Corn-soy Blend Research Articles

The Nutrient and Metabolite Profile of 3 Complementary Legume Foods with Potential to Improve Gut Health in Rural Malawian Children

BackgroundEnvironmental enteric dysfunction (EED), frequently seen in rural Malawian children, causes chronic inflammation and increases the risk of stunting. Legumes may be beneficial for improving nutrition and reducing the risk of developing EED in weaning children. ObjectiveThe objectives of this study were to determine the nutritional value, verify the food safety, and identify metabolite profiles of 3 legume-based complementary foods: common bean (CB), cowpea (CP), and traditional corn-soy blend (CSB). MethodsFoods were prepared by using local ingredients and analyzed for nutrient composition with the use of Association of Official Analytical Chemists (AOAC) standards (950.46, 991.43, 992.15, 996.06, and 991.36) for macro- and micronutrient proximate analysis. Food safety analysis was conducted in accordance with the Environmental Protection Agency (7471B) and AOAC (2008.02) standards. The metabolite composition of foods was determined with nontargeted ultra-performance LC–tandem mass spectrometry metabolomics. ResultsAll foods provided similar energy; CB and CP foods contained higher protein and dietary fiber contents than did the CSB food. Iron and zinc were highest in the CSB and CP foods, whereas CB and CP foods contained higher amounts of magnesium, phosphorus, and potassium. A total of 652 distinct metabolites were identified across the 3 foods, and 23, 14, and 36 metabolites were specific to the CSB, CB, and CP foods, respectively. Among the potential dietary biomarkers of intake to distinguish legume foods were pipecolic acid and oleanolic acid for CB; arabinose and serotonin for CSB; and quercetin and α- and γ-tocopherol acid for CP. No heavy metals were detected, and aflatoxin was measured only in the CSB (5.2 parts per billion). ConclusionsLegumes in the diet provide a rich source of protein, dietary fiber, essential micronutrients, and phytochemicals that may reduce EED. These food metabolite analyses identified potential dietary biomarkers of legume intake for stool, urine, and blood detection that can be used in future studies to assess the relation between the distinct legumes consumed and health outcomes. This trial was registered at clinicaltrials.gov as NCT02472262 and NCT02472301.

Effective delivery of social and behavior change communication through a Care Group model in a supplementary feeding program

BackgroundIn 2014, an intervention aimed at increasing the oil in corn soy blend (CSB) porridge prepared by caregivers of children with moderate acute malnutrition was implemented in Southern Malawi. This analysis describes the flow of key messages delivered through the Care Group model during this intervention.MethodsThe intervention provided a supplementary food ration of CSB and oil and used a Care Group model in which healthcare workers were trained to deliver social and behavior change communication (SBCC) to care group volunteers who then delivered messages to caregivers of beneficiary children. Healthcare workers also delivered messages to caregivers directly. Interviews and focus groups were conducted with all three groups in order to determine the exchange of key messages about ingredient use, storage, and purpose, which were analyzed descriptively.ResultsAnalysis of SBCC flow and information exchange showed that 100% of caregivers reported learning about the amounts of oil and CSB to use while preparing porridge and over 90% of caregivers, healthcare workers, and care group volunteers reported talking about it. Focus groups confirmed an effective flow of communication among these three groups.ConclusionThis analysis evaluated the flow of key SBCC messages through multiple, overlapping lines of communication among healthcare workers, care group volunteers, and caregivers; the effective transmission of these SBCC messages through this model may contribute to the success of a supplementary feeding intervention program.Trial registrationThe study was registered at ClinicalTrials.gov (NCT01873196).

Effectiveness of food supplements in increasing fat-free tissue accretion in children with moderate acute malnutrition: A randomised 2 × 2 × 3 factorial trial in Burkina Faso.

