Saskia de Pee and Martin W. Bloem: Food and Nutrition Bulletin

Current and potential role of specially formulated
foods and food supplements for preventing

malnutrition among 6- to 23-month-old children
and for treating moderate malnutrition among
6- to 59-month-old children
Saskia de Pee and Martin W. Bloem
Abstract many antinutrients, no milk (important for growth),

suboptimal micronutrient content, high bulk, and high
Reducing child malnutrition requires nutritious food, viscosity. Thus, for feeding young or malnourished
breastfeeding, improved hygiene, health services, and children, fortified blended foods need to be improved
(prenatal) care. Poverty and food insecurity seriously or replaced. Based on success with ready-to-use thera-
constrain the accessibility of nutritious diets that have peutic foods (RUTFs) for treating severe acute mal-
high protein quality, adequate micronutrient content nutrition, modifying these recipes is also considered.
and bioavailability, macrominerals and essential fatty Commodities for reducing child malnutrition should
acids, low antinutrient content, and high nutrient be chosen on the basis of nutritional needs, program
density. Diets based largely on plant sources with few circumstances, availability of commodities, and likeli-
animal-source and fortified foods do not meet these hood of impact. Data are urgently required to compare
requirements and need to be improved by processing the impact of new or modified commodities with that
(dehulling, germinating, fermenting), fortification, and of current fortified blended foods and of RUTF devel-
adding animal-source foods, e.g., milk, or other specific oped for treating severe acute malnutrition.
nutrients. Options include using specially formulated
foods (fortified blended foods, commercial infant cere-
als, or ready-to-use foods [RUFs; pastes, compressed Key words: Child malnutrition, complementary food
bars, or biscuits]) or complementary food supplements supplements, corn–soy blend, fortified blended foods,
(micronutrient powders or powdered complementary micronutrient powder, ready-to-use foods, RUTF, sup-
food supplements containing micronutrients, protein, plementary feeding
amino acids, and/or enzymes or lipid-based nutrient
supplements (120 to 250 kcal/day), typically containing
milk powder, high-quality vegetable oil, peanut paste, Introduction
sugar, and micronutrients. Most supplementary feeding
programs for moderately malnourished children supply The treatment of malnutrition, as well as its preven-
fortified blended foods, such as corn–soy blend, with tion, among children under 5 years of age requires
oil and sugar, which have shortcomings, including too consumption of nutritious food, including exclusive
breastfeeding for the first 6 months of life, followed
by breastfeeding in combination with complemen-
Saskia de Pee is affiliated with the World Food Programme,
Rome, and the Friedman School of Nutrition Science and tary foods thereafter until at least 24 months of age; a
Policy, Tufts University, Boston, Massachusetts, USA. Martin hygienic environment (clean drinking water, sanitary
W. Bloem is affiliated with theWorld Food Programme, Rome; facilities); access to preventive (immunization, vitamin
the Friedman School of Nutrition Science and Policy, Tufts A supplementation, etc.) as well as curative health
University, Boston, Massachusetts, USA; and the Bloomberg
School of Public Health, Johns Hopkins University, Baltimore, services, and good prenatal care.
Maryland, USA. In this article, the focus is on possible options for
Please direct queries to the corresponding author: Saskia de providing a nutritious diet, realizing the constraints
Pee, Policy, Strategy and Programme Support Division, World faced by many people whose children are at risk for
Food Programme, Via Cesare Giulio, 68/70 Parco de’Medici, developing or confirmed to be suffering from moder-
Rome 00148, Italy; e-mail: depee.saskia@gmail.com.
This publication reflects the personal views of the authors ate malnutrition (stunting as well as wasting), such as
and does not necessarily represent the decisions or the poli- poverty and food insecurity. Although the nutrient
cies of the World Health Organization or of the World Food density requirements proposed by Golden [1] are
Programme. for moderately malnourished children, much of the
S434 Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University.
