animal source foods are particularly rich sources of all six of these nutrients, and relatively small amounts of these foods, added to a vegetarian diet, can substantially increase nutrient adequacy. Snacks designed for Kenyan schoolchildren provided more nutrients when animal and plant foods were combined. A snack that provided only 20% of a child’s energy requirement could provide 38% of the calcium, 83% of the vitamin B-12 and 82% of the riboflavin requirements if milk was included. A similar snack that included ground beef rather than milk provided 86% of the zinc and 106% of the vitamin B-12 requirements, as well as 26% of the iron requirement. Food guides usually recommend several daily servings from animal source food groups (dairy products and meat or meat alternatives). An index that estimates nutrient adequacy based on adherence to such food guide recommendations may provide a useful method of quickly evaluating dietary quality in both developing and developed countries.

I.4. Journal of Pediatric Gastroenterology and Nutrition: 36:12–22. January, 2003, Philadelphia.

‘Linear Programming: A Mathematical Tool for Analyzing and Optimizing Children’s Diets During the Complementary Feeding Period’

ANDRÉ BRIEND, NICOLE DARMON, ELAINE FERGUSON, JUERGEN G. ERHARDT

Institut de Recherche pour le Développement, Paris, France; †Unité INSERM 557, Conservatoire National des Arts et Métiers, ISTNA, Paris, France; Department of Human Nutrition, Otago University, Dunedin, New Zealand; University of Hohenheim, Institute of Biological Chemistry and Nutrition, Stuttgart, Germany

ABSTRACT. During the complementary feeding period, children require a nutrient-dense diet to meet their high nutritional requirements. International interest exists in the promotion of affordable, nutritionally adequate complementary feeding diets based on locally available foods. In this context, two questions are often asked: 1) is it possible to design a diet suitable for the complementary feeding period using locally available food? and 2) if this is possible, what is the lowest-cost, nutritionally adequate diet available? These questions are usually answered using a “trial and error” approach. However, a more efficient and rigorous technique, based on linear programming, is also available. It has become more readily accessible with the advent of powerful personal computers. The purpose of this review, therefore, is to inform paediatricians and public health professionals about this tool. In this review, the basic principles of linear programming are briefly examined and some practical applications for formulating sound food-based nutritional recommendations in different contexts are explained. This review should facilitate the adoption of this technique by international health professionals.

II. Diagnosis

II.5. Journal of Nutrition. 129: 529S–530S, 1999.

‘Symposium: Causes and Etiology of Stunting. Introduction’

EDWARD A. FRONGILLO, JR.

Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853–6301

Introduction: This symposium considered why and how stunting of children occurs. As described in the comprehensive examination made by WHO of the use and interpretation of anthropometry (1995), stunting (i.e., short stature due to poor living environments) is one of the two most important indices of child well-being in use throughout the world. The assessment of stunting is integral to public health, clinical and research workers in many fields concerned with the well-being of children and with the biology of growth and development. In developing countries, 40% of children, 5 y of age are stunted [de Onis and Blössner 1997, WHO Subcommittee on Nutrition (SCN) 1997]. This means that 200 million young children are stunted. The timing of stunting is reasonably understood in that most stunting occurs before the age of 3 y, and stunted children usually become stunted adults. The consequences of becoming and remaining stunted are increased risk of morbidity, mortality, delays in motor and mental development, and decreased work capacity (SCN 1997, Waterlow and Schürch 1994). The causes and etiology of stunting are much less understood than are its timing and consequences. In particular, there is little understanding of why and how stunting occurs extensively in environments that are poor, but not desperately so, and in environments that seem to be improving. In a population, an individual child can become stunted or not. In addition, some populations are much more stunted than others (WHO 1995). This means that an understanding of why and how children become stunted is needed at both the individual and ecological levels…

II.6. Pediatrics. Vol. 107 No. 5 May 2001, www.pediatrics.org

‘Worldwide Timing of Growth Faltering: Implications for Nutritional interventions’

ROGER SHRIMPTON, CESAR G. VICTORA, MERCEDES DE ONIS, ROSA ANGELA COSTA LIMA, MONIKA BLÖSSNER AND GRAEME CLUGSTON.

Nutrition Unit, UNICEF, New York, New York; Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, RS, Brazil; and the Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland. Centre of International Child Health, Institute of Child Health, University College London, London, United Kingdom

ABSTRACT. Objective: It is widely assumed that growth faltering starts at around 3 months of age, but there has been no systematic assessment of its timing using representative national datasets from a variety of countries.

Methodology: The World Health Organization Global Database on Child Growth and Malnutrition includes the results of 39 nationally representative datasets from recent surveys in developing countries. Based on these data, mean z scores of weight for age, length/height for age, and weight for length/height were compared with the National Center for Health Statistics and Cambridge growth references, for children younger than 60 months.

Results: Mean weights start to falter at about 3 months of age and decline rapidly until about 12 months, with a markedly slower decline until about 18 to 19 months and a catch-up pattern after that. Growth faltering in weight for length/height is restricted to the first 15 months of life, followed by rapid improvement. For length/height for age, the global mean is surprisingly close to National Center for Health Statistics and Cambridge references at birth, but faltering starts immediately afterward, lasting well into the third year. Conclusions: These findings highlight the need for prenatal and early life interventions to prevent growth failure.

*II.7. Archives of Pediatrics & Adolescent Medicine. 2009; 163(2):126-130.

‘Comparison of the New World Health Organization Growth Standards and the National Center for Health Statistics Growth Reference Regarding Mortality of Malnourished Children Treated in a 2006 Nutrition Program in Niger’

NANCY M. DALE, REBECCA F. GRAIS, ANDREA MINETTI, JUHANI MIETTOLA, NOEL C. BARENGO.Department of Public Health and Clinical Nutrition University of Kuopio, Finland; Epicentre and Médecins Sans Frontières, Paris, France; Department of Public Health, University of Helsinki, Finland

Objective: To compare the National Centre for Health Statistics (NCHS) international growth reference with the new World Health Organization (WHO) growth standards for identification of the malnourished (wasted) children most at risk of death.

Design: Retrospective data analysis.

Setting: A Médecins Sans Frontières (Doctors Without Borders) nutrition program in Maradi, Niger, in 2006 that treated moderately and severely malnourished children.

Participants: A total of 53 661 wasted children aged 6 months to 5 years (272 of whom died) in the program were included.

Interventions: EpiNut (Epi Info 6.0; Centers for Disease Control and Prevention, Atlanta, Georgia) software was used to calculate the percentage of the median for the NCHS reference group, and the WHO (igrowup macro; Geneva, Switzerland) software was used to calculate z scores for the WHO standards group of the 53 661 wasted children.

Outcome Measures: The main outcome measures are the difference in classification of children as either moderate or severely malnourished according to the NCHS growth reference and the new WHO growth standards, specifically focusing on children who died during the program.

Results: Of the children classified as moderately wasted using the NCHS reference, 37% would have been classified as severely wasted according to the new WHO growth standards. These children were almost 3 times more likely to die than those classified as moderately wasted by both references, and deaths in this group constituted 47% of all deaths in the program.

Conclusions: The new WHO growth standards identifies more children as severely wasted compared with the NCHS growth reference, including children at high mortality risk who would potentially otherwise be excluded from some therapeutic feeding programs.

*II.8. PloS medicine. March 2009, Volume 6, Issue 3, www.plosmedicine.org.