BackgroundChildren with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplement (LNS) or corn-soy blend (CSB). We assessed the effectiveness of (a) matrix, i.e., LNS or CSB, (b) soy quality, i.e., soy isolate (SI) or dehulled soy (DS), and (c) percentage of total protein from dry skimmed milk, i.e., 0%, 20%, or 50%, in increasing fat-free tissue accretion.Methods and findingsBetween September 9, 2013, and August 29, 2014, a randomised 2 × 2 × 3 factorial trial recruited 6- to 23-month-old children with MAM in Burkina Faso. The intervention comprised 12 weeks of food supplementation providing 500 kcal/day as LNS or CSB, each containing SI or DS, and 0%, 20%, or 50% of protein from milk. Fat-free mass (FFM) was assessed by deuterium dilution technique. By dividing FFM by length squared, the primary outcome was expressed independent of length as FFM index (FFMI) accretion over 12 weeks. Other outcomes comprised recovery rate and additional anthropometric measures. Of 1,609 children, 4 died, 61 were lost to follow-up, and 119 were transferred out due to supplementation being switched to non-experimental products. No children developed allergic reaction. At inclusion, 95% were breastfed, mean (SD) weight was 6.91 kg (0.93), with 83.5% (5.5) FFM. In the whole cohort, weight increased 0.90 kg (95% CI 0.88, 0.93; p < 0.01) comprising 93.5% (95% CI 89.5, 97.3) FFM. As compared to children who received CSB, FFMI accretion was increased by 0.083 kg/m2 (95% CI 0.003, 0.163; p = 0.042) in those who received LNS. In contrast, SI did not increase FFMI compared to DS (mean difference 0.038 kg/m2; 95% CI −0.041, 0.118; p = 0.35), irrespective of matrix. Having 20% milk protein was associated with 0.097 kg/m2 (95% CI −0.002, 0.196) greater FFMI accretion than having 0% milk protein, although this difference was not significant (p = 0.055), and there was no effect of 50% milk protein (0.049 kg/m2; 95% CI −0.047, 0.146; p = 0.32). There was no effect modification by season, admission criteria, or baseline FFMI, stunting, inflammation, or breastfeeding (p > 0.05). LNS compared to CSB resulted in 128 g (95% CI 67, 190; p < 0.01) greater weight gain if both contained SI, but there was no difference between LNS and CSB if both contained DS (mean difference 22 g; 95% CI −40, 84; p = 0.49) (interaction p = 0.017). Accordingly, SI compared to DS increased weight by 89 g (95% CI 27, 150; p = 0.005) when combined with LNS, but not when combined with CSB. A limitation of this and other food supplementation trials is that it is not possible to collect reliable data on individual adherence.ConclusionsBased on this study, children with MAM mainly gain fat-free tissue when rehabilitated. Nevertheless, LNS yields more fat-free tissue and higher recovery rates than CSB. Moreover, current LNSs with DS may be improved by shifting to SI. The role of milk relative to soy merits further research.Trial registrationISRCTN registry ISRCTN42569496

The MFFAPP Tanzania Efficacy Study Protocol: Newly Formulated, Extruded, Fortified Blended Foods for Food Aid

Fortified blended foods (FBFs) are micronutrient-fortified blends of milled cereals and pulses that represent the most commonly distributed micronutrient-fortified food aid. FBFs have been criticized due to lack of efficacy in treating undernutrition, and it has also been suggested that alternative commodities, such as sorghum and cowpea, be investigated instead of corn and soybean. The Micronutrient Fortified Food Aid Pilot Project (MFFAPP) Tanzania efficacy study was the culmination of economic, processing, sensory, and nutrition FBF research and development. MFFAPP Tanzania was a 20-wk, partially randomized cluster design conducted between February and July 2016 that enrolled children aged 6–53 mo in the Mara region of Tanzania with weight-for-height z scores >−3 and hemoglobin concentrations <10.3 mg/dL. The intervention was complementary feeding of newly formulated, extruded FBFs (white sorghum cowpea variety 1, white sorghum-cowpea variety 2, red sorghum-cowpea, white sorghum-soy blend, and corn-soy blend 14) compared with Corn Soy Blend Plus (CSB+), a current US Agency for International Development–distributed corn-soy blend, and a no-FBF-receiving control. Screened participants (n = 2050) were stratified by age group (6–23 and 24–53 mo) and allocated to 1 of 7 FBF clusters provided biweekly. Biochemical and anthropometric data were measured every 10 wk at weeks 0, 10, and 20. The primary objectives of this study were to determine whether newly formulated, extruded corn-, soy-, sorghum-, and cowpea-based FBFs result in equivalent vitamin A or iron outcomes compared with CSB+. Changes in anthropometric outcomes were also examined. Results from the MFFAPP Tanzania Efficacy Study will inform food aid producers and distributers about whether extruded sorghum- and cowpea-based FBFs are viable options for improving the health of the undernourished. This trial was registered at clinicaltrials.gov as NCT02847962.

Experiences of Beneficiary Caregivers in a Supplementary Feeding Program in Southern Malawi

ObjectiveTo identify factors affecting successful implementation of a Supplementary Feeding Program (SFP) for treatment of moderate acute malnutrition, based on beneficiary caregivers' perceptions and experiences assessed through qualitative findings of a USAID/FFP funded Tufts University study in Southern MalawiMethodsQualitative data were collected as part of a 2014 feasibility study assessing programmatic changes designed to increase the amount of oil added to corn‐soy blend (CSB) porridge prepared by caregivers of beneficiary children receiving the food for treatment of moderate acute malnutrition. Nine FGDs were conducted using semi‐structured guides, with between 7–10 caregivers participating in each. Interviews were audiotaped, transcribed, de‐ identified, and then analyzed using QSR International's NVivo 10 Software. An inductive, thematic content analysis approach was used to identify common conceptual themes from the data. Consent was obtained from all FGD participants.ResultsThemes emerged relating to benefits and barriers of participating in the SFP, and its effects within the community. Commonly identified challenges with the SFP described by participants were: (a) poor communication: not knowing when to expect the distribution (e.g. having no fixed date or time, having no advance notice of when the distribution will arrive, or not everyone receives the message about the distribution); (b) problems with distribution: long wait time at the distribution site; distribution not arriving at the planned date or time; or ration not received by the intended beneficiary caregiver. Additionally, it was commonly described that the ration does not last until the next distribution because the child eats the CSB porridge more often than the recommended daily dosage. Among benefits, improvement in the health of the beneficiary children was cited often, as well as happier, more active children, and increased caregiver knowledge of good feeding practices. Participants also described resentment within their community: that the CSB is ‘better’ than other available flours; that beneficiaries are unfairly favored; and that others (not just the beneficiary child) are also entitled to receive the porridge. Several participants described experiencing confrontation with other community members as a result of not sharing their CSB ration.ConclusionThe study identifies important contextual issues that may affect implementation of a supplementary feeding program that may be relevant in other settings and helpful in avoiding potential challenges and unintended consequences. Programs should be designed to address barriers to collecting supplementary food rations (distance to distribution site and reliable means of communication). Community perceptions, norms, and economic status of other households potentially creating resentment and the pressure to share with non‐beneficiary households should also be considered.Support or Funding InformationThis research was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Tufts University under the terms of Contract AFP‐C‐00‐09‐00016‐00 and do not necessarily reflect the views of USAID or the United States Government.

