TY - BOOK
T1 - Nutritional Supplementation of Children with Moderate Acute Malnutrition
AU - Fabiansen, Christian
N1 - CURIS 2017 NEXS 320
PY - 2017
Y1 - 2017
N2 - Background
Moderate acute malnutrition (MAM), defined as moderate wasting or low mid-upper arm circumference
(MUAC), is widespread among children in low-income countries. Children with MAM are at immediate risk
of mortality and morbidity or deterioration into severe acute malnutrition. Children with MAM are treated
with food supplements from a matrix of either lipid-based nutrient supplements (LNS) or corn-soy blends
(CSB), but there is limited evidence on the effectiveness. Trials assessing the effects of supplements
typically use weight gain or nutritional recovery as primary outcome. In this PhD thesis results are
presented from the Treatfood (TF) study that used body composition, i.e. accretion of fat-free tissue, as
primary outcome, to test key factors in supplementary foods. In addition, an assessment was undertaken of
the use of short body length as exclusion criterion for supplementary feeding programs in MAM.
Methods
The TF study consisted of a pilot study and a main trial. Pilot work was conducted to adapt and develop the
deuterium dilution technique (D2O), used for measuring body composition, and specifically to establish the
D2O equilibration time (Paper I). The main trial was a randomised 2x2x3 factorial trial, that recruited 6-23
month-old children with MAM from Burkina Faso at five health centres. The intervention comprised 12-
weeks supplements with LNS or CSB (500 kcal/day), containing soy-isolate (SI) or dehulled-soy (DS), and dry
skimmed milk (%M: 0, 20 or 50% of protein).The trial was double-blinded with respect to soy and milk, but
not matrix. Fat-free mass (FFM) was measured by deuterium dilution. The primary outcome was change in
the FFM index (FFMI) over 12 weeks (Paper II). In addition, an observational study was nested in the
randomised trial with inclusion of children with MUAC between 115-124 mm, but weight-for-height z-score
(WHZ) ≥-2. This cohort was divided in two groups by body length at admission, <67 cm (short) and ≥67 cm
(long) and their growth were compared (Paper III).
Results
The D2O equilibration time was established to be three hours. In the main trial, of 1609 children
randomised, 61 were lost to follow-up and 119 were transferred out and four children died. At inclusion,
95% were breastfed, mean±SD weight was 6.91kg ±0.93, with 83.5% FFM. Weight increased 0.90 kg (95%CI
0.88; 0.93) comprising 93.5% FFM. FFMI was increased by LNS (vs CSB, 0.083 kg/m2, 0.003; 0.163), but not
SI (vs DS, 0.038 kg/m2, -0.042; 0.118). FFMI was also increased by 20%M (vs 0%M, 0.097 kg/m2, -0.002;
0.196), although only marginally significant, but not by 50%M (0.049 kg/m2 -0.047; 0.146). For weight, LNS
resulted in 128 (67; 190) g larger gain if SI was used, but not DS (22 g; -40; 84) (interaction p=0.01).
Accordingly, SI vs DS increased weight by 89 g (27; 150) in LNS, but not in CSB (-18, -80; 44).
In the nested observational study no evidence of a difference was found between the two length groups
(short and long) when evaluating growth in response to treatment, and there was no effect modification by
supplement matrix. The percentage increase in weight and MUAC and the development of weight and
MUAC gain velocities were similar and above what would be expected when comparing with the WHO
growth standard.
Conclusion
MAM is widespread among children in low-income countries and WHO recommends research to develop
cost-effective food supplements. In the TF study children with MAM, nutritionally rehabilitated with
modern sufficiently fortified supplements, showed a satisfying weight gain consisting mainly of fat-free
tissue. Nevertheless, LNS yielded more fat-free tissue and higher recovery rates than CSB. Moreover, LNS
with SI resulted in larger weight gain than LNS with DS. Overall LNS did not lead to excessive accumulation
of fat. Finally, growth rates were similar for children with MAM included by MUAC below and above 67 cm.
The findings presented in this thesis may have immediate relevance for malnutrition programs. First, it is
recommended to use LNS supplements in children with MAM. Secondly, it is recommended to admit
children <67 cm if their MUAC is between 115 and 124 mm and their WHZ is ≥-2. Thus, the policy of using
short body length, to restrict inclusion to supplementary feeding programs, should be discontinued.
