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ORIGINAL ARTICLE
Open Access

Alternative Ready-To-Use Therapeutic Food Yields Less Recovery Than the Standard for Treating Acute Malnutrition in Children From Ghana

Kristin Kohlmann, Meghan Callaghan-Gillespie, Julia M. Gauglitz, Matilda Steiner-Asiedu, Kwesi Saalia, Carly Edwards and Mark J. Manary
Global Health: Science and Practice June 2019, 7(2):203-214; https://doi.org/10.9745/GHSP-D-19-00004
Kristin Kohlmann
aDepartment of Pediatrics, Washington University, St. Louis, MO, USA.
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Meghan Callaghan-Gillespie
aDepartment of Pediatrics, Washington University, St. Louis, MO, USA.
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Julia M. Gauglitz
bCollaborative Mass Spectrometry Innovation Center, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, USA.
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Matilda Steiner-Asiedu
cDepartment of Nutrition and Food Science, University of Ghana, Legon, Ghana.
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Kwesi Saalia
cDepartment of Nutrition and Food Science, University of Ghana, Legon, Ghana.
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Carly Edwards
dProject Peanut Butter, Kumasi, Ghana.
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Mark J. Manary
aDepartment of Pediatrics, Washington University, St. Louis, MO, USA.
eChildren's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA.
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  • For correspondence: manarymj@wustl.edu
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  • FIGURE 1
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    FIGURE 1

    CONSORT Flow Diagram

    Abbreviation: RUTF, ready-to-use therapeutic food.

  • FIGURE 2
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    FIGURE 2

    Comparison of Outcomes Between A-RUTF and S-RUTF Among Ghanaian Children With Severe Acute Malnutrition

    Abbreviations: A-RUTF, alternative ready-to-use therapeutic food; CI, confidence interval; S-RUTF, standard ready-to-use therapeutic food.

    A: Recovery rates for A-RUTF and S-RUTF compared with intention-to-treat analysis (Fisher's exact test, **P≤.01).

    B: Median rate of weight gain during the first 4 weeks of treatment for A-RUTF and S-RUTF; error bar indicates 95% CIs, *P≤.05.

    C: Median rate of MUAC gain during first 4 weeks of treatment for A-RUTF and S-RUTF; error bar indicates 95% CIs, Mann-Whitney U test, *P≤.05.

  • FIGURE 3
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    FIGURE 3

    Comparison of Recovery Rates Between A-RUTF and S-RUTF Among Ghanaian Children With Moderate Acute Malnutrition

    Abbreviations: A-RUTF, alternative ready-to-use therapeutic food; S-RUTF, standard ready-to-use therapeutic food.

    Intention-to-treat analysis used (Fisher's exact test, **P<.01).

Tables

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    TABLE 1.

    Comparison of Project Peanut Butter and Ghana Health Service Malnutrition Management Protocols in Brong Ahafo, Ghana

    Project Peanut Butter ProtocolGhana Health Service CMAM Protocol
    SAM enrollment criteriaMUAC <11.5 cm or WLZ < −3 SD
    Bilateral pitting edema
    MUAC <11.5 cm or WLZ below −3 SD
    Bilateral pitting edema
    MAM treatment
    MUAC ≥11.5 cm, <12.5 cm
    WLZ between −2 and −3 SD
    Enrolled and treated with RUTFIncreased nutrition counseling during CWC
    RUTF dosage150 kcal/kg/day for SAM
    75 kcal/kg/day for MAM
    200 kcal/kg/day for SAM
    Follow-upBiweeklyWeekly
    Graduation criteriaMUAC >12.4 cm, or WFL > −2 SD for 1 visit (2 weeks)MUAC >12.4 cm, 3 consecutive weeks
    No edema, 3 consecutive weeks
    Discharge criteria3 consecutive visits missed (6 weeks)3 consecutive weeks missed
    Maximum duration of treatment12 weeks16 weeks
    • Abbreviations: CMAM, community management of acute malnutrition; CWC, Child Welfare Clinics; MAM, moderate acute malnutrition; MUAC, mid-upper arm circumference; RUTF, ready-to-use food; SAM, severe acute malnutrition; WLZ, weight-for-length z score.

    • View popup
    TABLE 2.

