Ready-to-Use Therapeutic Food for the Prevention of Wasting in Children

Abstract

HE EFFICACY AND EFFECTIVENESS OF READY-TO-USE therapeutic food (RUTF) for the treatment of wasting have been previously documented, 1,2 and its use as part of community-based treatment of severe acute malnutrition in children is now recommended. 3 The article by Isanaka and colleagues 4 in this issue of JAMA provides evidence that RUTF distributed for a 3-month period was efficacious in preventing wasting and severe wasting in children aged 6 to 60 months. In this cluster randomized controlled trial of 12 villages in Niger, all families with children aged 6 to 60 months with weight-for-height 80% or more of the National Center for Health Statistics reference standard received 92 g (providing 500 kcal) of RUTF daily for 3 months. The distribution of RUTF during the period of the year with documented food shortages improved weight maintenance among children and reduced wasting by 36% and severe wasting by 58%. This well-designed and implemented study extends current knowledge of RUTF from therapeutic use to the prevention of wasting in a population-based sample. However, whether untargeted distribution of RUTF would be a cost-effective, sustainable intervention compared with other approaches to prevent malnutrition remains to be determined. In Niger, as in many of parts of the world where rural populations rely on subsistence agriculture, food supply is short in the months before the harvest, and this study’s results are applicable to areas with seasonal or emergency food shortages. Different approaches would likely be necessary to prevent child growth faltering, weight loss, or both in locations with chronic food shortages. The appropriateness of RUTF for supplementation to children without wasting has been considered, 5 and efforts have been undertaken to develop suitable alternative products. Supplementation for 12 months with lipid-based RUTFs with lower energy content (108 to 256 kcal/d) have been shown to have positive 6,7 and sustained 8 effects on child growth and improved motor development. 7 In addition, although the study by Isanaka et al focused on weight and length, micronutrient deficiencies are extremely common and should be considered in supplementation programs. The lipid-based supplements have also been shown to improve iron status and reduce anemia prevalence. 9 Even when energy and protein needs may be met, the micronutrient density of complementary foods commonly used by poor populations in developing countries may not be adequate. 10 In regions where macronutrient intake may not be limiting for growth, strategies such as micronutrient powders may be more cost-effective. 11 Longerterm strategies that permit not only temporary relief of food shortage but improvements in the quantity and quality (ie, micronutrient density) of foods given to small children and in other conditions that result in child malnutrition should be a priority. The prevention of wasting reported by Isanaka et al in the villages with RUTF distribution highlights a shortterm benefit for children in the intervention group. It is unknown whether the targeted distribution of RUTF to children at higher risk but without wasting (ie, weightfor-height z score �1 or 0) would have the same effect. The authors recognize that the largest effect would likely be among children with the lowest weight-forheight z score at recruitment. This question could probably be answered using these data by including analyses of change in weight-for-height z score by weight status at recruitment.