Effective delivery of social‐behavioral change communication through a care group model in a supplementary feeding program: a descriptive analysis

ObjectiveA USAID/FFP‐Funded study implemented by Tufts University (Food Aid Quality Review) in Southern Malawi found that intensified social‐behavioral change communication (SBCC) in combination with an augmented oil ration resulted in an increase in proper preparation of Corn‐Soy Blend (CSB) porridge such that the full intended nutritional content reached the target population of children with moderate acute malnutrition. This analysis describes the flow of key SBCC messages delivered through a care‐group model during an intervention aimed at increasing the oil in porridge prepared by caregivers of beneficiary children, as well as the flow of these key messages among sub‐groups in this intervention – health care workers, care group volunteers, and caregivers of beneficiary children.MethodsThe intervention provided a supplementary food ration of CSB and oil and used a care group model in which healthcare workers were trained to deliver SBCC to care group volunteers who then delivered messages to caregivers of beneficiary children. Healthcare workers also delivered messages to caregivers directly. Interviews and focus group discussions were conducted with all 3 sub‐groups in order to determine the exchange of key messages about ingredient use, storage, and purpose, which were analyzed descriptively. The analysis tracked the flow of information between the groups, and ultimately to the beneficiary caregiver.ResultsAnalysis of SBCC flow and information exchange showed that 100% of caregivers reported learning about the amounts of oil and CSB to use while preparing porridge, and over 90% of caregivers, healthcare workers, and care group volunteers reported talking about it. Information flowed to caregivers along multiple lines of communication, and the reported exchange of this information was high among all groups. Focus groups confirmed an effective flow of communication amongst these 3 sub‐groups.ConclusionKey SBCC messages were provided and received according to healthcare workers, care group volunteers and caregivers; caregivers received information from multiple sources, contributing to the overall effectiveness of the intervention. While increasing the ration likely contributed to increasing the oil content in prepared CSB porridge, this analysis found that the SBCC was also an important component of the intervention.Support or Funding InformationThis research was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Tufts University under the terms of Contract AFP‐C‐00‐09‐00016‐00 and do not necessarily reflect the views of USAID or the United States Government.

Accelerated Shelf Life Studies: Testing Micronutrient Stability of New and Upgraded Food Aid Products

Accelerated shelf life and stability studies are a critical part of product research and development (R&amp;D) and are being included as new and upgraded food aid products are introduced. The aim here was to determine the vitamin and mineral stability and integrity of United States products included in the Food Aid Quality Review (FAQR) Phase II food aid effectiveness trials. Tests were carried out on Corn‐Soy Whey Blend (CSWB), Super Cereal Plus (SC Plus), Corn Soy Blend Plus (CSBP), Ready‐to‐Use Supplementary Food (RUSF) and Fortified Vegetable Oil. The samples were analyzed for vitamin content (vitamins A and C), mineral content (iron, calcium and phosphorus), peroxide levels and organoleptic properties (appearance, odor, taste, packaging appearance). Testing followed standard methods certified by the Association of Official Analytical Chemists (now AOAC International) and commonly used by the food industry and the United States Department of Agriculture (USDA) Official Testing laboratories. All products were stored at 40 degrees Centigrade (104 degrees Fahrenheit) and 75 percent relative humidity for a period of 26 weeks to mimic 26 months in real time. The products were sampled and tested seven times.Vitamin A levels in all fortified blended foods (FBFs) degraded substantially during testing but remained very stable in RUSF and fortified vegetable oil, both lipid‐based products. Peroxide levels remained below the maximum permitted in the FBFs compared to specifications, but reached and exceeded the maximum permitted in vegetable oil by week six (equivalent to six months storage). Organoleptic characteristics: FBFs all developed a slight grainy odor over the course of their shelf lives. Three of the four showed sparse black flecks at various points that were likely due to dark germ color and heat processing of the raw material (corn). RUSF odor, appearance, texture and packaging remained stable and normal. Appearance, taste and packaging characteristics of fortified vegetable oil remained unchanged despite an increase in peroxide values during the shelf life study period; a slight “oily” odor was detected only at week six. Mineral levels varied among the FBFs, mostly as expected, due partially to intrinsic differences in product ingredients. These findings highlight the role that that intrinsic values play in establishing specifications. Vitamin C (endline only) levels were uniformly low in all FBFs but within the normal range in the RUSF.The use of new types of ingredients and modifications in micronutrient levels, types and forms (vitamins and minerals) can have an impact on both shelf life duration and organoleptic properties of FBFs through the supply chain. Accelerated shelf life studies are industry standard for new product development and should be adopted as due diligence and become standard for all new or upgraded food aid products. Shelf life protocols and conditions should be harmonized among aid organizations working on product development for comparable data and results. Further research is needed to optimize vitamin A delivery in the USAID food aid basket, including improving vitamin A stability in dry premixes for inclusion in FBF production and determining the most appropriate delivery mechanism. Packaging material innovation is required to reduce degradation of vitamin A and other vitamins.Support or Funding InformationThis research was funded by the United States Agency for International Development's (USAID) Office of Food for Peace (FFP) under USAID Contract AFP‐C‐00‐09‐00016‐00 with the Friedman School of Nutrition Science and Policy for Phase II of the Food Aid Quality Review (FAQR). The studies were conducted by Global Food &amp; Nutrition Inc. and Covance Laboratories.