Specially formulated foods and food supplements S435
dietary recommendations and complementary food Such advice is characterized by emphasis on consump-
supplements proposed for improving dietary quality tion from all food groups (anywhere between four and
are also relevant for young children (6 to 23 months) at eight groups are distinguished), changing the kinds of
risk for developing moderate malnutrition, i.e., among foods chosen from these food groups (thus, for exam-
populations with a high prevalence of stunting among ple, to alternate plant and animal sources of protein),
children 2 to 5 years of age and wasting among those 6 frequent and responsive feeding, and ensuring good
to 59 months of age. Therefore, much of the discussion energy density [3–5]. The article by Ashworth and
in this article is applicable to young (6 to 23 months) Ferguson in this supplement [3] assesses whether and
and growth-faltering children as well as to moderately how nutrient requirements proposed for moderately
malnourished children (wasted children with weight- malnourished children can be met by selecting locally
for-height < –2 and ≥ –3 z-scores or stunted children available foods and examines the evidence for an
with height-for-age < –2 z-scores). impact of diets and programs based on promotion of
We will also cover a range of interventions, from locally available foods.
food-assistance programs for people who are wholly Table 1 shows the nutrient groups and active com-
dependent on food assistance (refugees, people affected pounds that are essential for good child growth and
by man-made or disaster-related emergencies) and development together with the main dietary sources of
populations requiring food assistance during lean or these nutrients and compounds and comments on the
bad harvest periods, to populations that are not typi- consumption of these foods. In summary, a relatively
cally food insecure but consume a relatively monoto- wide variety of foods is required, including breastmilk,
nous diet with too few good-quality foods to provide staples (for energy and some micronutrients), legumes
vulnerable groups with the required intake of specific or lentils (particularly for protein), animal-source foods
essential nutrients (such as micronutrients, macromin- (good sources of protein, minerals, and some vitamins),
erals, essential amino acids, and essential fatty acids). vegetables and fruits (for vitamins, minerals, and vita-
This article starts with a discussion of options for min C to enhance absorption of nonheme iron), oil
dietary improvement, modification possibilities for (for energy and essential fatty acids), and a source of
ready-to-use therapeutic foods (RUTFs), improvement iodine such as salt (but note that a high sodium intake
of fortified blended foods, and different kinds, roles, in moderately malnourished children is not desirable).
limitations, and applications of complementary food Table 2 shows the important characteristics of diets
supplements. These considerations are then compared for young malnourished children (adapted from the
with current practices in programs treating moderately article by Michaelsen et al. [2]) and considerations
wasted children as reported in response to a question- with regard to foods required to realize consumption
naire that was sent out by Anne Ashworth and Saskia of such diets.
de Pee between February and August 2008. This assess- However, as one respondent to the questionnaire on
ment of current practices is then followed by program- current programs (see below) said:
matic considerations for expansion of the use of new …very often the causes of malnutrition are attributable
food supplement products for preventing and treating to wide-scale food insecurity…. In such instances, there
moderate malnutrition among young children. is simply no choice of food at household level, lack of
This article complements the articles in this issue by variety and high market prices create inaccessibility to
Golden [1], Michaelsen et al. [2], and Ashworth and a diversity of foods, in addition to exhausted household
Ferguson [3], with Golden having established the nutri- assets with which to purchase or barter and as such,
ent requirements, Michaelsen et al. having reviewed the people are often reported to be living off a single staple….
value and limitations of specific foods and food groups, During such times, diet diversity cannot be promoted,
based on their content of nutrients and antinutrients, so education will focus on the importance of personal
hygiene and household sanitation, appropriate breast
and Ashworth and Ferguson having assessed the
feeding and timely complementary feeding practices.
