Tackling moderate malnutrition: the next frontier.

Abstract

Malnutrition kills. Not too startling a statement, yet only a decade ago, few child-health experts appreciated that the majority of childhood deaths in the developing world were the result of the interactive effect of malnutrition and infectious diseases. Today, few remain incognizant of the link, and the subject of severe malnutrition has appropriately been the focus of much recent international attention, resulting in improved understanding of the problem, new approaches being developed and tested, and stronger partnerships being established (1,2). However, many child health practitioners remain oblivious to one key fact: more than 83% of malnutritionrelated deaths are the consequence of mild-to-moderate rather than severe malnutrition (3). Strategies involving only the screening and treatment of the severely malnourished will do little to address this problem. Children who are mildly underweight (Z score between −1 and −2) have about a two-fold higher risk of death than do those who are better nourished. This risk increases to fivefold to eightfold in moderately (Z scores between −2 and −3) to severely (Z score < −3) underweight children (4). These children betray no outward signs of malnutrition to the casual observer and thus are frequently ignored or missed by health services, aid agencies and development programs. In this issue of the Journal, an article by Maleta et al. (5) is a valuable addition to the scant literature specifically examining interventions involving food supplementation for moderately malnourished children. In a randomized trial of moderately malnourished children, maize and soy flour (an indigenous diet) were compared to ready-to-use food (RTUF) in a 3-month, home-treatment program. Both of their main conclusions, while not unexpected, are important and worthy of further deliberation. First, both supplements resulted in modest weight gain, but the effects lasted longer after RTUF supplementation; and second, despite providing supplements at no cost to participants and delivering them to the home, less than half of both supplements were consumed by the children. Commercial supplementary foods have been studied previously and have generally had a favorable influence on growth. The intervention used in this study, a recently developed spread (the RTUF) has attractive qualities. It has a very high energy density (23 kJ/g), is micronutrient fortified, does not need to be cooked before consumption, has excellent storage (bacteriostatic) properties, and importantly, is considered palatable by children (6). It has been successfully used at therapeutic feeding centers and in emergency relief situations. Two major disadvantages are its limited availability and its cost. However, even these constraints have been successfully overcome in a Malawian setting similar to the one in which the study by Maleta et al. was conducted. An almost identical RTUF, with similar anthropometric and health benefits, was produced locally at about a third of the cost of the imported product (7). The improved weight gain in the RTUF group for three months after the supplementation period ended is somewhat puzzling. The researchers’ hypothesis that the children may have had a better appetite as a consequence of the correction of micronutrient deficiency is plausible but was not confirmed in a Beninese study (8) and requires further investigation. The lack of a significant effect on linear growth can be explained by the relatively short duration of the trial. Because weight responds faster to intervention than does length, a longer period might have resulted in detectable differences. The poor consumption of the supplements provided at no cost is of concern, but the phenomenon has been described in previous studies. In one study of growth retarded children whose energy intake did not meet requirements, as much as 25% of food offered was not consumed (9). The researchers attribute the poor compliance noted during the fortnightly 24-hour recall to possible “domestic diversion” or the premature exhausDeclaration: The author has no potential sources of bias that might have an impact upon his commentary and has received no financial support from any company involved with the article discussed or its competitors. Journal of Pediatric Gastroenterology and Nutrition 38:143–145 © February 2004 Lippincott Williams & Wilkins, Inc., Philadelphia