Costing Methods for a Cluster‐Randomized Cost‐Effectiveness Trial Comparing the Performance of Four Supplementary Foods in Treating Sierra Leonean Children with Moderate Acute Malnutrition (MAM)

It is widely recognized that cost‐effectiveness (CE) estimates generated by economic evaluations should enter into decision‐making for health and nutrition policy and programming. However, many existing evaluations of nutrition interventions focus on effectiveness, assessing comparative nutrition and health outcomes without considering their associated costs. Moreover, despite recognizing the importance of measuring costs in generating CE estimates, many researchers find costing to be a challenging task with limited guidance and few examples of cost data collection methods in the international nutrition literature. This communication aims to help guide researchers on costing methods for research for cost‐effective policy‐making and programming.As part of the Food Aid Quality Review Phase III (FAQR III) Project, a USAID/FFP‐funded project implemented by Tufts University, a comprehensive costing protocol was designed for a cluster‐randomized field trial in Sierra Leone evaluating the comparative cost‐effectiveness of treating children under‐5 with MAM with one of four iso‐caloric supplementary foods: Super Cereal Plus with amylase, Corn‐Soy Blend Plus given with fortified vegetable oil (FVO), an innovative formulation called Corn‐Soy‐Whey Blend given with FVO, and Ready‐to‐Use‐Supplementary Food. The primary effectiveness outcome is recovery from MAM defined as reaching MUAC ≥ 12.5 cm within the 12‐week treatment period.To determine CE, we will assess costs using three “lenses”. The Program Costs lens includes non‐research costs incurred as part of this trial, including fixed, start‐up and ongoing costs of food products, transportation, storage, programming, beneficiaries, personnel, equipment, materials and facilities. Monetary costs and opportunity costs incurred within these components will be estimated using data collected from key informant interviews, direct observation, time tracking forms as well as accounting documents and inventory records. The Adjusted Program Costs lens will be the estimated costs for an NGO seeking to replicate this program in a similar setting. Interviews with local NGO partners and market surveys will be conducted to estimate the costs that an NGO would face. The third lens will conduct Policy Experiments to estimate costs that may be incurred when moving from the current limited setting to larger‐scale and longer interventions.Within each lens, we will calculate summary cost estimates per study arm including total program cost, cost per child treated, and cost per child‐month treated. We will link these cost estimates to the primary effectiveness measure, recovery from MAM, to derive the CE estimate of cost per recovered child and compare CE among the four study arms. Both absolute CE measures (e.g. cost per child recovered for each arm) and relative CE measures (e.g. incremental cost‐effectiveness ratio comparing each arm to a reference arm) will be calculated.Support or Funding InformationThis research is made possible by the generous support of the American people through the U.S. Agency for International Development (USAID) Office of Food for Peace of the Bureau for Democracy, Conflict and Humanitarian Assistance, and the World Food Programme under the terms of the Contract AID‐OAA‐C‐16‐00020, managed by Tufts University. The contents are the responsibility of Tufts University and its partners in the Food Aid Quality Review (FAQR) and do not necessarily reflect the views of USAID, the United States Government, or the World Food Programme.

Lipid-based Nutrient Supplements Do Not Affect Gut Bifidobacterium Microbiota in Malawian Infants: A Randomized Trial.

The aim of the study was to assess the effect of nutritional supplementation with lipid-based nutrient supplements (LNS) and corn-soy blend flour on Bifidobacterium and Staphylococcus aureus gut microbiota composition in Malawian infants. In addition, the microbiota changes over time were characterized in the study infants. Healthy 6-month-old Malawian infants were randomly assigned to 1 of 4 intervention schemes for a 6-month period. Infants in the control group were not provided with any supplementary food. Infants in other 3 groups received either micronutrient-fortified corn-soy blend, micronutrient-fortified LNS with milk protein base, or micronutrient-fortified LNS with soy protein base between 6 and 12 months of age. Fecal bifidobacteria and S aureus gut microbiota at 6 and 12 months of age were analyzed by quantitative real-time polymerase chain reaction method. There was no difference in change in bacterial prevalence or counts between the intervention groups during the 6-month study period. When looking at the total study population, higher counts of total bacteria (P = 0.028), Bifidobacterium genus (P = 0.027), B catenulatum (P = 0.031), and lower counts of B infantis (P < 0.001), B lactis (P < 0.001), B longum (P < 0.001), and S aureus (P < 0.001) were detected in the children's stools at 12 months rather than at 6 months of age. The dietary supplementation did not have an effect on the Bifidobacterium and S aureus microbiota composition of the study infants. The fecal bifidobacterial diversity of the infants, however, changed toward a more adult-like microbiota profile within the observed time.