adequacy of dietary recommendations for moderately
malnourished children using locally available foods in Where the diet consists largely of plant foods with
relatively food-secure but poor households. very few animal-source foods and fortified foods,*
as is the case for many children and their families in
developing countries, there are a number of issues to
Option 1. Local diet: Required food be addressed. As can be concluded from tables 1 and
groups and options for improving nutrient 2, plant foods, especially staples (maize, wheat, rice),
adequacy legumes, lentils, and vegetables, contain considerable
Among relatively food-secure populations (i.e., those

* Typical fortified foods that tend to be available in devel-
with adequate energy intake per capita), the primary oping-country markets are fortified flour, fortified noodles,
approach to prevent and treat malnutrition is by pro- fortified margarine, fortified milk (powder), and fortified
viding dietary advice about which foods to consume. complementary foods.
S436 S. de Pee and M.W. Bloem
TABLE 1. Essential nutrients and active compounds and their dietary sources, including recommended home processing
where applicable
Nutrients and active com-
pounds of concern Dietary sources Comments
Vitamins, plant origin Vegetables and fruits, grains Bioavailability (due to antinutrient content of plant foods)
as well as absolute quantity of foods to be consumed is of
concern
Minerals Animal-source foods and When largely relying on plant foods, intake has to be high
plant foods (can, for example, be increased by using a dried leaf
concentrate), and bioavailability has to be improved, par-
ticularly by reducing contents of phytate and polyphenols
and/or adding vitamin C. For example, bioavailability of
iron is much higher from meat than from vegetables (25%
vs. 2%–10%) [6]
Vitamins, animal origin Breastmilk, animal milk, No single animal-source food provides all the MNs that are
(especially vitamin B6, organ meat, red meat, required from animal-source foods in adequate amounts.a
vitamin B12, retinol) poultry, fish, eggs, butter Thus, a variety of animal-source foods is required
(retinol)
Iodine Seafood, including algae, The use of iodized salt contributes greatly to the prevention
and iodized salt of iodine-deficiency disorders (approximately 70% of the
world’s households are covered)
Proteins, to result in a diet Soybeans, peanuts, legumes, Same comment as for vitamins from animal-source foods.
with high PDCAAS score breastmilk, animal milk, A mixture of foods is required to ensure adequate intake
organ meat, red meat, of all essential amino acids. Plant sources of protein also
poultry, fish, eggs have a relatively high content of antinutrients, which
affects absorption of minerals
Essential fatty acids, espe- Fatty fish or their products, Only fatty fish and a few oils have a favorable fatty acid
cially those with a favora- soybean oil, rapeseed oil profile, and these are not generally consumed in large
ble n-6:n-3 ratio (~ 6) (also known as canola oil) amounts in most developing-country diets
Growth factor from milkb Dairy products (breastmilk, Skimmed-milk powder when reconstituted with water is
animal milk, yogurt, not appropriate for young children because of the lack
cheese) of fat. Full-cream milk powder is usually skimmed-milk
powder to which powdered vegetable fat has been added.
When reconstituted with clean, safe water, this is good
milk for children. Cheese is not recommended for feeding
young malnourished children [2]
Phytase, α-amylase Present in grains themselves, These processes require modification of food processing as
released when germinating well as use of whole grains rather than purchased flour.
(requires soaking for 24 h), Also, the impact of these food-processing technologies on
malting (i.e., when germi- improving mineral bioavailability and MN status has not
nating or adding malt), or been shown to be substantial enough to markedly reduce
fermenting MN deficiencies
MN, micronutrient; PDCAAS, protein digestibility-corrected amino acid score
a. Even breastmilk is a poor source of certain micronutrients. When a child is born with adequate stores, these stores, in combination with
exclusive breastmilk consumption for the first 6 months of life from an adequately nourished mother, will ensure that all needs are met.
