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Kerac M.,Valid International | Kerac M.,University College London | Bahwere P.,Valid International | Bahwere P.,Free University of Brussels | And 3 more authors.
PLoS ONE | Year: 2014

Background: Management of Severe Acute Malnutrition (SAM) plays a vital role in achieving global child survival targets. Effective treatment programmes are available but little is known about longer term outcomes following programme discharge. Methods: From July 2006 to March 2007, 1024 children (median age 21.5 months, IQR 15-32) contributed 1187 admission episodes to an inpatient-based SAM treatment centre in Blantyre, Malawi. Long term outcomes, were determined in a longitudinal cohort study, a year or more after initial programme discharge. We found information on 88%(899/1024). Results: In total, 42%(427/1024) children died during or after treatment. 25%(105/427) of deaths occurred after normal programme discharge, >90 days after admission. Mortality was greatest among HIV seropositive children: 62%(274/445). Other risk factors included age <12 months; severity of malnutrition at admission; and disability. In survivors, weight-forheight and weight-for-age improved but height-for-age remained low, mean -2.97 z-scores (SD 1.3). Conclusions: Although SAM mortality in this setting was unacceptably high, our findings offer important lessons for future programming, policy and research. First is the need for improved programme evaluation: most routine reporting systems would have missed late deaths and underestimated total mortality due to SAM. Second, a more holistic view of SAM is needed: while treatment will always focus on nutritional interventions, it is vital to also identify and manage underlying clinical conditions such as HIV and disability. Finally early identification and treatment of SAM should be emphasised: our results suggest that this could improve longer term as well as short term outcomes. As international policy and programming becomes increasingly focused on stunting and post-malnutrition chronic disease outcomes, SAM should not be forgotten. Proactive prevention and treatment services are essential, not only to reduce mortality in the short term but also because they have potential to impact on longer term morbidity, growth and development of survivors. © 2014 Kerac et al.


Dibari F.,Valid International | Dibari F.,University College London | Bahwere P.,Valid International | Le Gall I.,MSF France | And 4 more authors.
Public Health Nutrition | Year: 2012

Objective To understand factors affecting the compliance of malnourished, HIV-positive adults with a nutritional protocol using ready-to-use therapeutic food (RUTF; Plumpy'nut ®).Design Qualitative study using key informant interviews, focus group discussions and direct observations. Setting Ministry of Health HIV/programme supported by Médecins Sans Frontièrs (MSF) in Nyanza Province, Kenya. Subjects Adult patients (n 46) currently or previously affected by HIV-associated wasting and receiving anti-retroviral therapy, their caregivers (n 2) and MoH/MSF medical employees (n 8).Results Thirty-four out of forty-six patients were receiving RUTF (8360 kJ/d) at the time of the study and nineteen of them were wasted (BMI < 17 kg/m 2). Six of the thirteen wasted out-patients came to the clinic without a caregiver and were unable to carry their monthly provision (12 kg) of RUTF home because of physical frailty. Despite the patients' enthusiasm about their weight gain and rapid resumption of labour activities, the taste of the product, diet monotony and clinical conditions associated with HIV made it impossible for half of them to consume the daily prescription. Sharing the RUTF with other household members and mixing with other foods were common. Staff training did not include therapeutic dietetic counselling.Conclusions The level of reported compliance with the prescribed dose of RUTF was low. An improved approach to treating malnourished HIV-positive adults in limited resource contexts is needed and must consider strategies to support patients without a caregiver, development of therapeutic foods more suited to adult taste, specific dietetic training for health staff and the provision of liquid therapeutic foods for severely ill patients. © 2011 The Authors.


Bisimwa G.,Free University of Brussels | Owino V.O.,Valid Nutrition | Bahwere P.,Valid International | Bahwere P.,Free University of Brussels | And 4 more authors.
American Journal of Clinical Nutrition | Year: 2012

Background: Evidence of the effectiveness of lipid-based ready-touse complementary foods (RUCF) at improving linear growth among infants aged 6-12 mo is scarce, and further work is warranted. Objective: The objective was to assess the effectiveness of a fortified soybean-maize-sorghum RUCF paste compared with a fortified corn soy blend (UNIMIX) porridge on the prevalence of underweight and stunting among infants in South Kivu Province, Democratic Republic of Congo. Design: Infants were randomly assigned at 6 mo of age to receive either RUCF (n = 691) or UNIMIX (n = 692) for 6 mo. In addition to admission and monthly anthropometric measurements, hemoglobin, triglyceride, and cholesterol were measured at enrollment and at the end of the study. Results: No significant differences in the prevalence of stunting (RUCF: 48.6%; UNIMIX: 46.4%; P = 0.31), the prevalence of underweight (RUCF: 20.4%; UNIMIX: 18.2%; P = 0.42), or weight gain (RUCF: 1.2 ± 0.7 kg; UNIMIX: 1.3 ± 0.7 kg; P = 0.08) were found. A small but statistically significant difference in length gain (RUCF: 5.2 ± 2.0; UNIMIX: 5.4 ± 2.0; P = 0.03) was found. No significant differences in the concentrations of hemoglobin, serum triglyceride, and serum cholesterol were found between the 2 groups. Conclusion: No significant differences were found between the RUCF and UNIMIX in the reduction of the prevalence of stunting and underweight at 12 mo of age among rural Congolese infants. This trial was registered at controlled-trials.com as ISRCTN20267635. © 2012 American Society for Nutrition.