Trial of ready-to-use supplemental food and corn-soy blend in pregnant Malawian women with moderate malnutrition: a randomized controlled clinical trial

Malnutrition during pregnancy in sub-Saharan Africa is associated with poor birth outcomes. This study compared maternal and offspring anthropometry for moderately malnourished pregnant women receiving ready-to-use supplemental food (RUSF), a fortified corn-soy blend (CSB+) with a daily multiple micronutrient antenatal supplement [United Nations International Multiple Micronutrient Preparation (UNIMMAP)], or standard of care comprising CSB+ and iron and folic acid (IFA). A single-blind randomized controlled clinical trial was conducted in southern Malawi among 1828 pregnant women with moderate malnutrition, defined as a midupper arm circumference (MUAC) ≥20.6 and ≤23.0 cm. Women received 1 of 3 dietary treatment regimens that provided ∼900 kcal/d and 33-36 g protein/d. Maternal and infant anthropometry were followed until the child was 3 mo old. Newborns had a mean length-for-age z score of -1.3 ± 1.2 and 22% were stunted at birth. Mothers receiving RUSF had the highest weight gain during supplementation (3.4 ± 2.6, 3.0 ± 2.2, and 3.2 ± 2.4 kg for the RUSF, CSB+ with UNIMMAP, and CSB+ with IFA groups, respectively; P = 0.03). Newborn birth weights and lengths were similar across intervention groups, but the incidence of newborns with a birth weight <2.4 kg (weight-for-age z score <-2) was higher in the CSB+ with UNIMMAP group than the other groups (17%, 18%, and 24% for the CSB+ with IFA, RUSF, and CSB+ with UNIMMAP groups, respectively; P = 0.02). At birth, HIV-exposed newborns had a similar length and weight as newborns without HIV exposure, but their head circumference was smaller (34.0 ± 1.5 and 34.3 ± 1.6 cm, respectively; P = 0.02). At 3 mo of age, HIV-exposed infants had smaller weights, lengths, and head and arm circumferences than infants without HIV exposure. RUSF improved maternal weight gain compared with CSB+ with UNIMMAP. The large amount of food given and the modest effect on linear growth in newborns suggests that stunting in utero is unlikely to be reduced by supplemental food alone. This trial was registered at clinicaltrials.gov as NCT02120599.

New formulations for fortified‐blended foods: the MFFAPP Tanzania efficacy trial

BackgroundFortified‐blended foods (FBFs) are micronutrient fortified, partially precooked blends of cereals and pulses that are the most commonly distributed micronutrient‐fortified food aid globally. Along with reformulation to improve FBF quality, it has been suggested that alternative commodities like sorghum and cowpea be considered for FBF formulation due to their drought tolerance, and local and regional availability in food aid receiving regions.ObjectivesOur primary objective was to determine whether newly formulated, extruded corn, soy, sorghum and cowpea‐based FBFs would result in equivalent or better hemoglobin and anemia outcomes compared with CSB+, the most commonly distributed FBF by the United States Agency for International Development. Secondary outcomes included evaluation of anthropometric and z‐score changes in height, weight, and mid‐upper arm circumference among groups.MethodsTwenty‐week, partially randomized cluster control trial located in the Mara region of Tanzania between February and July 2016. White sorghum cowpea (WSC‐1, WSC‐2), red sorghum‐cowpea (RSC), white sorghum‐soy (WSS), extruded corn‐soy blend (CSB14), or CSB+ were provided to 2186 children divided into two age groups (6–23 and 24–53 months) in seven clusters. A negative control received no FBF until study end. At 0, 10, and 20 weeks, health questionnaires, hemoglobin, and anthropometric measurements were collected. Anemia prevalence, height, weight, MUAC, WAZ, LAZ, and WHZ were calculated for each cluster at each time point. Differences in baseline socioeconomic factors, food intake and unadjusted outcomes were analyzed with SAS. Absolute anemia risk reduction was calculated for all FBFs and control compared to CSB+. Improvement and deterioration in HAZ and LAZ were also analyzed.ResultsNewly formulated FBFs were non‐inferior, or superior, to CSB+ in all outcome measures. At end line, there were significant absolute anemia risk reductions in all newly formulated FBFs compared to CSB+ in at least one age group; CSB14 and WSC‐1 anemia prevalence was significantly reduced in both age groups. In both groups, there were significant improvements in control, WSC‐2, and WSS consuming groups' HAZ scores from baseline to end line, and more children's HAZ scores improved than deteriorated compared to control in all FBFs groups.ConclusionResults suggest that sorghum and cowpea may be suitable alternatives to corn‐soy based FBFs. Socioeconomic and health factors will be analyzed in adjusted models for all outcomes.Support or Funding InformationUnited States Department of Agriculture (USDA) Foreign Agricultural Service under the Micronutrient Fortified Food Aid Products Pilot (MFFAPP) program, contract number #FFE‐621‐2012/033‐00.