Introducing complementary foods early reduces the bioavailability of some micronutrients, particularly minerals, from breastmilk and
could thus increase the risk of deficiencies when the complementary foods are not of appropriate composition. Children born prematurely
or with low birthweight need micronutrient supplements, in addition to exclusive breastmilk consumption, from approximately 2 months
of age.
b. The presence of factors in milk (peptides or non-phytate-bound phosphorus that promote growth is very likely but not fully proven as yet) [7, 8].
amounts of antinutrients (such as phytate, polyphenols, should be increased in order to compensate for the
lectins, and inhibitors of protease and α-amylase), lower bioavailability, or both. Furthermore, oil or sugar
which reduce mineral bioavailability and interfere should be added to increase energy density.
with digestion of specific compounds. Therefore, spe- Figure 1 summarizes options for improving nutri-
cial processing to reduce the content of antinutrients tional quality of a largely plant-source based diet
should be used, the content of vitamins and minerals when adding animal source foods and fortified foods
TABLE 2. Important characteristics of diets appropriate for young children to prevent and treat moderate malnutrition and
considerations
Important characteristicsa Considerations
High content of MNs, especially type II Calcium, phosphorus, magnesium, and potassium are nutrients that are
nutrients not contained in most MN formulations such as MN powders and are
required in larger amounts (hundreds of milligrams instead of < 10 mg)
High energy density Fat and sugar increase energy content with minimum increase of volume,
but adequate MN content/1,000 kcal of diet or meal needs to be ensured
Adequate protein content Requires mixture of legumes, lentils, and animal-source foods
High protein quality and availability
Low content of antinutrients Requires processing of staples, legumes, and lentils, industrially or at
household level
Adequate fat content Requires consumption of 30–40 energy % from fat contributed by foods
Appropriate fat quality, especially n-3/n-6 that have the right fatty acid composition — i.e., fatty fish or its prod-
PUFA content ucts (fish oil), or soybean, rapeseed, or canola oil
Acceptability: taste, texture, and cultural As much as possible, use locally available foods
acceptability
Easy to prepare The processing of plant foods to reduce antinutrient content should be
done industrially, where (especially urban) populations have good
access to such foods, because these are time-consuming and more and
more people are switching to use of convenient-to-prepare foods
Affordable Poverty is the main reason why many children lack an adequate amount
of animal-source and fortified foods in their diet
Affordable, fortified, processed foods as well as subsidized and for-free
distribution options need to be developed
Low risk of contamination Food-production and food-processing standards need to ensure low risks
of microbes, toxins, and contaminants
MN, micronutrient; PUFA, polyunsaturated fatty acid
a. Source: adapted from Michaelsen et al. [2].
in adequate amounts is not feasible, due to cost or malnutrition and increased understanding of what
availability issues. The options are divided into proce- nutrients and foods are required has also stimulated
dures that can be performed at home and those that interest and research and development efforts on the
are performed during industrial processing of foods. part of food manufacturers to process foods and pro-
Home procedures consist of processing and prepara- duce active ingredients for inclusion in special foods or
tion practices using only locally available, unprocessed for use in food preparation.
foods (germination, soaking, or fermenting to reduce
antinutrient contents and increase bioavailability, as
well as preservation of plant-source foods to increase Option 2. Modifying RUTFs for maximizing
intake of the micronutrients they can provide) or addi- catch-up growth among moderately
tion of those nutrients that are lacking through the malnourished children
use of complementary food supplements (i.e., home
fortification or point-of-use fortification). We now move from populations with food security but
Home-fortification options are discussed in greater limited access to quality foods to populations facing
detail below (Option 4: Complementary Food Sup- food insecurity and a high prevalence of child malnutri-
plements). Very little information is available on the tion, including severe wasting. It is in these populations
effectiveness of home-processing steps to reduce that RUTFs for treatment of children suffering from
antinutrient content for increasing mineral bioavail- severe acute malnutrition used in Community-Based
ability (which has been the main focus) [2, 9]. For Management of Severe Acute Malnutrition (CMAM)
industrial processes, including the use of enzymes, programs are increasingly making a difference to child
more information is available about their impact survival [13–16], and the question has arisen about what
[10–12], but none has been implemented at scale for foods to provide to moderately malnourished children.