Owino V.O.,Valid Nutrition | Bahwere P.,Valid International | Bahwere P.,Free University of Brussels | Bisimwa G.,Free University of Brussels | And 2 more authors.
American Journal of Clinical Nutrition | Year: 2011

Background: Lipid-based ready-to-use foods are currently used for infant feeding, but their potential effect on breast-milk intake is not well documented. Objective: The objective was to assess the breast-milk intake of 9-10-mo-old infants given either a ready-to-use complementary food (RUCF) paste or a standard corn-soy blend (UNIMIX) porridge in South Kivu, Democratic Republic of Congo. Design: Infants were randomly assigned at 6 mo of age to receive either RUCF (n = 700) or UNIMIX (n = 700) for 6 mo. Breast-milk intake was measured at 9-10 mo in a subsample of 58 infants (29 from each group). Mothers received a dose of ≈30 g deuterium oxide. Predose and postdose saliva samples were collected from both mothers and infants over 2 wk. Breast-milk intake (g/d) was measured from saliva samples by using infrared spectroscopy. Results: Mean (±SD) breast-milk intake was not significantly (P = 0.69) different between the 2 groups: RUCF (705 ± 236 g/d) and UNIMIX (678 ± 285 g/d). Mean (±SD) nonmilk oral water intakes were 338.3 ± 251.1 and 336.4 ± 227.2 g/d for RUCF and UNIMIX, respectively (P = 0.98). Conclusions: No differences in breast-milk intake were observed between infants consuming either RUCF or UNIMIX. The deuterium-dose-to-the- mother dilution technique is an affordable technique that we recommend for periodic evaluation of breast-milk intake in resource-poor settings. This trial is registered at controlled-trials.com as ISRCTN20267635. © 2011 American Society for Nutrition.


The present study was aimed at evaluating whether white rice, brown rice, and rice flour consumption has any association with selected measures of dietary intake and nutritional status, including various variables of energy intake, major vitamin and mineral intakes, weigh status, blood pressure, cholesterol level, and serum folate level for adults 20 years and older. Data from the National Health and Nutrition Examination Survey (NHANES) 2007–2008 and the Food Commodity Intake Database were used. Rice consumers had a significantly higher energy intake, yet they had lower percentage calorie intake from fat and saturated fat. Rice consumers also had significantly higher intakes of a range of nutrients. Rice consumers had lower waist circumference, triceps skinfold, and were significantly more likely to have a body mass index less than or equal to 25. © , Copyright © Taylor & Francis Group, LLC.


Dibari F.,Valid International | Dibari F.,University College London | Bahwere P.,Valid International | Huerga H.,MSF France Kenya | And 4 more authors.
Nutrition | Year: 2013

Objective: To develop a method for determining the acceptability and safety of ready-to-use therapeutic foods (RUTF) before clinical trialing. Acceptability was defined using a combination of three consumption, nine safety, and six preference criteria. These were used to compare a soy/maize/sorghum RUTF (SMS-RUTFh), designed for the rehabilitation of human immunodeficiency virus/tuberculosis (HIV/TB) wasted adults, with a peanut-butter/milk-powder paste (P-RUTF; brand: Plumpy'nut) designed for pediatric treatment. Methods: A cross-over, randomized, controlled trial was conducted in Kenya. Ten days of repeated measures of product intake by 41 HIV/TB patients, >18 y old, body mass index (BMI) 18-24 kg·m-2, 250 g were offered daily under direct observation as a replacement lunch meal. Consumption, comorbidity, and preferences were recorded. Results: The study arms had similar age, sex, marital status, initial BMI, and middle upper-arm circumference. No carryover effect or serious adverse events were found. SMS-RUTFh energy intake was not statistically different from the control, when adjusted for BMI on day 1, and the presence of throat sores. General preference, taste, and sweetness scores were higher for SMS-RUTFh compared to the control (P < 0.05). Most consumption, safety, and preference criteria for SMS-RUTFh were satisfied except for the average number of days of nausea (0.16 versus 0.09 d) and vomiting (0.04 versus 0.02 d), which occurred with a higher frequency (P < 0.05). Conclusion: SMS-RUTFh appears to be acceptable and can be safely clinically trialed, if close monitoring of vomiting and nausea is included. The method reported here is a useful and feasible approach for testing the acceptability of ready-to-use foods in low income countries. © 2013 Elsevier Inc.