Newly Formulated Fortified Blended Foods Result in Improved Protein Quality and Iron Bioavailability in Broiler Chickens

BackgroundCorn and soybean based fortified blended foods (FBFs) have been the primary food aid product provided by the United States. Sorghum and cowpea have been suggested as alternative FBF commodities because they are drought‐tolerant, can be locally grown in areas where food aid is provided, and are not genetically modified.ObjectiveTo determine protein quality and iron bioavailability of newly formulated sorghum, cowpea, soy, and corn‐based FBFs, compared with the current United States Agency for International Development corn and soy blend FBF, CSB+, in broiler chickens, which have been suggested to be a good model for iron bioavailability.MethodsNine groups of one‐day old broiler chicks (n = 10) consumed control chicken diet for one week before being randomized to consume prepared FBFs. The FBFs consisted of corn‐soy blend 14, white sorghum‐soy, white sorghum‐cowpea, white sorghum‐cowpea with soy protein isolate (instead of whey protein concentrate) extruded FBFs, two over‐extruded white sorghum‐cowpea FBFs (one with soy protein isolate), a non‐extruded sorghum‐cowpea FBF, CSB+, or a control chicken diet for 21 days. Results were analyzed by one‐way ANOVA with LSD test using SAS Studio 3.6.ResultsAll newly formulated FBFs resulted in significantly higher protein efficiency ratio and caloric efficiency than CSB+. Unlike CSB+, all newly formulated FBFs resulted in significantly increased hepatic iron levels compared to the control group. The white sorghum‐soy group had significantly increased body weight compared to all other FBFs, except the corn‐soy blend 14 group.ConclusionNewly formulated FBFs' higher protein quality and iron bioavailability compared to CSB+, suggests they are of higher nutritional quality. Further research is needed to identify the best new FBF formulations.Support or Funding InformationSupported by USDA‐MFFAPP.

Provision of preventive lipid-based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes

Provision of preventive lipid-based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes

Program changes are effective and cost‐effective in increasing the amount of oil used in preparing corn soy blend porridge for treatment of moderate acute malnutrition in Malawi

Corn Soy Blend (CSB) porridge is commonly prepared with oil for treatment of moderate acute malnutrition (MAM). A recent review recommended that 30 g of oil be used with 100 g of CSB to increase energy density and micronutrient absorption. This study assessed the effectiveness and cost‐effectiveness of program changes aimed at achieving that target oil:CSB ratio in prepared porridge. Caregivers of children in MAM supplementary feeding programs were assigned to three groups: a control group received monthly rations of 1 L oil, 8 kg CSB in bulk, and social and behavior change communication (SBCC); intervention groups received 2.6 L oil, 8 kg CSB provided either in bulk (Group 1) or four 2‐kg packages with printed messages (Group 2), and enhanced SBCC emphasizing the target oil:CSB ratio. Compared to the control, both intervention groups had higher mean added oil per 100 g CSB (18 g, p < 0.01, and 13 g, p= 0.04, higher in groups 1 and 2, respectively), and greater odds of meeting or exceeding the target ratio (28.4, p< 0.01, and 12.7, p= 0.02, in groups 1 and 2, respectively). Cost per caregiver reaching the target ratio was most favorable in Group 1 ($391 in Group 1, $527 in Group 2, and $1,666 in the control). Enhanced SBCC combined with increased oil ration resulted in increased use of oil in CSB porridge in a supplementary feeding program. Modified packaging did not improve effectiveness. However, both interventions were more cost‐effective than standard programming.

A Tale of Two Measures: Self‐Report and Lab‐Assessed Values in Amount of Oil Added to CSB Porridge Prepared by Caregivers of Children with Moderate Acute Malnutrition in Southern Malawi