    Ingredient and Nutrient Composition of Study Foodsa

    Ingredient/NutrientAlternative-RUTFStandard-RUTF
    Ingredient
    Cereal/grain, sorghum, g/100 g9.00—
    Legume, g/100 g
        Groundnut14.0027.00
        Soybean2.00—
    Milk, g/100 g
        Dry, nonfat, regular, without added vitamin A and vitamin D5.0025.00
        Whey protein concentrate 34%20.18—
    Oil, g/100 g
        Canola20.50—
        Palm—15.48
        Soybean—2.92
    Sugar, g/100 g25.0024.64
    Micronutrient and vitamin premix, g/100 g2.922.96
    Emulsifier, g/100 g1.402.00
    Nutrient
    Energy, kcal/100 g560559
    Protein, g/100 g14.515.8
    Lipids, g/100 g29.233.0
    n-6 fatty acids, g/100 g6.35.7
    n-3 fatty acids, g/100 g1.90.03
    • Abbreviation: RUTF, ready-to-use therapeutic food.

    • ↵a Both foods were a soft, brown, homogeneous paste with small granules perceptible to the tongue. They were packaged in identical, unlabeled metalized polyethylene terephthalate sachets with the only marking being a colored dot to indicate the type of RUTF.

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    TABLE 3.

    Characteristics of Study Children at Enrollment

    CharacteristicSevere Acute MalnutritionModerate Acute Malnutrition
    A-RUTF (n=199)S-RUTF (n=202)A-RUTF (n=443)S-RUTF (n=426)
    Male, No. (%)88 (44.2)94 (46.5)189 (42.7)163 (38.3)
    Age, months, mean (SD)14.38 (8.0)13.25 (7.6)15.79 (9.3)13.89 (7.2)
    Roof made of metal, No. (%)152 (76.4)153 (75.7)358 (80.8)346 (81.2)
    Animals sleep with child, No. (%)120 (60.3)127 (62.9)259 (58.5)275 (64.6)
    Electricity in home, No. (%)111 (55.8)113 (55.9)285 (65.2)267 (62.7)
    Clean water source, No. (%)83 (41.7)91 (45.0)206 (46.5)206 (48.4)
    Edema, No. (%)5 (2.5)3 (1.5)——
    Mid-upper arm circumference, cm, mean (SD)11.1 (0.9)11.0 (0.8)12.2 (0.4)12.2 (0.4)
    Weight, kg, mean (SD)6.28 (1.3)6.12 (1.2)7.34 (1.3)7.19 (1.2)
    Length, cm, mean (SD)69.8 (7.5)68.5 (6.6)72.4 (7.2)71.2 (6.6)
    Weight-for-length, z score, mean (SD)-3.16 (0.8)-3.07 (0.9)−2.08 (0.6)−1.97 (0.6)
    Length-for-age, z score, mean (SD)-2.56 (1.4)-2.64 (1.4)−1.98 (1.2)−1.80 (1.1)
    Weight-for-age, z score, mean (SD)-3.65 (0.9)-3.64 (1.0)−2.59 (0.7)−2.41 (0.9)
    • Abbreviations: A-RUTF, alternative ready-to-use therapeutic food; SD, standard deviation; S-RUTF, standard ready-to-use therapeutic food.

    • View popup
    TABLE 4.

    Comparison of Outcomes Between Assigned Treatment Food for Ghanaian Children With Severe Acute Malnutrition and Moderate Acute Malnutrition

    OutcomeAssigned A-RUTFAssigned S-RUTFP Valuea
    All study participantsn=642n=628
    Defaulted,b No. (%)116 (18.1)68 (10.8)<.001
    Died, No. (%)1 (0.2)4 (0.6).21
    Recovered, No. (%)516 (80.4)554 (88.2)<.001
    Remained malnourished, No. (%)9 (1.4)2 (0.3).06
    Rate of weight gain,c g/kg/d, mean (SD)1.88 (1.8)2.04 (2.0).31
    Rate of MUAC gain,c mm/d, mean (SD)0.16 (0.2)0.18 (0.2).04
    Participants with SAMn=199n=202
    Defaulted,b No. (%)60 (30.1)41 (20.3).03
    Died, No. (%)1 (0.5)3 (1.5).62
    Recovered, No. (%)130 (65.3)156 (77.2).01
    Remained malnourished, No. (%)8 (4.0)2 (1.0).06
    Rate of weight gain,c g/kg/d, mean (SD)2.40 (2.4)2.90 (2.6).04
    Rate of MUAC gain,c mm/d, mean (SD)0.20 (0.2)0.25 (0.2).047
    Participants with MAMn=443n=426
    Defaulted,b No. (%)56 (12.6)27 (6.3).002
    Died, No. (%)0 (0.0)1 (0.2)>.99
    Recovered, No. (%)386 (87.1)398 (93.4).003
    Remained malnourished, No. (%)1 (0.2)0 (0)>.99
    Rate of weight gain,c g/kg/d, mean (SD)1.66 (1.5)1.61 (1.5).62
    Rate of MUAC gain,c mm/d, mean (SD)0.13 (0.2)0.14 (0.2).29
    • Abbreviations: A-RUTF, alternative ready-to-use therapeutic food; MAM, moderate acute malnutrition; MUAC, mid-upper arm circumference; SAM, severe acute malnutrition; S-RUTF, standard ready-to-use therapeutic food.