human consumption, for various reasons. However, Children suffering from severe acute malnutrition
the recent increase of commitment to reducing child who are being rehabilitated go through a phase of
moderate malnutrition before reaching the discharge impact on linear growth, weight gain, and length
criteria of having gained adequate weight. Thus, RUTF of stay in the program among moderately wasted
provides all the nutrients required to promote growth children.
and health among children with severe acute malnutri- » Project Peanut Butter in Malawi produces a peanut/
tion and could therefore also, in principle, be consid- soybean paste from 25% whole roasted soybean (not
ered for treating moderately malnourished children. dehulled), 20% soybean oil, 26% peanut paste, 27%
In fact, its effectiveness for such use has been shown sugar, and 2% micronutrients (providing 1 RDA per
in a study in Malawi [17] as well as in a program in daily dose of 125 g). This product was compared with
Niger [18]. fortified blended food with additional fish powder,
However, RUTF probably provides nutrients in and no difference in linear growth was observed [21].
excess of what moderately malnourished children need, The absence of milk in the spread and the addition
and providing RUTF is not realistic for the vast major- of fish powder to the fortified blended food may
ity of identified children with moderate malnutrition, explain this absence of difference. Studies are also
due to the limited production capacity of this special being done with spreads that include milk powder
product,* ** the cost of the product, and the accept- comparing these spreads with fortified blended food
ability of the product where peanuts (an important (Likuni Phala). A recent study suggests that such a
ingredient) are not commonly consumed. Because of spread (at 25 or 50 g/day) has a greater impact than
this, efforts are being undertaken to modify the RUTF fortified blended food on severe stunting but not on
recipe so that costs are lower and more locally available weight gain [22]. However, another study that com-
ingredients are used. Figure 2 illustrates some of the pared milk/peanut spread, soybean/peanut spread,
options that can be considered when trying to modify and corn–soy blend found that recovery from mod-
the RUTF recipe. When just the nutrient content of erate wasting was higher in both groups receiving
RUTF is considered, quite a number of options exist for spreads than in the group receiving corn–soy blend
exchange of ingredients. However, when antinutrient (80% vs. 72% recovery) [23].
content, palatability, processing, storage, and packaging » Indian RUFC (Ready-to-Use Food for Children) has
are also considered, the options become more limited. been developed by WFP India and includes chick-
Four products for moderately malnourished children peas, rice flour, a higher amount of oil to replace
that are basically modifications of the RUTF recipe peanuts, and less skimmed-milk powder to reduce
have been identified so far, as follows: costs. Because chickpeas contain more antinutrients
» Supplementary Plumpy produced by Nutriset, than peanuts and because the milk content has been
France. In this product, the skimmed-milk powder reduced from 30% in RUTF to 10% in Indian RUFC,
of RUTF (Plumpy’Nut) has been replaced with whey the impact on growth and micronutrient status
and soy protein isolates*** to reduce costs (see tables of moderately malnourished children needs to be
3 and 4, last categories of products). Otherwise, the assessed.
ingredients and nutrient contents are the same as » A baked biscuit has been developed by a consortium
those of RUTF. The product is being used in a few of German and Indonesian universities in collabo-
programs and in operational studies that assess its ration with Church World Service that consists of
wheat flour, peanut paste, soybeans, oil, sugar, and
* The anticipated production capacity of ready-to-use food micronutrient premix and is locally produced in
(RUF) by the Plumpy’field Network of Nutriset, the main Indonesia. This product also has a higher antinutrient
producers of RUTF, by the end of 2010 is 63,800 metric tons, content than RUTF because of the inclusion of wheat
[Mamane Zeilani, Scaling up Production of RUF, Interna-
tional Workshop on the Integration of CMAM. FANTA/AED/ flour and soybeans and probably has less impact
Washington. 28-30 April 2008, Washington, DC (http://www. on linear growth because of the absence of milk.