‘Prognostic Accuracy of WHO Growth Standards to Predict Mortality in a Large-Scale Nutritional Program in Niger’

NATHANAEL LAPIDUS, FRANCISCO J. LUQUERO, VALÉRIE GABOULAUD, SUSAN SHEPHERD, REBECCA F. GRAIS

Epicentre, Paris, France, European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden, Médecins Sans Frontières, Paris, France

ABSTRACT. Background: Important differences exist in the diagnosis of malnutrition when comparing the 2006 World Health Organization (WHO) Child Growth Standards and the 1977 National Center for Health Statistics (NCHS) reference. However, their relationship with mortality has not been studied. Here, we assessed the accuracy of the WHO standards and the NCHS reference in predicting death in a population of malnourished children in a large nutritional program in Niger.

Methods and Findings: We analyzed data from 64,484 children aged 6–59 mo admitted with malnutrition (80% weight-for-height percentage of the median [WH]% [NCHS] and/or mid-upper arm circumference [MUAC] < 110 mm and/or presence of edema) in 2006 into the Médecins Sans Frontières (MSF) nutritional program in Maradi, Niger. Sensitivity and specificity of weight-for height in terms of Z score (WHZ) and WH% for both WHO standards and NCHS reference were calculated using mortality as the gold standard. Sensitivity and specificity of MUAC were also calculated. The receiver operating characteristic (ROC) curve was traced for these cut-offs and its area under curve (AUC) estimated. In predicting mortality, WHZ (NCHS) and WH% (NCHS) showed AUC values of 0.63 (95% confidence interval [CI] 0.60–0.66) and 0.71 (CI 0.68–0.74), respectively. WHZ (WHO) and WH% (WHO) appeared to provide higher accuracy with AUC values of 0.76 (CI 0.75–0.80) and 0.77 (CI 0.75–0.80), respectively. The relationship between MUAC and mortality risk appeared to be relatively weak, with AUC ¼ 0.63 (CI 0.60–0.67). Analyses stratified by sex and age yielded similar results.

Conclusions: These results suggest that in this population of children being treated for malnutrition, WH indicators calculated using WHO standards were more accurate for predicting mortality risk than those calculated using the NCHS reference. The findings are valid for a population of already malnourished children and are not necessarily generalizable to a population of children being screened for malnutrition. Future work is needed to assess which criteria are best for admission purposes to identify children most likely to benefit from therapeutic or supplementary feeding programs.

II.9. World Health Organization, Unicef. 2009.

‘WHO child growth standards and the identification of severe Acute malnutrition in infants and children. A Joint Statement by the World Health Organization and the United Nations Children’s Fund’

This statement presents the recommended cut-offs, summarizes the rationale for their adoption and advocates for their harmonized application in the identification of 6–60 month old infants and children for the management of severe acute malnutrition (SAM). It also reviews the implications on patient load, on discharge criteria and on programme planning and monitoring.

*II.10. A poster shown by MSF at the 10th World Commonwealth Association of Pediatric Gastroenterologists and Nutritionists (CAPGAN) Conference on Diarrhea and Malnutrition, Blantyre (Malawi), 12-16 August 2009

‘Activity report of a community-based therapeutic feeding program with mid-upper arm circumference (MUAC) as exclusive admission criteria’

GEZA HARCZI, YODIT BEKELE, SYLVIE GOOSSENS, ANDREA MINETTI, MARIE OUANNES, LORETXU PINOGES

Background and objective: Despite the objective of extending treatment to a larger number of children with community-based nutritional programs, mid-upper arm circumference (MUAC) <110 mm often remains the least sensitive anthropometric criteria among those currently in use, thus excluding a greater number of children in need from treatment.

In September 2007, MSF-France implemented a large-scale therapeutic feeding program (TFP) for the treatment of severe acute malnutrition (SAM) in Burkina Faso. The objectives of the program were to:

• Treat cases of SAM through a community-based approach
• Admit children to treatment through an exclusive MUAC criteria and/or edema
• Validate the admission criteria and develop an adapted criteria for discharge

Methods: Individual patient charts were entered into a database used for program monitoring and in-depth analysis.

Admission criteria to treatment was MUAC <120 mm and/or edema. From September 2007 through March 2009, children were considered as recovered when clinically well, with good appetite and weight >15% of admission weight. As of April 2009, children were discharged by the same clinical criteria, but instead of weight gain >15%, MUAC >=124 mm is now used.

Results: Baseline patient characteristics (Sep 2007-Dec 2008, N=23,108): 94.4% of children admitted with MUAC had mean weight-for-height Z-score (WHZ) <-3 (WHO standard). Female-to-male ratio was 1:1, and median age was 14 months, for children admitted by MUAC. 92.2% of children admitted by MUAC went directly to outpatient units; 82.2% were treated exclusively at home. 3.8% had edema, with median age 24 months.

*II.11. Tropical Medicine and International Health. Volume 14 no 10 p 1210–1214 October 2009

‘Impact of the shift from NCHS growth reference to WHO2006 growth standards in a therapeutic feeding programme in Niger’

A. MINETTI, M. SHAMS ELDIN, I. DEFOURNY AND G. HARCZI

Epicentre and Médecins Sans Frontières, Paris, France

SUMMARY. Objectives: To describe the implementation of the WHO2006 growth standards in a therapeutic feeding programme.

Methods: Using programme monitoring data from 21 769 children 6–59 months admitted to the Médecins Sans Frontières therapeutic feeding programme during 2007, we compared characteristics at admission, type of care and outcomes for children admitted before and after the shift to the WHO 2006 standards. Admission criteria were bipedal oedema, MUAC <110 mm, or weight-for-height (WFH) of <-70% of the median (NCHS) before mid-May 2007, and WFH <-3 z score (WHO2006) after mid-May 2007.

Results: Children admitted with the WHO2006 standards were more likely to be younger, with a higher proportion of males, and less malnourished (mean WFH -3.6 z score vs. mean WFH -4.6 z score). They were less likely to require hospitalization or intensive care (28.4% vs. 77%; 2.8% vs. 36.5%) and more likely to be treated exclusively on an outpatient basis (71.6% vs. 23%). Finally, they experienced better outcomes (cure rate: 89% vs. 71.7%, death rate: 2.7% vs. 6.4%, default rate: 6.7% vs. 12.3%).

Conclusions: In this programme, the WHO2006 standards identify a larger number of malnourished children at an earlier stage of disease facilitating their treatment success.

III. Epidemiology

III.12. International Journal of Epidemiology. 1985;14:32–38.

‘Sick individuals and sick populations’

GEOFFREY ROSE

Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, U.K

ABSTRACT. Aetiology confronts two distinct issues: the determinants of individual cases, and the determinants of incidence rate. If exposure to a necessary agent is homogeneous within a population, then case/control and cohort methods will fail to detect it: they will only identify markers of susceptibility. The corresponding strategies in control are the ‘high-risk’ approach, which seeks to protect susceptible individuals, and the population approach, which seeks to control the causes of incidence. The two approaches are not usually in competition, but the prior concern should always be to discover and control the causes of incidence.

III.13. British Medical Journal. Volume 301. 3 November 1990.