ObjectiveTo compare self‐reported with laboratory‐assessed grams oil per 100 grams Corn‐Soy Blend (CSB) in porridge prepared by caregivers of beneficiary children receiving the food as treatment for moderate acute malnutritionMethodsThis was a secondary analysis of an effectiveness study conducted in Southern Malawi in 2014 assessing 2 interventions designed to increase the amount of oil added to CSB porridge prepared by caregivers, with a target of 30 g added oil per 100 g CSB. The Control Group received standard monthly ration: 1 L oil, 8 kg CSB in bulk. Intervention groups received 2.6 L oil, 8 kg CSB provided either in bulk (Group 1) or in 4 2‐kg packages with printed messages (Group 2), and social behavior change communication to meet added oil target (Groups 1 and 2). Data were collected through structured interviews with caregivers and lab analysis of porridge samples. Paired sample t‐tests compared oil added to CSB porridge (oil g per 100 g CSB) from self‐report and lab analysis within each study group (Wilcoxon when appropriate); ANOVA test assessed the mean difference (self‐report – lab value) between the study groups. Bland‐Altman plots were used to display the discrepancy between the 2 measures.ResultsA total of 584 caregivers participated: n=192 in Group 1; n=196 in Group 2; n=196 in the Control Group. The mean ± SDs of added oil (in g per 100 g CSB) from self‐report and lab analysis, respectively, were: 30±9 and 28±16 (Group 1), 30±9 and 25±15 (Group 2), 15±9 and 12±10 (Control). Estimated added oil from self‐report was significantly higher than lab analysis within each study group (p&lt;0.05 for all). Among the study groups, the mean differences between the measures of added oil (reported – lab) were not significant (p=0.56). A cluster of observations in the intervention groups had abnormally high fat content in lab assessed values; sensitivity analysis excluding this cluster showed mean lab values of added oil were reduced to 22±12 in both intervention groups, causing differences in self‐report versus lab to become significantly larger in the intervention groups compared to control (p=0.002). Bland‐Altman plots revealed a clear bias between the 2 measures in the intervention groups: participants tended to over‐report the amount of oil used, but as the lab‐assessed amount increased (i.e. as their behavior changed towards using more oil) there was a shift towards under‐reporting. This was less evident in the control group. Both self–report and lab‐assessed values showed the same relationships among the study groups, with Groups 1 and 2 having more added oil than the Control.ConclusionCaregivers in the intervention groups reported what they were instructed to do, regardless of whether lab analysis reflected the targeted behavior change. While self‐report was not as reliable as the lab measure, both conveyed that intervention group caregivers added more oil to porridge than the control group. Laboratory analysis was critical to determine the precise magnitude of added oil to CSB porridge.Support or Funding InformationThis research was performed under the extension of the Food Aid Quality Review (FAQR II) project implemented for the USAID Office of Food for Peace, under the terms of Cooperative Agreement AFP‐C‐00‐09‐00016‐00, by the Tufts University Friedman School of Nutrition Science and Policy.

Prenatal supplementation with Corn Soya Blend Plus reduces the risk of maternal anemia in late gestation and lowers the rate of preterm birth but does not significantly improve maternal weight gain and birth anthropometric measurements in rural Cambodian women: a randomized trial

Corn Soya Blend (CSB) Plus is a fortified dietary supplement used to help Cambodian women meet their nutritional requirements in pregnancy, although little is known about its ability to improve pregnancy outcomes. This study assessed the effect of prenatal CSB Plus supplementation on birth weight and secondary outcomes of low birth weight (<2500 g), small for gestational age, birth length and head circumference, preterm birth (<37 wk), maternal weight gain, and anemia at 24-28 wk, 30-32 wk, and 36-38 wk of gestation among rural Cambodian women. A cluster-randomized trial was conducted in 75 villages in Kampong Chhnang Province, in which 547 women received CSB Plus (treatment) during the first trimester until delivery or continued their normal diet (control) based on their village residence. All women received routine daily iron folic acid tablets and were treated with additional iron folic acid if they were anemic (hemoglobin <11 g/dL). Cluster-adjusted linear mixed-effect and logistic regression models were used to examine group differences. There was no significant difference in birth weight between the CSB Plus and control group (46 g; 95% CI: -31, 123 g; P = 0.24). Significant reductions were observed in preterm birth (OR = 0.33; 95% CI: 0.12, 0.89) and anemia at 36-38 wk (OR = 0.51; 95% CI: 0.34, 0.77). There were no significant differences in low birth weight, small for gestational age, birth length, head circumference, or maternal weight gain. A higher rate of fetal loss was observed in the treatment group (10.2% compared with 3.7%; P < 0.01). In Cambodian women, CSB Plus consumed during pregnancy did not significantly increase maternal weight gain or improve birth size but did reduce maternal anemia in late gestation and preterm birth in comparison with women consuming a normal diet. The unexpectedly higher rate of fetal loss in the treatment group is concerning and warrants further investigation. This trial was registered at clinicaltrials.gov as NCT01413776.

Short children with a low midupper arm circumference respond to food supplementation: an observational study from Burkina Faso

The management of children with moderate acute malnutrition (MAM) is based on food supplementation in outpatient programs. When midupper arm circumference (MUAC) is used as the sole admission criterion, it is common practice to exclude children with lengths <67 cm from treatment. The WHO calls for research to determine the treatment effect among children with MAM included by MUAC and aged ≥6 mo with lengths <67 cm. We hypothesized that among children given supplementary feeding based on an MUAC of 115-124 mm as the sole criterion, there would be no difference in growth rate between children <67 cm and those ≥67 cm in length at program admission. This was an observational study nested in a randomized trial that investigated the effectiveness of new formulations of corn-soy blend and lipid-based nutrient supplements. Children aged 6-23 mo were included if their MUAC was between 115 and 124 mm but with a weight-for-height z score (WHZ) ≥-2. This cohort was divided into 2 groups by length at admission: <67 cm ("short") and ≥67 cm ("long"). Linear mixed-effects models and regression models were used to compare gains in weight and MUAC while adjusting for intervention, season, sex, age, and site. Weight-gain velocity (expressed as g · kg(-1) · d(-1)) and MUAC-gain velocity (expressed as 0.01 mm · cm(-1) · d(-1)) were not different between short and long children. Weight-gain velocity was slightly higher in the shortest quartile of length (P = 0.03), whereas there was no effect modification by stunting across length quartiles (P = 0.32). We found no evidence of a difference in percentage of weight gain or weight-gain velocity during supplementary feeding in short or long children aged 6-23 mo. We recommend a policy change to include children <67 cm in supplementary feeding programs if their MUAC is between 115 and 124 mm and their WHZ is ≥-2. This could benefit millions of children currently excluded from supplementary feeding. This trial was registered at www.controlled-trials.com as ISRCTN42569496.