fantaproject.org/downloads/pdfs/D3.S8.Zeilani.pdf], which Although the last three products are likely to be
is sufficient to treat 5.3 million of the 19 million children less effective than RUTF, they are presumably better
under 5 years of age suffering from severe acute malnutrition
worldwide. Of the total anticipated production, 77% will be than fortified blended food, the main product that is
produced in France and the remaining 23% in 10 countries currently provided to children with moderate acute
across Central America, Africa, and the Middle East (300 to malnourishment (see sections below on Current Pro-
3,000 metric tons/year at each location). The products will grams for Moderately Malnourished Children and
include RUTF (Plumpy’Nut) and its related RUF products Ready-to-Use Foods vs. To-Be-Prepared Foods: Storage
(Supplementary Plumpy, Plumpy’Doz, and Nutributter).
By the end of 2011, production capacity will have reached and Preparation).
100,000 metric tons/year (Mamane Zeilani, personal com-
munication, September 2008).
** At present (December 2008), manufacturers of RUF Option 3. Fortified blended foods: Current
include Compact, Hilina, Nutriset, Project Peanut Butter, STA,
and Valid Nutrition. composition and improvement options
*** Earlier versions of Supplementary Plumpy had a some-
what different formulation. Fortified blended foods, such as corn–soy blend and
Local diet: Issues Modification options

Not enough of Home fortification to correct too low nutrient intake
• MNs (cause: low intake • Add MNs (MN powder, lipid-based nutrient supplement, MN-fortified protein powder
of animal-source and or dried leaf concentrate [but has limited content of vitamins found in animal-source
fortified foods and low foods])
bioavailability) • Add n-3 PUFAs (soybean oil [alpha-linolenic acid or ALA], fish oil [docosahexae-
• n-3 PUFAs noic acid or DHA], separate or added to home fortificant such as lipid-based nutrient
• Essential amino acids supplements)
• Add protein extract or add amino acids, such as lysine, to home fortificant (MN-fortified
protein powder or lipid-based nutrient supplement)
Processing of food — at home Adding enzymes, when industrially
• Soaking, germination, malting; requires processing food or at home, to reduce
whole grain (i.e., not applicable to flour) and
phytate content, by
time • Soaking fortified blended food ingre-
• Fermentation; specific practice for specific dients together with phytase, before
foods, not too easy to introduce extrusion cooking and drying; requires
equipment (conditioner and dryer)
Too much of Processing of food — industrial • Adding phytase to the processed prod-
• Phytate (binding minerals, • Roasting, milling, extrusion cooking are uct (note: needs time to act once food
including phosphorus) normally done but do not have enough has been prepared)
• Other antinutrients such impact on phytate content • Adding phytase to prepared product
as polyphenols, trypsin • Dehulling, degerming; requires specific (i.e., home fortification)
inhibitors equipment and results in up to 25%–35% of Note: Last two options require approval
product being discarded/requiring alterna- for young human use and a different
tive use (animal feed?) and cost implications phytase because of different temperature
• Malting (as occurs in germination) pro- and pH (see also footnote to fig. 3).
duces phytase and α-amylase, which reduces • Using germinated flour for making por-
phytate content and converts starch into ridge, as it will then be less thick and
sugars. Using germinated flour for porridge have less phytate
Other issues • Adding malt to the prepared product
• Low energy density in also makes it less thick so that children can
consume more (home fortification) to reduce viscosity
watery porridges and phytate content
• Bulk and viscosity are lim- Note: The latter two processes are not nor-
iting intake mally done
Increasing energy density
• Adding oil and sugar will increase energy density without increasing volume very much.