‘The population mean predicts the number of deviant individuals’

GEOFFREY ROSE, SIMON DAY

Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, U.K

ABSTRACT. Objective – To examine the relation between the prevalence of deviation and the mean for the whole population in characteristics such as blood pressure and consumption of alcohol. Design – Re-examination of standardised data from the Intersalt study, an international, multicentre study on the determinants of blood pressure. Setting and subjects – Samples of adults representing 52 populations in 32 countries. Main outcome measures – The relations, expressed as correlation coefficients, between the mean population values for blood pressure, body mass index, alcohol consumption, and sodium intake and the prevalence of, respectively, hypertension (e140 mm Hg), obesity (body mass index 30 kg/M2), high alcohol intake (¢300 ml/week), and high sodium intake (¢e250 mmol/day). Results – There were close and independent associations between the population mean and the prevalence of deviance for each of the variables examined: correlation coefficients were 0-85 for blood pressure, 0-94 for body mass index, 0 97 for alcohol intake, and 0-78 for sodium intake. Conclusions – These findings imply that distributions of health related characteristics move up and down as a whole: the frequency of «cases» can be understood only in the context of a population’s characteristics. The population thus carries a collective responsibility for its own health and well being, including that of its deviants.

III.14. Bulletin of the World Health organization. 1995, 73 (4): 443-448.

‘The effects of malnutrition on child mortality in developing countries’

D.L PELLETIER, E.A. FRONGILLO, JR, D.G. SCHROEDER, J.P. HABICHT

Division of Nutritional Sciences, Cornell University, Ithacca. New York, USA.

Conventional methods of classifying causes of death suggest that about 70% of the deaths of children (aged 0-4 years) worldwide are due to diarrhoeal illness, acute respiratory infection, malaria, and immunizable diseases. The role of malnutrition in child mortality is not revealed by these conventional methods, despite the long-standing recognition of the synergism between malnutrition and infectious diseases. This paper describes a recently-developed epidemiological method to estimate the percentage of child deaths (aged 6-59 months) which could be attributed to the potentiating effects of malnutrition in infectious disease. The result from 53 developing countries with nationally representative data on child weight-for-age indicate that 56% of child deaths were attributable to malnutrition’s potentiating effects, and 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition. For individual countries, malnutrition’s total potentiating effects on mortality ranged from 13% to 66%, with at least three-quarters of this arising from mild-to-moderate malnutrition in each case.

These results show that malnutrition has a far more powerful impact on child mortality than is generally appreciated, and suggest that strategies involving only the screening and treatment of the severely malnourished will do little to address this impact. The methodology provided in this paper makes it possible to estimate the effects of malnutrition on child mortality in any population for which prevalence data exist.

III.15. American Journal of Clinical Nutrition: 1997:65:1062-9. USA. 1997

‘A prospective study of malnutrition in relation to child mortality in the Sudan’

WAFAIE W FAWZI, M GUILLERINO HERRERA, DONNA L SPIEGELMAN, ALAWIA EL AMIN, PENELOPE NESTEL, AND KAMAL A MOHAMED

Departments of Nutrition and Epidemiology and Biostatistics, Harvard School of Public Health, Boston; the Harvard Institute for International Development, Boston: the Department of International Health, Iohns Hopkins School of Hygiene and Public Health, Baltimore; and the Ministry of Health, Sudan.

ABSTRACT: We examined prospectively the relation between malnutrition and mortality among Sudanese children. A cohort of 28 753 children between the ages of 6 mo and 6 y was examined every 6 mo for 18 mo. Two hundred thirty-two children died during 18 mo of follow-up (480 624 child-months). Low weight-for-height was associated with an increased risk of mortality (P <0.0001). Even children with Z scores between -1 and -2 were 50% more likely to die in the following 6 mo than were children with Z scores > -1 (multivariate relative mortality: 1.5; 95% CI: 1.1, 2.2). There was also an inverse relation between height-for-age and mortality (P <0.0001). Among breast-fed children, the relative mortality associated with a Z score for weight-for-height of < -3 compared with > -2 was 7.3 (95% CI: 3.3, 15.9); among children not breast-fed, it was 26.0 (95% CI: 12.8, 53.0: P for interaction = 0.001). A strong and significant synergy was also found between infection and wasting or stunting as predictors of child mortality (P for interaction = 0.001 and 0.02, respectively). In developing countries, children who are below the customary cut-off point of -2 Z for weight-for-height may be at higher risk of death. Breast-feeding and reduction of morbidity should be advocated in programs designed to reduce malnutrition and mortality among children.

III.16. Journal of Nutrition. 133: 316S–321S, 2003, American Society for Nutritional Sciences.

“Symposium: Nutrition and Infection, Prologue and Progress Since 1968.

Historical Concepts of Interactions, Synergism and Antagonism between Nutrition and Infection”

NEVIN S. SCRIMSHAW

Massachusetts Institute of Technology, Cambridge, MA and Food and Nutrition Programme,United Nations University, Tokyo, Japan

ABSTRACT. In the 1950s textbooks of nutrition made little or no mention of a relation to infection. The same was true for treatises on infectious disease. Relevant studies in experimental animals and a number of classical clinical observations were available pointing out the role of infection in precipitating nutritional disorders. However, clinicians and nutritionists did not recognize the importance of the relationship. The field and metabolic studies of the Institute of Nutrition of Central America and Panama (INCAP) in the 1950s demonstrated that malnutrition and infection in humans are generally synergistic. These studies stimulated the review of available evidence that resulted in the 1968 WHO monograph on “Interactions of Nutrition and Infection.” It provided extensive evidence for the role of infections in precipitating clinical malnutrition and for the impact of malnutrition on morbidity and mortality from infection. The high frequency of diarrhea in underprivileged young children led to intensive studies in many countries of its effect on nutritional status and to recognition of the high prevalence of “weanling diarrhea.” The effects of infection on nutritional status were then extensively and elegantly investigated at Fort Detrick, MD, and hormonal and cytokine mechanisms identified. The subsequent explosion in knowledge of cell-mediated immune mechanisms has led to an understanding of how malnutrition lowers this resistance. Today, recognition of the synergistic relationship between nutrition and infection influences most public health interventions to prevent malnutrition.

III.17. www.thelancet.com, published Online, January 17, 2008.

‘Maternal and Child Undernutrition 1. Maternal and child undernutrition: global and regional exposures and health consequences’

ROBERT E BLACK, LINDSAY H ALLEN, ZULFIQAR A BHUTTA, LAURA E CAULFIELD, MERCEDES DE ONIS, MAJID EZZATI, COLIN MATHERS, JUAN RIVERA.

Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; USDA, ARS Western Human Nutrition Research Center, Davis, CA, USA; Aga Khan University, Karachi, Pakistan; World Health Organization, Geneva, Switzerland; Harvard School of Public Health, Boston, MA, USA; and Mexico National Institute of Public Health, Cuernavaca, Mexico

Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in substantial increases in mortality and overall disease burden. In this paper, we present new analyses to estimate the effects of the risks related to measures of undernutrition, as well as to suboptimum breastfeeding practices on mortality and disease. We estimated that stunting, severe wasting, and intrauterine growth restriction together were responsible for 2.2 million deaths and 21% of disability-adjusted life-years (DALYs) for children younger than 5 years. Deficiencies of vitamin A and zinc were estimated to be responsible for 0.6 million and 0.4 million deaths, respectively, and a combined 9% of global childhood DALYs. Iron and iodine deficiencies resulted in few child deaths, and combined were responsible for about 0.2% of global childhood DALYs. Iron deficiency as a risk factor for maternal mortality added 115 000 deaths and 0.4% of global total DALYs. Suboptimum breastfeeding was estimated to be responsible for 1.4 million child deaths and 44 million DALYs (10% of DALYs in children younger than 5 years). In an analysis that accounted for co-exposure of these nutrition-related factors, they were together responsible for about 35% of child deaths and 11% of the total global disease burden. The high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of interventions to reduce their occurrence or ameliorate their consequences.