Owino V.O.,Valid Nutrition | Irena A.H.,Valid International | Dibari F.,Valid International | Collins S.,Valid International
Maternal and Child Nutrition | Year: 2014

Peanut milk-based ready-to-use therapeutic food (P-RUTF) primarily used to treat severe acute malnutrition at community setting is expensive. We developed an alternative milk-free soybean-maize-sorghum-based RUTF (SMS-RUTF) using locally grown ingredients that have the potential to support local economy and reduce the cost of RUTF. We describe the production process and results of acceptability of the new product. Acceptability and tolerance of SMS-RUTF was compared with P-RUTF among 45 children aged 4-11 years old based on a cross-over design. Each child consumed 250g RUTF for 10 days followed by a five-day washout period and a subsequent 10-day period on the second RUTF. The SMS-RUTF was as acceptable as the P-RUTF among normal children aged 4-11 years of age with no associated adverse effects. SMS-RUTF was stable for at least 12 months without detectable microbiological or chemical deterioration. The major challenge encountered in SMS-RUTF development was the difficulty to accurately determine key nutrient composition due to its high oil content. Use of diversified locally available ingredients to produce RUTF is feasible. The SMS-RUTF meets expected standards and is acceptable to children aged 4-11 months old. Effectiveness and cost-effectiveness of SMS-RUTF is required. © 2012 John Wiley & Sons Ltd.


Guerrero S.,Valid International | Myatt M.,University College London | Collins S.,Valid International
Disasters | Year: 2010

One of the most important elements behind the success of Community-based Therapeutic Care (CTC) programmes for the treatment of severe acute malnutrition has been their ability to achieve high levels of coverage. In CTC, coverage is measured using the Centric System Area Sampling (CSAS) method, which provides accurate and reliable estimates of programme coverage as well as information on the primary reasons for non-attendance. Another important feature of CTC programmes is their use of socio-cultural assessments to determine potential barriers to access and to develop context-specific responses. By analysing data on non-attendance provided by CSAS surveys, in conjunction with data from socio-cultural assessments, it is possible to identify common factors responsible for failures in programme coverage. This paper focuses on an analysis of data from 12 CTC programmes across five African countries. It pinpoints three common factors (distance to sites, community awareness of the programme, and the way in which rejections are handled at the sites) that, together, account for approximately 75 per cent of non-attendance. © 2010 The Author(s). Journal compilation © Overseas Development Institute, 2010.


Irena A.H.,Valid International | Mwambazi M.,University of Zambia | Mulenga V.,University of Zambia
Nutrition Journal | Year: 2011

Introduction. Mortality of children with Severe Acute Malnutrition (SAM) in inpatient set-ups in sub-Saharan Africa still remains unacceptably high. We investigated the prevalence and effect of diarrhea and HIV infection on inpatient treatment outcome of children with complicated SAM receiving treatment in inpatient units. Method. A cohort of 430 children aged 6-59 months old with complicated SAM admitted to Zambia University Teaching Hospital's stabilization centre from August to December 2009 were followed. Data on nutritional status, socio-demographic factors, and admission medical conditions were collected up on enrollment. T-test and chi-square tests were used to compare difference in mean or percentage values. Logistic regression was used to assess risk of mortality by admission characteristics. Results: Majority, 55.3% (238/430) were boys. The median age of the cohort was 17 months (inter-quartile range, IQR 12-22). Among the children, 68.9% (295/428) had edema at admission. The majority of the children, 67.3% (261/388), presented with diarrhea; 38.9% (162/420) tested HIV positive; and 40.5% (174/430) of the children died. The median Length of stay of the cohort was 9 days (IQR, 5-14 days); 30.6% (53/173) of the death occurred within 48 hours of admission. Children with diarrhea on admission had two and half times higher odds of mortality than those without diarrhea; Adjusted OR = 2.5 (95% CI 1.50-4.09, P < 0.001). The odds of mortality for children with HIV infection was higher than children without HIV infection; Adjusted OR = 1.6 (95% CI 0.99-2.48 P = 0.5). Conclusion: Diarrhea is a major cause of complication in children with severe acute malnutrition. Under the current standard management approach, diarrhea in children with SAM was found to increase their odds of death substantially irrespective of other factors. © 2011 Irena et al; licensee BioMed Central Ltd.


Bahwere P.,Valid International
Food and Nutrition Bulletin | Year: 2014

Natural and man-made disasters, including floods, droughts, earthquakes, and armed conflicts, create nutrition crises. Unfortunately, the frequency and severity of such disasters have been increasing since the beginning of the 20th century, and their contribution to the burden of acute malnutrition is increasing every year. However, their contribution to the burden of acute malnutrition is underrecognized due to the ways in which global statistics are built and causes of death are reported. Fortunately, the success of the current protocol for treatment of severe acute malnutrition (SAM) and the integrated approach to treatment has created a momentum allowing expanded coverage of treatment of SAM, especially in humanitarian emergency contexts. For this progress to be maintained and accelerated, changes in nutrition information systems at the national and global levels are needed, and the persisting barriers to the expansion and integration of treatment of SAM into routine health systems need to be removed. Emergency funding approaches and objectives have to include sustaining and amplifying the achievements of the short-term palliative interventions. Nutrition programs implemented in emergency contexts have the capacity to contribute to answering priority research questions, and this capacity should be more optimally utilized. © 2014, The Nevin Scrimshaw International Nutrition Foundation.

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