AB - Background
Moderate acute malnutrition (MAM), defined as moderate wasting or low mid-upper arm circumference
(MUAC), is widespread among children in low-income countries. Children with MAM are at immediate risk
of mortality and morbidity or deterioration into severe acute malnutrition. Children with MAM are treated
with food supplements from a matrix of either lipid-based nutrient supplements (LNS) or corn-soy blends
(CSB), but there is limited evidence on the effectiveness. Trials assessing the effects of supplements
typically use weight gain or nutritional recovery as primary outcome. In this PhD thesis results are
presented from the Treatfood (TF) study that used body composition, i.e. accretion of fat-free tissue, as
primary outcome, to test key factors in supplementary foods. In addition, an assessment was undertaken of
the use of short body length as exclusion criterion for supplementary feeding programs in MAM.
Methods
The TF study consisted of a pilot study and a main trial. Pilot work was conducted to adapt and develop the
deuterium dilution technique (D2O), used for measuring body composition, and specifically to establish the
D2O equilibration time (Paper I). The main trial was a randomised 2x2x3 factorial trial, that recruited 6-23
month-old children with MAM from Burkina Faso at five health centres. The intervention comprised 12-
weeks supplements with LNS or CSB (500 kcal/day), containing soy-isolate (SI) or dehulled-soy (DS), and dry
skimmed milk (%M: 0, 20 or 50% of protein).The trial was double-blinded with respect to soy and milk, but
not matrix. Fat-free mass (FFM) was measured by deuterium dilution. The primary outcome was change in
the FFM index (FFMI) over 12 weeks (Paper II). In addition, an observational study was nested in the
randomised trial with inclusion of children with MUAC between 115-124 mm, but weight-for-height z-score
(WHZ) ≥-2. This cohort was divided in two groups by body length at admission, <67 cm (short) and ≥67 cm
(long) and their growth were compared (Paper III).
Results
The D2O equilibration time was established to be three hours. In the main trial, of 1609 children
randomised, 61 were lost to follow-up and 119 were transferred out and four children died. At inclusion,
95% were breastfed, mean±SD weight was 6.91kg ±0.93, with 83.5% FFM. Weight increased 0.90 kg (95%CI
0.88; 0.93) comprising 93.5% FFM. FFMI was increased by LNS (vs CSB, 0.083 kg/m2, 0.003; 0.163), but not
SI (vs DS, 0.038 kg/m2, -0.042; 0.118). FFMI was also increased by 20%M (vs 0%M, 0.097 kg/m2, -0.002;
0.196), although only marginally significant, but not by 50%M (0.049 kg/m2 -0.047; 0.146). For weight, LNS
resulted in 128 (67; 190) g larger gain if SI was used, but not DS (22 g; -40; 84) (interaction p=0.01).
Accordingly, SI vs DS increased weight by 89 g (27; 150) in LNS, but not in CSB (-18, -80; 44).
In the nested observational study no evidence of a difference was found between the two length groups
(short and long) when evaluating growth in response to treatment, and there was no effect modification by
supplement matrix. The percentage increase in weight and MUAC and the development of weight and
MUAC gain velocities were similar and above what would be expected when comparing with the WHO
growth standard.
Conclusion
MAM is widespread among children in low-income countries and WHO recommends research to develop
cost-effective food supplements. In the TF study children with MAM, nutritionally rehabilitated with
modern sufficiently fortified supplements, showed a satisfying weight gain consisting mainly of fat-free
tissue. Nevertheless, LNS yielded more fat-free tissue and higher recovery rates than CSB. Moreover, LNS
with SI resulted in larger weight gain than LNS with DS. Overall LNS did not lead to excessive accumulation
of fat. Finally, growth rates were similar for children with MAM included by MUAC below and above 67 cm.
The findings presented in this thesis may have immediate relevance for malnutrition programs. First, it is
recommended to use LNS supplements in children with MAM. Secondly, it is recommended to admit
children <67 cm if their MUAC is between 115 and 124 mm and their WHZ is ≥-2. Thus, the policy of using
short body length, to restrict inclusion to supplementary feeding programs, should be discontinued.
UR - https://rex.kb.dk/primo-explore/fulldisplay?docid=KGL01010343109&context=L&vid=NUI&search_scope=KGL&tab=default_tab&lang=da_DK
M3 - Ph.D. thesis
SN - 978-87-93476-96-7
BT - Nutritional Supplementation of Children with Moderate Acute Malnutrition
PB - Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen
CY - Copenhagen
ER -