III.18. www.thelancet.com, published Online, January 17, 2008.

“Maternal and Child Undernutrition 2. Maternal and child undernutrition: consequences for adult health and human capital”

CESAR G VICTORA, LINDA ADAIR, CAROLINE FALL, PEDRO C HALLAL, REYNALDO MARTORELL, LINDA RICHTER, HARSHPAL SINGH SACHDEV.

Universidade Federal de Pelotas, Pelotas, Brazil; MRC Epidemiology Resource Centre, University of Southampton, Southampton, UK; Sitaram Bhartia Institute of Science and Research, New Delhi, India; Hubert Department of Global Health, Emory University, Atlanta, USA; University of North Carolina at Chapel Hill, Chapel Hill, USA; and Human Sciences Research Council, Durban, South Africa

In this paper we review the associations between maternal and child undernutrition with human capital and risk of adult diseases in low-income and middle-income countries. We analysed data from five long-standing prospective cohort studies from Brazil, Guatemala, India, the Philippines, and South Africa and noted that indices of maternal and child under-nutrition (maternal height, birthweight, intrauterine growth restriction, and weight, height, and body-mass index at 2 years according to the new WHO growth standards) were related to adult outcomes (height, schooling, income or assets, offspring birthweight, body-mass index, glucose concentrations, blood pressure). We undertook systematic reviews of studies from low-income and middle-income countries for these outcomes and for indicators related to blood lipids, cardiovascular disease, lung and immune function, cancers, osteoporosis, and mental illness. Undernutrition was strongly associated, both in the review of published work and in new analyses, with shorter adult height, less schooling, reduced economic productivity, and – for women – lower offspring birthweight. Associations with adult disease indicators were not so clear-cut. Increased size at birth and in childhood were positively associated with adult body-mass index and to a lesser extent with blood pressure values, but not with blood glucose concentrations. In our new analyses and in published work, lower birthweight and undernutrition in childhood were risk factors for high glucose concentrations, blood pressure, and harmful lipid profiles once adult body-mass index and height were adjusted for, suggesting that rapid postnatal weight gain – especially after infancy – is linked to these conditions. The review of published works indicates that there is insufficient information about long-term changes in immune function, blood lipids, or osteoporosis indicators. Birthweight is positively associated with lung function and with the incidence of some cancers, and undernutrition could be associated with mental illness. We noted that height-for-age at 2 years was the best predictor of human capital and that undernutrition is associated with lower human capital. We conclude that damage suffered in early life leads to permanent impairment, and might also affect future generations. Its prevention will probably bring about important health, educational, and economic benefits. Chronic diseases are especially common in undernourished children who experience rapid weight gain after infancy.

III.19. The Journal of Clinical Investigation. Volume 118 Number 4 April 2008. www.jci.org

‘New challenges in studying nutrition-disease interactions in the developing world’

ANDREW M. PRENTICE, M. ERIC GERSHWIN, ULRICH E. SCHAIBLE, GERALD T. KEUSCH, CESAR G. VICTORA, AND JEFFREY I. GORDON.

MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, United Kingdom. MRC Keneba, Keneba, The Gambia. Division of Rheumatology, Allergy and Clinical Immunology, Genome and Biomedical Sciences Facility, University of California, Davis, Davis, California, USA. Department of Infectious and Tropical Diseases, Immunology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Boston University Medical Campus and School of Public Health, Boston, Massachusetts, USA. Universidade Federal de Pelotas, Pelotas, Brazil. Center for Genome Sciences, Washington University School of Medicine, St. Louis, Missouri, USA.

ABSTRACT. Latest estimates indicate that nutritional deficiencies account for 3 million child deaths each year in less-developed countries. Targeted nutritional interventions could therefore save millions of lives. However, such interventions require careful optimization to maximize benefit and avoid harm. Progress toward designing effective life-saving interventions is currently hampered by some serious gaps in our understanding of nutrient metabolism in humans. We highlight some of these gaps and make some proposals as to how improved research methods and technologies can be brought to bear on the problems of undernourished children in the developing world.

III.20. Public Health Nutrition. March 2009. journals.cambridge.org

‘Incidence and duration of severe wasting in two African populations’

MICHEL GARENNE, DOULADEL WILLIE, BERNARD MAIRE, OLIVIER FONTAINE, ROGER EECKELS, ANDRÉ BRIEND AND JAN VAN DEN BROECK

Institut Pasteur, Epidemiologie des Maladies Emergentes,, Paris, France. Epidemiology Research Unit, Tropical Medicine Research Institute, University of West Indies, Kingston, Jamaica. IRD, Montpellier, France. World Health Organization, Geneva, Switzerland. Department ofPaediatrics, Catholic University of Leuven, Leuven, Belgium

ABSTRACT. Objective: The present study aimed to compare two situations of endemic malnutrition among < 5-year-old African children and to estimate the incidence, the duration and the case fatality of severe wasting episodes. Design: Secondary analysis of longitudinal studies, conducted several years ago, which allowed incidence and duration to be calculated from transition rates. The first site was Niakhar in Senegal, an area under demographic surveillance, where we followed a cohort of children in 1983–5. The second site was Bwamanda in the Democratic Republic of Congo, where we followed a cohort of children in 1989–92. Both studies enrolled about 5000 children, who were followed by routine visits and systematic anthropometric assessment, every 6 months in the first case and every 3 months in the second case. Results: Niakhar had less stunting, more wasting and higher death rates than Bwamanda. Differences in cause-specific mortality included more diarrhoeal diseases, more marasmus, but less malaria and severe anaemia in Niakhar. Severe wasting had a higher incidence, a higher prevalence and a more marked age profile in Niakhar. However, despite the differences, the estimated mean durations of episodes of severe wasting, calculated by multi-state life table, were similar in the two studies (7.5 months). Noteworthy were the differences in the prevalence and incidence of severe wasting depending on the anthropometric indicator (weight for-height Z-score ≤–3.0 or mid upper-arm circumference < 110mm) and the reference system (National Center for Health Statistics 1977, Centers for Disease Control and Prevention 2000 or Multicentre Growth Reference Study 2006). Conclusions: Severe wasting appeared as one of the leading cause of death among under-fives: it had a high incidence (about 2% per child-semester), long duration of episodes and high case fatality rates (6 to 12%).

III.21. PloS Medicine. June 2009, Volume 6, Issue 6, e1000101. www.plosmedicine.org

‘Seasonal Hunger: A Neglected Problem with Proven Solutions’

BAPU VAITLA, STEPHEN DEVEREUX, SAMUEL HAUENSTEIN SWAN

Fletcher School, Tufts University, Medford, Massachusetts, United States of America, Institute of Development Studies, University of Sussex, Brighton, United Kingdom, Action Against Hunger–UK, London, United Kingdom

Summary Points: Most of the world’s acute hunger and undernutrition occurs not in conflicts and natural disasters but in the annual “hunger season”, the time of year when the previous year’s harvest stocks have dwindled, food prices are high, and jobs are scarce. We know what works in fighting seasonal hunger and undernutrition: there are identifiable policy and program successes in contexts around the world, but they often operate on a small scale and in isolation. Community-based interventions to treat acute undernutrition and promote growth of preschool children are examples of successful interventions that should be scaled up. Global scale-up of a basic “minimum essential” intervention package against seasonal hunger would cost around 0.1% of global GDP and save millions of lives, while protecting millions more from severe illness. Focusing on seasonal hunger would be an effective way to leverage resources for the attainment of the hunger-related Millennium Development Goal.