However, sugar should be added in limited amounts, and adequate micronutrient density
(/1,000 kcal) should be ensured
FIG. 1. Options to modify the currently prevailing local diet, largely consisting of plant foods, to treat moderate malnutri-
tion among children under 5 years of age or prevent it among young children (6–23 mo) where intake of animal-source and
fortified foods is limited due to access (affordability and availability) constraints. MN, micronutrient; PUFA, polyunsaturated
fatty acid
wheat–soy blend, have been provided as one of the only programs* to be provided to moderately malnourished
fortified food-assistance commodities among many dif- children as well as other vulnerable groups (pregnant
ferent populations, and for a wide range of purposes, for and lactating women and people chronically ill with
the past 30 years or more. They consist of 20% to 25% HIV/AIDS or tuberculosis). In 2007, WFP distributed
soybeans, 75% to 80% corn or wheat, and a micronutri- 242,000 metric tons of fortified blended foods, includ-
ent premix. Because of the protein content and quality ing 192,000 metric tons of corn–soy blend, to specific
(total protein digestibility-corrected amino acid score groups as well as to general populations because of the
[PDCAAS] of corn–soy blend: 65%) from the soybeans micronutrient and protein contents.
and the additional micronutrients, fortified blended
foods have been regarded as being of reasonably good * Items included in the food basket used in food-assistance
nutritional value for limited cost and are being produced programs typically include staples (whole grains of rice,
in more than 20 countries around the globe. Fortified wheat, and/or corn, or flour in the case of wheat and corn;
blended foods also became the products of choice from flour has a shorter shelf-life than whole grains but can, and
should, be fortified), pulses (grams, lentils), cooking oil (forti-
the few nonperishable food items used in food-assistance fied with vitamin A), iodized salt, and fortified blended foods
(the main source of micronutrients unless fortified flour is
part of the food basket).
RUTF Steps to be explored for reducing costs and increasing local production
Positive Negative Modify from… …to, options Comments/drawbacks
• Shown to promote • Production capac- • 30% full-fat milk • Lower the milk • Minimum milk content is
growth very well ity not enough to powder content unknown
• Can be safely also treat moderate • 25% ground • Replace milk • Whey availability is linked to
stored and used in acute malnutrition peanuts powder with whey cheese production
communities and • Costs of ingredients • 15% soybean or concentrate • If milk contains growth
households are high, especially rapeseed/canola • Use soy protein factor, soy protein is
milk oil isolates (provided disadvantageous
• Peanut taste is not • 28% sugar that phytate con- • Protein content of lentils
familiar in certain (lactoserum, tent is lower) and beans is comparable to
parts of the world maltodextrin) • Use other leg- that of soybeans and peanuts
(e.g., South Asia), • 2% vitamins and umes, such as (20–30 g/100 g vs. 35 and
and in those places minerals, includ- beans, peas, or 23g/100 g, respectively), but
peanut availability is ing macromin- lentils, instead of they contain very little fat
also limited erals (type II peanuts (< 1 g/100 g vs. 18 and 45
nutrients) • When replacing g/100g, respectively) and
peanuts, their oil have relatively high amounts
content needs to of phytate and other antinu-
be compensated trients. Thus with how
for to reduce antinutrients,
enzymes?
• Texture, consistency, and
homogeneity to be adapted
FIG. 2. Steps to be explored for the development of an effective ready-to-use supplementary food of lower cost than ready-
to-use therapeutic food (RUTF) for moderately malnourished children
However, fortified blended foods are not well adapted Figure 3 summarizes the advantages and disadvan-
to meet the nutritional needs of young or moderately tages of corn–soy blend and other fortified blended
malnourished children, for several reasons [24–27]: foods when provided to young moderately malnour-
» They do not contain all the required nutrients in ished children, as well as options that are or may be
adequate amounts; considered for improvement. The options for improv-
» They contain a relatively large amount of antinutri- ing the nutritional quality range from modifica-
ents and fibers, especially when prepared from non- tions that are relatively easy to implement (changing
dehulled soybeans and nondegermed, nondehulled micronutrient premix, adding milk powder, dehulling
maize or wheat (see below); soybeans) to those that require substantial adjustments
» They do not provide enough energy per serving and to the production process (degerming maize, adding
are bulky; more oil during production, exploring use of phytase
» The overall fat content and essential fatty acid levels during production).
