Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59-month-old children Saskia de Pee and Martin W. Bloem Abstract many antinutrients, no milk (important for growth), suboptimal micronutrient content, high bulk, and high Reducing child malnutrition requires nutritious food, viscosity. Thus, for feeding young or malnourished breastfeeding, improved hygiene, health services, and children, fortified blended foods need to be improved (prenatal) care. Poverty and food insecurity seriously or replaced. Based on success with ready-to-use thera- constrain the accessibility of nutritious diets that have peutic foods (RUTFs) for treating severe acute mal- high protein quality, adequate micronutrient content nutrition, modifying these recipes is also considered. and bioavailability, macrominerals and essential fatty Commodities for reducing child malnutrition should acids, low antinutrient content, and high nutrient be chosen on the basis of nutritional needs, program density. Diets based largely on plant sources with few circumstances, availability of commodities, and likeli- animal-source and fortified foods do not meet these hood of impact. Data are urgently required to compare requirements and need to be improved by processing the impact of new or modified commodities with that (dehulling, germinating, fermenting), fortification, and of current fortified blended foods and of RUTF devel- adding animal-source foods, e.g., milk, or other specific oped for treating severe acute malnutrition. nutrients. Options include using specially formulated foods (fortified blended foods, commercial infant cere- als, or ready-to-use foods [RUFs; pastes, compressed Key words: Child malnutrition, complementary food bars, or biscuits]) or complementary food supplements supplements, corn–soy blend, fortified blended foods, (micronutrient powders or powdered complementary micronutrient powder, ready-to-use foods, RUTF, sup- food supplements containing micronutrients, protein, plementary feeding amino acids, and/or enzymes or lipid-based nutrient supplements (120 to 250 kcal/day), typically containing milk powder, high-quality vegetable oil, peanut paste, Introduction sugar, and micronutrients. Most supplementary feeding programs for moderately malnourished children supply The treatment of malnutrition, as well as its preven- fortified blended foods, such as corn–soy blend, with tion, among children under 5 years of age requires oil and sugar, which have shortcomings, including too consumption of nutritious food, including exclusive breastfeeding for the first 6 months of life, followed by breastfeeding in combination with complemen- Saskia de Pee is affiliated with the World Food Programme, Rome, and the Friedman School of Nutrition Science and tary foods thereafter until at least 24 months of age; a Policy, Tufts University, Boston, Massachusetts, USA. Martin hygienic environment (clean drinking water, sanitary W. Bloem is affiliated with theWorld Food Programme, Rome; facilities); access to preventive (immunization, vitamin the Friedman School of Nutrition Science and Policy, Tufts A supplementation, etc.) as well as curative health University, Boston, Massachusetts, USA; and the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, services, and good prenatal care. Maryland, USA. In this article, the focus is on possible options for Please direct queries to the corresponding author: Saskia de providing a nutritious diet, realizing the constraints Pee, Policy, Strategy and Programme Support Division, World faced by many people whose children are at risk for Food Programme, Via Cesare Giulio, 68/70 Parco de’Medici, developing or confirmed to be suffering from moder- Rome 00148, Italy; e-mail: [email protected]. This publication reflects the personal views of the authors ate malnutrition (stunting as well as wasting), such as and does not necessarily represent the decisions or the poli- poverty and food insecurity. Although the nutrient cies of the World Health Organization or of the World Food density requirements proposed by Golden [1] are Programme. for moderately malnourished children, much of the S434 Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. Specially formulated foods and food supplements S435 dietary recommendations and complementary food Such advice is characterized by emphasis on consump- supplements proposed for improving dietary quality tion from all food groups (anywhere between four and are also relevant for young children (6 to 23 months) at eight groups are distinguished), changing the kinds of risk for developing moderate malnutrition, i.e., among foods chosen from these food groups (thus, for exam- populations with a high prevalence of stunting among ple, to alternate plant and animal sources of protein), children 2 to 5 years of age and wasting among those 6 frequent and responsive feeding, and ensuring good to 59 months of age. Therefore, much of the discussion energy density [3–5]. The article by Ashworth and in this article is applicable to young (6 to 23 months) Ferguson in this supplement [3] assesses whether and and growth-faltering children as well as to moderately how nutrient requirements proposed for moderately malnourished children (wasted children with weight- malnourished children can be met by selecting locally for-height < –2 and ≥ –3 z-scores or stunted children available foods and examines the evidence for an with height-for-age < –2 z-scores). impact of diets and programs based on promotion of We will also cover a range of interventions, from locally available foods. food-assistance programs for people who are wholly Table 1 shows the nutrient groups and active com- dependent on food assistance (refugees, people affected pounds that are essential for good child growth and by man-made or disaster-related emergencies) and development together with the main dietary sources of populations requiring food assistance during lean or these nutrients and compounds and comments on the bad harvest periods, to populations that are not typi- consumption of these foods. In summary, a relatively cally food insecure but consume a relatively monoto- wide variety of foods is required, including breastmilk, nous diet with too few good-quality foods to provide staples (for energy and some micronutrients), legumes vulnerable groups with the required intake of specific or lentils (particularly for protein), animal-source foods essential nutrients (such as micronutrients, macromin- (good sources of protein, minerals, and some vitamins), erals, essential amino acids, and essential fatty acids). vegetables and fruits (for vitamins, minerals, and vita- This article starts with a discussion of options for min C to enhance absorption of nonheme iron), oil dietary improvement, modification possibilities for (for energy and essential fatty acids), and a source of ready-to-use therapeutic foods (RUTFs), improvement iodine such as salt (but note that a high sodium intake of fortified blended foods, and different kinds, roles, in moderately malnourished children is not desirable). limitations, and applications of complementary food Table 2 shows the important characteristics of diets supplements. These considerations are then compared for young malnourished children (adapted from the with current practices in programs treating moderately article by Michaelsen et al. [2]) and considerations wasted children as reported in response to a question- with regard to foods required to realize consumption naire that was sent out by Anne Ashworth and Saskia of such diets. de Pee between February and August 2008. This assess- However, as one respondent to the questionnaire on ment of current practices is then followed by program- current programs (see below) said: matic considerations for expansion of the use of new …very often the causes of malnutrition are attributable food supplement products for preventing and treating to wide-scale food insecurity…. In such instances, there moderate malnutrition among young children. is simply no choice of food at household level, lack of This article complements the articles in this issue by variety and high market prices create inaccessibility to Golden [1], Michaelsen et al. [2], and Ashworth and a diversity of foods, in addition to exhausted household Ferguson [3], with Golden having established the nutri- assets with which to purchase or barter and as such, ent requirements, Michaelsen et al. having reviewed the people are often reported to be living off a single staple…. value and limitations of specific foods and food groups, During such times, diet diversity cannot be promoted, based on their content of nutrients and antinutrients, so education will focus on the importance of personal and Ashworth and Ferguson having assessed the hygiene and household sanitation, appropriate breast feeding and timely complementary feeding practices. adequacy of dietary recommendations for moderately malnourished children using locally available foods in Where the diet consists largely of plant foods with relatively food-secure but poor households. very few animal-source foods and fortified foods,* as is the case for many children and their families in developing countries, there are a number of issues to Option 1. Local diet: Required food be addressed. As can be concluded from tables 1 and groups and options for