IV. Treatment

IV.22. British Journal of Nutrition. (2001), 85, Suppl. 2, S175–S179

‘Highly nutrient-dense spreads: a new approach to delivering multiple micronutrients to high-risk groups’

ANDRÉ BRIEND

Institut de Recherche pour le Développement, ISTNA-CNAM, Paris, France

ABSTRACT. Using a highly fortified food is the most attractive option to bringing missing nutrients to vulnerable groups. The recent development of a highly nutrient-dense spread (HNDS) for the treatment of malnourished children may have some relevance for other high-risk groups. Traditionally, severely malnourished children are fed for 3-4 weeks during their recovery with adapted milk feeds prepared by mixing dried skimmed milk, oil and sugar with a vitamin and mineral complex. This approach, however, is difficult to implement, since these feeds are excellent growth media for bacteria, and they must be prepared and fed under close supervision. This constraint led to the development of a HNDS, which is obtained by replacing part of the dried skimmed milk with a mixture of groundnut butter and powdered lactoserum. This spread can be eaten without dilution with water and preliminary trials showed that children preferred this HNDS to traditional liquid diets. In HNDS all powdered ingredients are embedded in fat which protects vitamins against oxidation and increases the shelf life of this product. Spreads also have a very low humidity and bacteria do not grow in it. Attempts to use spreads to supplement other vulnerable groups such as moderately malnourished children and pregnant women are discussed.

IV.23. The Lancet. Vol 358, August 11, 2001.

‘Viewpoint. Changing the way we address severe malnutrition during famine’

STEVE COLLINS

Valid International, Oleuffynon, Old Hall, Llanidloes, Powys and Centre for International Child Health,Institute of Child Health, London

This year, yet again, saw widespread food insecurity and famine across the horn of Africa. Again, humanitarian agencies set up operations to implement various relief programmes. Nutritional interventions included general ration distribution to the whole of an affected population; blanket supplementary feeding to all members of an identified risk group; and targeted dry supplementary feeding centres for moderately malnourished and therapeutic feeding centres for the severely malnourished. As is usual in emergencies, many of the therapeutic feeding centres were hard to set up and did not achieve an adequate coverage of all the severely malnourished. This combination of delays and low coverage meant that many therapeutic feeding centres achieved little overall impact on mortality. I believe that the present focus on therapeutic feeding centres as the sole mode of treating severely malnourished people during famine is inappropriate and often counter-productive. A new concept of community-based therapeutic care is necessary to complement therapeutic feeding centres’ interventions if famine relief programmes are to address the plight of the severely malnourished in an efficient and effective manner. During an emergency, the community-based therapeutic care approach could quickly provide good coverage and appropriate treatment for large numbers of severely malnourished people. The principles behind community-based therapeutic care are, however, developmental, empowering communities to cope more effectively with crisis and with transition back to normality. This is very different to the therapeutic feeding centres’ approach that disempowers communities, requires very large amounts of external staff and resources, and undermines the infrastructure. Although emergency community-based therapeutic care programmes could be large-scale and implemented quickly, they could also evolve into developmental Hearth model nutritional programmes without changing their conceptual basis. Conversely, Hearth programmes, although largely sustainable, could in times of crisis quickly scale-up into rapid effective emergency interventions. Creating such a continuum between emergency and developmental approaches has long been a holy grail of humanitarianism.

IV.24. Journal of American Medical Association. June 2, 2004 – Vol 291, No. 21 2563

‘Impact of the Mexican Program for Education, Health, and Nutrition (Progresa) on Rates of Growth and Anemia in Infants and Young Children A Randomized Effectiveness Study’

JUAN A. RIVERA, DANIELA SOTRES-ALVAREZ, JEAN-PIERRE HABICHT, TERESA SHAMAH, SALVADOR VILLALPANDO.

Instituto Nacional de Salud Publica, Centro de Investigacion en Nutricion y Salud, Cuernavaca,Mexico; and Division of Nutritional Sciences, Cornell University, New York, NY

Context: Malnutrition causes death and impaired health in millions of children. Existing interventions are effective under controlled conditions; however, little information is available on their effectiveness in large-scale programs.

Objective: To document the short-term nutritional impact of a large-scale, incentive based development program in Mexico (Progresa), which included a nutritional component.

Design, Setting, and Participants: A randomized effectiveness study of 347 communities randomly assigned to immediate incorporation to the program in 1998 (intervention group; n=205) or to incorporation in 1999 (crossover intervention group; n=142). A random sample of children in those communities was surveyed at baseline and at 1 and 2 years afterward. Participants were from low-income households in poor rural communities in 6 central Mexican states. Children (N=650) 12 months of age or younger (n=373 intervention group; n=277 crossover intervention group) were included in the analyses.

Intervention: Children and pregnant and lactating women in participating households received fortified nutrition supplements, and the families received nutrition education, health care, and cash transfers. Main Outcome Measures: Two-year height increments and anemia rates as measured by blood hemoglobin levels in participating children.

Results: Progresa was associated with better growth in height among the poorest and younger infants. Age- and length-adjusted height was greater by 1.1 cm (26.4 cm in the intervention group vs 25.3 cm in the crossover intervention group) among infants younger than 6 months at baseline and who lived in the poorest households. After 1 year, mean hemoglobin values were higher in the intervention group (11.12 g/dL; 95% confidence interval [CI], 10.9-11.3 g/dL) than in the crossover intervention group (10.75 g/dL; 95% CI, 10.5-11.0 g/dL) who had not yet received the benefits of the intervention (P=.01). There were no differences in hemoglobin levels between the 2 groups at year 2 after both groups were receiving the intervention. The age-adjusted rate of anemia (hemoglobin level<11 g/dL) in 1999 was higher in the crossover intervention group than in the intervention group (54.9% vs 44.3%; P=.03), whereas in 2000 the difference was not significant (23.0% vs 25.8%, respectively; P=.40).

Conclusion: Progresa, a large-scale, incentive-based development program with a nutritional intervention, is associated with better growth and lower rates of anemia in low-income, rural infants and children in Mexico.

IV.25. Journal of Health, Population and Nutrition. 2005 Dec;23(4):351-357

‘Supplemental Feeding with Ready-to-Use Therapeutic Food in Malawian Children at Risk of Malnutrition’

MONICA P. PATEL, HEIDI L. SANDIGE, MACDONALD J. NDEKHA, ANDRÉ BRIEND, PER ASHORN, AND MARK J. MANARY.

Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, College of Medicine, University of Malawi, Blantyre, Malawi, Institut de Recherche pour le Développement, Paris, France, and Paediatric Research Centre, Tampere University Hospital, Tampere, Finland

ABSTRACT. The study was a controlled, comparative clinical effectiveness trial of two supplementary feeding regimens in children at risk of malnutrition from seven centres in rural Malawi. Being at risk of malnutrition was defined as weight-for-height <85%, but >80% of the international standard. Astepped-wedge design with systematic allocation was used for assigning children to receive either ready-to-use therapeutic food (RUTF) (n=331) or micronutrient-fortified corn/soy-blend (n=41) for up to eight weeks. The primary outcomes were recovery, defined as weight-for-height >90%, and the rate of weight gain. Children receiving RUTF were more likely to recover (58% vs 22%; difference 36%; 95% confidence interval [CI] 20-52) and had greater rates of weight gain (3.1 g/kg/day vs 1.4 g/kg/day; difference 1.7; 95% CI 0.8-2.6) than children receiving corn/soy-blend. The results of this preliminary work suggest that supplementary feeding with RUTF promotes better growth in children at risk of malnutrition than the standard fortified cereal/legume-blended food.

IV.26. American Journal of Clinical Nutrition. 2005;81:864 –70.

‘Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial 1–4’

MICHAEL A CILIBERTO, HEIDI SANDIGE, MACDONALD J NDEKHA, PER ASHORN, ANDRÉ BRIEND, HEATHER M CILIBERTO, AND MARK J MANARY

Department of Pediatrics, Washington University School of Medicine, St Louis, MO; the College of Medicine, University of Malawi, Blantyre, Malawi; the Institut de Recherche pour le Développement, Paris, France; and the Paediatric Research Centre, Tampere University Hospital, Tampere, Finland.

ABSTRACT. Background: Childhood malnutrition is common in Malawi, and the standard treatment, which follows international guidelines, results in poor recovery rates. Higher recovery rates have been seen in pilot studies of home-based therapy with ready-to-use therapeutic food (RUTF).

Objective: The objective was to compare the recovery rates among children with moderate and severe wasting, kwashiorkor, or both receiving either home-based therapy with RUTF or standard inpatient therapy.

Design: A controlled, comparative, clinical effectiveness trial was conducted in southern Malawi with 1178 malnourished children. Children were systematically allocated to either standard therapy (186 children) or home-based therapy with RUTF (992 children) according to a stepped wedge design to control for bias introduced by the season of the year. Recovery, defined as reaching a weight-for height z score > - 2, and relapse or death were the primary outcomes. The rate of weight gain and the prevalence of fever, cough, and diarrhea were the secondary outcomes.

Results: Children who received home-based therapy with RUTF were more likely to achieve a weight-for-height z score > - 2 than were those who received standard therapy (79% compared with 46%; P < 0.001) and were less likely to relapse or die (8.7% compared with
16.7%; P < 0.001). Children who received home-based therapy with RUTF had greater rates of weight gain (3.5 compared with 2.0 g · kg-1· d-1; difference: 1.5; 95% CI: 1.0, 2.0 g· kg-1 d-1) and a lower prevalence of fever, cough, and diarrhea than did children who received standard therapy. Conclusion: Home-based therapy with RUTF is associated with better outcomes for childhood malnutrition than is standard therapy.

IV.27. www.thelancet.com. Published Online, September 26, 2006.

‘Management of severe acute malnutrition in children’

STEVE COLLINS, NICKY DENT, PAUL BINNS, PALUKU BAHWERE, KATE SADLER, ALISTAIR ALLAM

Valid International Ltd, Oxford, UK; and Centre for International Child Health, Institute of Child Health, Guilford Street, London, UK

Severe acute malnutrition (SAM) is defined as a weight-for-height measurement of 70% or less below the median, or three SD or more below the mean National Centre for Health Statistics reference values, the presence of bilateral pitting oedema of nutritional origin, or a mid-upper-arm circumference of less than 110 mm in children age 1–5 years. 13 million children under age 5 years have SAM, and the disorder is associated with 1 million to 2 million preventable child deaths each year. Despite this global importance, child-survival programmes have ignored SAM, and WHO does not recognise the term “acute malnutrition”. Inpatient treatment is resource intensive and requires many skilled and motivated staff. Where SAM is common, the number of cases exceeds available inpatient capacity, which limits the effect of treatment; case-fatality rates are 20–30% and coverage is commonly under 10%. Programmes of community-based therapeutic care substantially reduce case-fatality rates and increase coverage rates. These programmes use new, ready-to-use, therapeutic foods and are designed to increase access to services, reduce opportunity costs, encourage early presentation and compliance, and thereby increase coverage and recovery rates. In community-based therapeutic care, all patients with SAM without complications are treated as outpatients. This approach promises to be a successful and cost-effective treatment strategy.

*IV. 28 New England Journal of Medicine: 354;3. January 19, 2006.

‘Crisis in Niger — Outpatient Care for Severe Acute Malnutrition’

MILTON TECTONIDIS

Médecins Sans Frontières, Paris, France.

A report about an intervention addressing the needs of several tens of thousands cases of severe acute malnutrition, in a single operation (Niger, 2005) and in an outpatient care network for most of the patients.

IV.29. The World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund. May 2007.

‘Community-based management of severe acute malnutrition’

Severe acute malnutrition remains a major killer of children under five years of age. Until recently, treatment has been restricted to facility-based approaches, greatly limiting its coverage and impact. New evidence suggests, however, that large numbers of children with severe acute malnutrition can be treated in their communities without being admitted to a health facility or a therapeutic feeding centre. The community-based approach involves timely detection of severe acute malnutrition in the community and provision of treatment for those without medical complications with ready-to-use therapeutic foods or other nutrient-dense foods at home. If properly combined with a facility-based approach for those malnourished children with medical complications and implemented on a large scale, community-based management of severe acute malnutrition could prevent the deaths of hundreds of thousands of children.

*IV.30. Field Exchange. Emergency Nutrition network. September 2007 Issue 31

‘Management of moderate acute malnutrition with RUTF in Niger’

ISABELLE DEFOURNY, GWENOLA SEROUX, ISSALEY ABDELKADER, AND GÉZA HARCZI

Médecins Sans Frontières, Maradi, Niger and Paris, France

In 2006, MSF operated 11 outpatient feeding centres attached to integrated health centres

(Centres de Santé Intégrés), along with two inpatient referral feeding units, in two districts of Maradi region with an estimated population of 900,000 people. Moderately malnourished children were admitted to these units and treated with the same medical and dietary protocols used for severe acutely malnourished patients (with the exception of no systematic antibiotic treatment at admission). Within the programme, the distinction between moderate and severe acute malnutrition was abandoned in favour of a distinction between complicated and non-complicated acute malnutrition. Children were admitted according to standard criteria for acute malnutrition: weight-for-height (W/H) ratio < 80% of the NCHS median, and/or mid-upper arm circumference (MUAC) < 110 mm and/or bilateral pitting oedema. Complicated acute malnutrition was defined as acute malnutrition accompanied by anorexia and/or severe pathology. Complicated cases were admitted to one of the two inpatient units for stabilisation. All non-complicated cases were admitted directly to weekly follow-up care in one of the 11 outpatient feeding units, and were referred to inpatient units only if they developed complications during the course of their treatment. As in 2005, Plumpy’nut® (1,000 kcal/day) was used as the RUTF offered to all outpatients. Although the protocol did not distinguish between severe and moderate malnutrition (using complicated and non-complicated acute malnutrition classifications instead), data were collected and are presented here in terms of moderate and severe, to facilitate analysis and for the sake of clarity. An admitted child was considered cured after maintaining a W/H ratio > 80% (NCHS reference) on two consecutive visits. Upon discharge, patients were given an additional week of RUTF treatment as well as a 25-kg ration of fortified blended flour (Unimix) and 5 litres of cooking oil.