Gut microbiota in Malawian infants in a nutritional supplementation trial.

To examine whether two forms of lipid-based nutrient supplements (LNS) or a micronutrient-fortified corn-soya blend were associated with development of the gut microbiota in Malawian infants, to assess the microbiota profiles at the age of 6 and 18 months and to follow the changes during the 12-month period. This was a substudy of a 4-arm randomised controlled trial conducted in rural Malawi. Infants at the age of 6 months were randomised to receive no supplement during the primary follow-up period (control), 54 g/day of micronutrient-fortified LNS with milk protein base (milk LNS), 54 g/day of micronutrient-fortified LNS with soya protein base (soya LNS), or 71 g/day of micronutrient-fortified corn-soya blend for 12 months. Stool samples were collected at baseline (6 months) and end of trial (18 months). The 16S rRNA gene was amplified and subjected to multiplex sequencing. A total of 213 infants had paired microbiota data at 6 and 18 months of age. The Dirichlet-multinomial test showed no significant difference in microbiota profile between the four intervention groups at either age (each P > 0.10). Bifidobacterium longum was most abundant at both ages. Lactobacillus ruminis, Shigella and Salmonella were present. The abundance of Prevotella and Faecalibacterium increased with age (each P < 0.001), while Bifidobacteriaceae and Enterobacteriaceae exhibited significant decrease (each P < 0.001). Nutritional supplementation by LNS or corn-soya blend for twelve months did not affect the gut microbiota profile in the rural Malawian context.

Impact of lipid‐based nutrient supplements and corn–soy blend on energy and nutrient intake among moderately underweight 8–18‐month‐old children participating in a clinical trial

Nutrition interventions have an effect on growth, energy and nutrient intake, and development, but there are mixed reports on the effect of supplementation of energy-dense foods on dietary intake. This substudy aimed at assessing the effect of supplementation with corn-soy blend (CSB) or lipid-based nutrient supplement (LNS) on energy and nutrient intake in moderately underweight children participating in a clinical trial. A total of 188 children aged 8-18 months participated and received daily either 284 kcal from CSB or 220 kcal from LNS and no supplements (control). An interactive 24-h recall method was used to estimate energy and nutrient intakes in the groups. Total mean energy intake was 548 kcal, 551 kcal and 692 kcal in the control, CSB and LNS groups, respectively (P = 0.011). The mean (95% confidence interval) intake of energy and protein were 144 (37-250; P < 0.001) and 46 (1.5-7.6; P < 0.001) larger, respectively, in the LNS group than among the controls. No significant differences were observed between the control and CSB groups. Energy intake from non-supplement foods was significantly lower in the CSB group compared with the control group, but not in the LNS group, suggesting a lower displacement of non-supplement foods with LNS. Both CSB and LNS supplementation resulted in higher intakes of calcium, iron, zinc and vitamin C compared with controls (all P ≤ 0.001). This study indicates that LNS might be superior to CSB to supplement underweight children as it results in higher energy intake, but this requires confirmation in other settings.

Effect of complementary feeding with lipid‐based nutrient supplements and corn–soy blend on the incidence of stunting and linear growth among 6‐ to 18‐month‐old infants and children in ruralMalawi

Low nutritional value of complementary foods is associated with high incidence of childhood growth stunting in low-income countries. This study was done to test a hypothesis that dietary complementation with lipid-based nutrient supplements (LNS) promotes linear growth and reduces the incidence of severe stunting among at-risk infants. A total of 840 6-month-old healthy infants in rural Malawi were enrolled to a randomised assessor-blinded trial. The participants received 12-month supplementation with nothing, milk-LNS, soy-LNS, or corn-soy blend (CSB). Supplements provided micronutrients and approximately 280 kcal energy per day. Outcomes were incidence of severe and very severe stunting [length-for-age z-score, (LAZ) < -3.00 and <-3.50, respectively], and change in LAZ. The incidence of severe stunting was 11.8%, 8.2%, 9.1% and 15.5% (P = 0.098) and that of very severe stunting 7.4%, 2.9%, 8.0% and 6.4% (P = 0.138) in control, milk-LNS, soy-LNS and CSB groups, respectively. Between 9 and 12 months of age, the mean change in LAZ was -0.15, -0.02, -0.12 and -0.18 (P = 0.045) for control, milk-LNS, soy-LNS and CSB groups, respectively. There was no significant between-group difference in linear growth during other age-intervals. Although participants who received milk-LNS had the lowest incidence of severe and very severe stunting, the differences between the groups were smaller than expected. Thus, the results do not provide conclusive evidence on a causal association between the LNS supplementation and the lower incidence of stunting. Exploratory analyses suggest that provision of milk-LNS, but not soy-LNS promotes linear growth among at-risk infants mainly between 9 and 12 months of age.