    • ↵a Statistical comparisons made using Student's t test for continuous parameters and Fisher's exact test for categorical parameters.

    • ↵b Defaulters were treated as unrecovered in the calculation of recovery rates.

    • ↵c Calculated for the first 4 weeks of treatment.

    • View popup
    Table 5.

    Untargeted Metabolomic Assessment of A-RUTF and S-RUTF

    Metabolite ClassSpecific Metabolites Identified Only in Alternative RUTFPathobiological Significance
    Phosphatidylcholines1,2-Dipalmitoleoyl-sn-glycero-3-phosphocholine
    1-O-Hexadecyl-2-deoxy-2-thio-S-acetyl-sn-glyceryl-3 phosphorylcholine
    1-Stearoyl-2-myristoyl-sn-glycero-3-phosphocholine
    1-Palmitoyl-2-docosahexaenoyl-sn-glycero-3-phosphocholine
    PC(O-16:0/16:1)
    PC(18:1/20:2)
    PC(18:0/20:4)
    Palmitoyleicosapentaenoyl phosphatidylcholine
    Major component of most biological membranes, found in soy foods
    Phosphoethanolamines2-Arachidonoyl-1-palmitoyl-sn-glycero-3-phosphoethanolamine
    2-Linoleoyl-1-palmitoyl-sn-glycero-3-phosphoethanolamine
    Ethanolamine derivative of phospholipids
    Cholesterols4-Cholestenone
    7-Oxocholesterol
    4-Beta-hydroxycholesterol 4-acetate
    Oxidized forms of cholesterol, the likely source in RUTF is dairy products
    CeramidesCeramide (18:1/16:0)
    N-Palmitoyl-d-sphingosine
    A lipid component of cell membranes that enhances membrane rigidity and facilitates cell signaling through the membrane
    PhytosterolsCholestan-3-one
    Dihydrodaidzein
    Plant-derived sterols typically found in soy products
    IsoflavonesGenistin
    Glycitin
    6″-O-Acetylgenistin
    6″-O-Acetylglycitin
    Daidzin
    Isoflavonoid compounds almost entirely derived from legume species, interact with estrogen receptors
    VitaminsFlavine mononucleotideForm of riboflavin
    Glucosyl glucose(3beta,5xi,9xi,18xi,22beta)-22,25-Dihydroxyolean-12-en-3-yl 6-deoxy-alpha-l-mannopyranosyl-(1->2)-beta-d-xylopyranosyl-(1->2)-beta-d-glucopyranosiduronic acidA small carbohydrate component of cellulose
    Specific metabolites identified only in standard RUTF
    Phosphatidylcholines1-Palmitoyl-2-stearoyl-sn-glycero-3-phosphocholine
    1-Docosahexaenoyl-2-stearoyl-sn-glycero-3-phosphocholine
    1-Palmitoyl-2-oleoyl-sn-glycerol
    Major component of most biological membranes
    LipidsErucic acid
    Glycerol 1-myristate
    Minor components of edible oils; fatty acid and a monoglyceride
    Phenylpropranoids14-(Methylpentadecanoylamino)-3-phenylpropanoic acid
    3,5-Dimethoxy-4-hydroxycinnamic acid
    3-Hydroxy-4-methoxycinnamic acid
    Food additive made from cinnamic acid and a natural product in coffee and tea
    PhenylethylamidePhenylethylamide 359Flavoring agent, naturally occurs in peanut
    • Abbreviations: A-RUTF, alternative ready-to-use therapeutic food; S-RUTF, standard ready-to-use therapeutic food.

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Alternative Ready-To-Use Therapeutic Food Yields Less Recovery Than the Standard for Treating Acute Malnutrition in Children From Ghana
Kristin Kohlmann, Meghan Callaghan-Gillespie, Julia M. Gauglitz, Matilda Steiner-Asiedu, Kwesi Saalia, Carly Edwards, Mark J. Manary
Global Health: Science and Practice Jun 2019, 7 (2) 203-214; DOI: 10.9745/GHSP-D-19-00004

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Alternative Ready-To-Use Therapeutic Food Yields Less Recovery Than the Standard for Treating Acute Malnutrition in Children From Ghana
Kristin Kohlmann, Meghan Callaghan-Gillespie, Julia M. Gauglitz, Matilda Steiner-Asiedu, Kwesi Saalia, Carly Edwards, Mark J. Manary
Global Health: Science and Practice Jun 2019, 7 (2) 203-214; DOI: 10.9745/GHSP-D-19-00004
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