Results were analysed by using individual based data from MSF programme monitoring, by means of a database comprised of information from individual treatment cards. A total of 64,733 children were admitted for acute malnutrition in the MSF nutritional programme in 2006. Of these, 92.5% (59,880) were children with moderate malnutrition, and 7.5% (4,853) were children with severe malnutrition. Of the children admitted, 93.1% were less than 36 months of age, a trend consistent with past years. Readmission rates were 8.9% for moderate and 4.2% for severe cases. Of the children, 89.6% of moderate and 58.2% of severe cases were admitted directly into outpatient care. A total of 10,651 children (8,389 moderate and 2,262 severe) spent at least part of their treatment in an inpatient centre. Analysis of results for 59,698 moderate malnourished children showed a cure rate of 95.5%, death rate of 0.4%, and default rate of 3.4%. Average length of stay was 31.4 days, and average daily weight gain was 5.28g/kg body weight/day. Approximately 75% of children had a W/H ratio > 85% of the NCHS reference median on discharge. For the 4,796 severe cases discharged, the cure rate was 81.3%, death rate 3.0%, and default rate 10.3%. Average length of stay was 42.6 days, and average daily weight gain 8g/kg body weight/day.

IV.31. www.thelancet.com. Published Online, January 17, 2008.

‘Maternal and Child Undernutrition 3. What works? Interventions for maternal and child undernutrition and survival’

ZULFIQAR A BHUTTA, TAHMEED AHMED, ROBERT E BLACK, SIMON COUSENS, KATHRYN DEWEY, ELSA GIUGLIANI, BATOOL A HAIDER, BETTY KIRKWOOD, SAUL S MORRIS, H P S SACHDEV, MEERA SHEKAR.

Aga Khan University, Karachi, Pakistan; Center for Health and Population Research, Dhaka, Bangladesh; Johns Hopkins Bloomberg School of Public Health, Baltimore; London School of Hygiene and Tropical Medicine, London, UK; University of California, Davis, CA, USA; Federal University of Rio Grande de Sul, Porto Alegre, Brazil; Sitaram Bhartia Institute of Science and Research, New Delhi, India; and World Bank, Washington DC, USA

We reviewed interventions that affect maternal and child undernutrition and nutrition-related outcomes. These interventions included promotion of breastfeeding; strategies to promote complementary feeding, with or without provision of food supplements; micronutrient interventions; general supportive strategies to improve family and community nutrition; and reduction of disease burden (promotion of handwashing and strategies to reduce the burden of malaria in pregnancy). We showed that although strategies for breast-feeding promotion have a large effect on survival, their effect on stunting is small. In populations with sufficient food, education about complementary feeding increased height-forage Z score by 0·25 (95% CI 0.01–0.49), whereas provision of food supplements (with or without education) in populations with insufficient food increased the height-for-age Z score by 0.41 (0.05–0.76). Management of severe acute malnutrition according to WHO guidelines reduced the case-fatality rate by 55% (risk ratio 0.45, 0.32–0.62), and recent studies suggest that newer commodities, such as ready-to-use therapeutic foods, can be used to manage severe acute malnutrition in community settings. Effective micronutrient interventions for pregnant women included supplementation with iron-folate (which increased haemoglobin at term by 12 g/L, 2.93–21.07) and micronutrients (which reduced the risk of low birth-weight at term by 16% (relative risk 0.84, 0.74–0.95). Recommended micronutrient interventions for children included strategies for supplementation of vitamin A (in the neonatal period and late infancy), preventive zinc supplements, iron supplements for children in areas where malaria is not endemic, and universal promotion of iodised salt. We used a cohort model to assess the potential effect of these interventions on mothers and children in the 36 countries that have 90% of children with stunted linear growth. The model showed that existing interventions that were designed to improve nutrition and prevent related disease could reduce stunting at 36 months by 36%; mortality between birth and 36 months by about 25%; and disability-adjusted life-years associated with stunting, severe wasting, intrauterine growth restriction, and micronutrient deficiencies by about 25%. To eliminate stunting in the longer term, these interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women’s empowerment.

*IV.32. PLoS ONE. www.plosone.org. 1 May 2009, Volume 4, Issue 5, e5455

‘A Large-Scale Distribution of Milk-Based Fortified Spreads: Evidence for a New Approach in Regions with High Burden of Acute Malnutrition’

ISABELLE DEFOURNY, ANDREA MINETTI, GEZA HARCZI, STÉPHANE DOYON, SUSAN SHEPHERD, MILTON TECTONIDIS, JEAN-HERVÉ BRADOL, MICHAEL GOLDEN

Médecins sans Frontières, Paris, France, University of Aberdeen, Aberdeen, Scotland

ABSTRACT. Background: There are 146 million underweight children in the developing world, which contribute to up to half of the world’s child deaths. In high burden regions for malnutrition, the treatment of individual children is limited by available resources. Here, we evaluate a large-scale distribution of a nutritional supplement on the prevention of wasting. Methods and Findings: A new ready-to-use food (RUF) was developed as a diet supplement for children under three. The intervention consisted of six monthly distributions of RUF during the 2007 hunger gap in a district of Maradi region, Niger, for approximately 60,000 children (length: 60–85 cm). At each distribution, all children over 65 cm had their Mid-Upper Arm Circumference (MUAC) recorded. Admission trends for severe wasting (WFH < 70% NCHS) in Maradi, 2002–2005 show an increase every year during the hunger gap. In contrast, in 2007, throughout the period of the distribution, the incidence of severe acute malnutrition (MUAC < 110 mm) remained at extremely low levels. Comparison of year-over-year admissions to the therapeutic feeding program shows that the 2007 blanket distribution had essentially the same flattening effect on the seasonal rise in admissions as the 2006 individualized treatment of almost 60,000 children moderately wasted. Conclusions: These results demonstrate the potential for distribution of fortified spreads to reduce the incidence of severe wasting in large population of children 6–36 months of age. Although further information is needed on the cost-effectiveness of such distributions, these results highlight the importance of re-evaluating current nutritional strategies and international recommendations for high burden areas of childhood malnutrition.

IV.33. American Journal of Clinical Nutrition. 2009;89:382–90.

‘Post intervention growth of Malawian children who received 12-months of dietary complementation with a lipid-based nutrient supplement or maize-soy flour’

JOHN C PHUKA, KENNETH MALETA, CHRISSIE THAKWALAKWA, YIN BUN CHEUNG, ANDRÉ BRIEND, MARK J MANARY, AND PER ASHORN

College of Medicine, University of Malawi, Blantyre, Malawi; the Department of International Health, University of Tampere Medical School, Finland; the Clinical Trials and Epidemiology Research Unit, Singapore, the Department of Child Health and Development, World Health Organization, Geneva, Switzerland, and IRD, Département Sociétés et Santé, Paris, France; WashingtonUniversity School of Medicine, St Louis, MO; and the Department of Paediatrics, Tampere University Hospital, Tampere, Finland..

ABSTRACT. Background: Therapeutic feeding with micronutrient-fortified lipid-based nutrient supplements (LNSs) has proven useful in the rehabilitation of severely malnourished children. We recently reported that complementary feeding of 6–18-mo-old infants with an LNS known as FS50 was associated with improved linear growth and a reduction in the incidence of severe stunting during the supplementation period.

Objective: Our objective was to assess whether a reduction in stunting seen with 12-mo LNS supplementation was sustained over a subsequent 2-y non-intervention period.

Design: One hundred eighty-two 6-mo-old healthy rural Malawian infants were randomly assigned to receive daily supplementation for 12 mo with 71 g of maize-soy flour [likuni phala (LP); control group, 282 kcal] or either 50 g of FS50 (264 kcal; main intervention group), or 25 g of FS25 (130 kcal). Main outcome measures were incidence of severe stunting and mean z score changes in weight-for-age, length-for-age, and weight-for-length during a 36-mo follow-up period.

Results: The cumulative 36-mo incidence of severe stunting was 19.6% in LP, 3.6% in FS50, and 10.3% in FS25 groups (P = 0.03). Mean weight-for-age changes were –1.09, –0.76, and –1.22 (P = 0.04); mean length-for-age changes were –0.47, –0.37, and –0.71 (P =0.10); and mean weight-for-length changes were –1.52, –1.18, and –1.48 (P = 0.27). All differences were more marked among individuals with baseline length-for-age below the median. Differences in length developed during the intervention at age 10–18 mo, whereas weight differences continued to increase after the intervention.

Conclusions: Twelve-month-long complementary feeding with 50 g/d FS50 is likely to have a positive and sustained impact on the incidence of severe stunting in rural Malawi. Half-dose intervention may not have the same effect. This trial was registered at clinical-trials.gov as NCT00131209.

*IV.34. Journal of American Medical Association. 2009;301(3):277-285

‘Effect of Preventive Supplementation with Ready-to-Use Therapeutic Food on the Nutritional Status, Mortality, and Morbidity of Children Aged 6 to 60 Months in Niger. A Cluster Randomized Trial’

SHEILA ISANAKA, NOHELLY NOMBELA, ALI DJIBO, MARIE POUPARD, DOMINIQUE VAN BECKHOVEN, VALÉRIE GABOULAUD, PHILIPPE J. GUERIN, REBECCA F. GRAIS.

Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, Massachusetts; Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland; Ministry of Health, Niamey, Niger; Infectious and Tropical Disease Service, Hospital Delafontaine, Saint Denis, France; Epidemiology Section, Scientific Institute of Public Health, Brussels, Belgium; Department of Psychiatry, Hôpital Avicenne, Bobigny, France; Epicentre, Paris, France (Drs Guerin and Grais); and Harvard Humanitarian Initiative, Cambridge, Massachusetts

Context: Ready-to-use therapeutic foods (RUTFs) are an important component of effective outpatient treatment of severe wasting. However, their effectiveness in the population-based prevention of moderate and severe wasting has not been evaluated.

Objective: To evaluate the effect of a 3-month distribution of RUTF on the nutritional status, mortality, and morbidity of children aged 6 to 60 months in Niger.

Design, Setting, and Participants: A cluster randomized trial of 12 villages in Maradi, Niger. Six villages were randomized to intervention and 6 to no intervention. All children in the study villages aged 6 to 60 months were eligible for recruitment.

Intervention: Children with weight-for-height 80% or more of the National Center for Health Statistics reference median in the 6 intervention villages received a monthly distribution of 1 packet per day of RUTF (92 g [500 kcal/d]) from August to October 2006. Children in the 6 non-intervention villages received no preventive supplementation. Active surveillance for conditions requiring medical or nutritional treatment was conducted monthly in all 12 study villages from August 2006 to March 2007.

Main Outcome Measures: Changes in weight-for-height z score (WHZ) according to the World Health Organization Child Growth Standards and incidence of wasting (WHZ <−2) over 8 months of follow-up.

Results: The number of children with height and weight measurements in August, October, December, and February was 3166, 3110, 2936, and 3026, respectively. The WHZ difference between the intervention and non-intervention groups was −0.10 z (95% confidence interval [CI], −0.23 to 0.03) at baseline and 0.12 z (95% CI, 0.02 to 0.21) after 8 months of follow-up. The adjusted effect of the intervention on WHZ from baseline to the end of follow-up was thus 0.22 z (95% CI, 0.13 to 0.30). The absolute rate of wasting and severe wasting, respectively, was 0.17 events per child-year (140 events/841 child-years) and 0.03 events per child-year (29 events/943 child-years) in the intervention villages, compared with 0.26 events per child-year (233 events/895 child-years) and 0.07 events per child-year (71 events/1029 child-years) in the non-intervention villages. The intervention thus resulted in a 36% (95% CI, 17% to 50%; P < .001) reduction in the incidence of wasting and a 58% (95% CI, 43% to 68%; P < .001) reduction in the incidence of severe wasting. There was no reduction in mortality, with a mortality rate of 0.007 deaths per child-year (7 deaths/986 child-years) in the intervention villages and 0.016 deaths per child-year (18 deaths/1099 child-years) in the non-intervention villages (adjusted hazard ratio, 0.51; 95% CI, 0.25 to 1.05).

Conclusion: Short-term supplementation of non-malnourished children with RUTF reduced the decline in WHZ and the incidence of wasting and severe wasting over 8 months.

IV.35. WHO, UNICEF, WFP and UNHCR Consultation on the Dietary Management of Moderate Malnutrition in Under-5 Children by the Health Sector. September 30th October 3rd, 2008.

‘Background paper. Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6-23 months old and treating moderate malnutrition among 6-59 months old children’

SASKIA DE PEE, MARTIN W. BLOEM

World Food Programme, Rome, Italy; Friedman School of Nutrition Science and Policy, Tufts University, Boston; Bloomberg School of Public Health, Johns Hopkins University, Baltimore

ABSTRACT. Reducing child malnutrition requires nutritious food, breastfeeding, improved hygiene, health services, and (prenatal) care. Poverty and food insecurity seriously constrain accessibility of nutritious diets, including high protein quality, adequate micronutrient content and bioavailability, macro-minerals and essential fatty acids, low anti-nutrient content, and high nutrient density. Largely plant-source-based diets with few animal source and fortified foods do not meet these requirements and need to be improved by processing (dehulling, germinating, fermenting), fortification, and adding animal source foods, e.g. milk, or other specific nutrients. Options include using specially formulated foods: fortified blended foods (FBFs), commercial infant cereals, ready-to-use foods i.e. pastes/compressed bars/biscuits, or complementary food supplements (CFS): micronutrient powders (MNP); powdered CFS containing (micro)nutrients, protein, amino acids and/or enzymes; or lipid-based nutrient supplements (LNS), 120-500 kcal/d, typically containing milk powder, high-quality vegetable oil, peanut-paste, sugar, (micro)nutrients. Most supplementary feeding programs for moderately malnourished children supply FBFs, such as corn soy blend, with oil and sugar, which has shortcomings: too many anti-nutrients, no milk (important for growth), suboptimal micronutrient content, high bulk and viscosity. Thus, for feeding young or malnourished children, FBFs need to be improved or replaced. Based on success with ready-to-use therapeutic foods (RUTF) for treating severe acute malnutrition, modifying that recipe is also considered. Commodities for reducing child malnutrition should be chosen based on nutritional needs, program circumstances, availability of commodities, and likelihood of impact. Data are urgently required to compare impact of new or modified commodities to current (FBFs) and to RUTF developed for treating severe acute malnutrition.