are low; To limit the costs of improving corn–soy blend,
» They contain no milk powder, which increasingly some of the improvements could be applied to fortified
appears to be important for linear growth of young blended foods used for young malnourished children
malnourished children [7, 8]. but not necessarily to fortified blended foods used
The issue of too low energy density has been partly for other vulnerable groups (pregnant and lactating
addressed in supplementary feeding programs by women, people suffering from HIV/AIDS or tubercu-
providing the corn–soy blend (or wheat–soy blend) losis). For practical reasons, however, the number of
together with oil and sugar (commonly reported different varieties of fortified blended food used in an
weight-based ratio, 10:1:1; see program section, ‘Cur- operation should be limited (preferably to not more
rent programs for moderately malnourished chil- than two) in order not to confuse program implement-
dren’, below for more information on ratios used). ers and beneficiaries with different, but very similar,
Sometimes these ingredients are mixed together in products for different target groups that all have to be
the feeding or health center before distribution; other distributed and prepared separately.
times they are provided alongside corn–soy blend to The three main buyers and distributors of corn–soy
be mixed at home. Unfortunately, very little is known blend are the World Food Programme (WFP), UNICEF,
about the preparation and consumption of corn–soy and the US Agency for International Development
blend at home, both by the malnourished child and by (USAID). The characteristics of the products they
his or her family members. purchase are described below.
TABLE 3. Classification of complementary food supplements

Kind of product Nutrients and active Most appropriate
(examples) substances contained Ingredients used Impact shown or expected target groups
MN powders (Sprinkles, MNs (type I and zinc) MNs and carrier Yes, on nutritional anemia Those with MN
MixMe)a (maltodextrin or Assumed to have impact deficiencies; not
rice flour) on other MN deficien- very effective for
cies as well promoting linear
growth
Powdered complemen- MNs, some with mac- MNs, soy protein Formulation using whole- Those at risk for
tary food supplements, rominerals (i.e., type concentrate or fat soybean flour with 6 faltering linear
consisting of protein II nutrients), high- processed whole- mg iron as NaFeEDTA,b growth (6–24 mo)
and/or specific amino quality protein, or fat soybean flour impact shown on Impact on growth
acids and MNs (Ying limiting amino acids (also contains anemia and linear remains to be
yang Bao, TopNutri) essential fatty growth proven
acids), additional Providing several nutri-
amino acids ents essential for linear
(lysine) for some growth
Impact depends on bio-
availability of vitamins
and minerals and should
possibly be enhanced
with dairy protein and
essential fatty acids
Powdered complemen- MNs, macrominer- MNs, macromin- Impact not yet shown Those at risk for
tary food supplements, als for some (i.e., erals (calcium, Fortificants should impact faltering linear
consisting of protein type II nutrients), potassium, mag- MN deficiencies, type growth (6–24 mo)
and/or specific amino high-quality protein nesium?), lysine, II nutrients, and lysine Impact to be
acids, enzymes, and or limiting amino malt to impact growth, and confirmed
MNs (MixMe Plus)c acids, enzymes for reduced viscosity to
malting or phytate increase energy intake
destruction Note: contains no dairy
protein or essential fatty
acids
Lipid-based nutrient MNs, macrominerals, Nutributter: Yes, study from Ghana Those at risk for
supplement ≤ 20 g, ~ dairy protein, essen- Peanut paste, showed impact on MN faltering linear
108 kcal (Nutributter) tial fatty acids (n-3 sugar, vegetable deficiencies, linear growth (6–24 mo)
PUFAs) fat, skimmed- growth, motor develop- Appears to be most
milk powder, ment [19, 20] comprehensive
whey powder, complementary
MNs, malto- food supplement
dextrin, cocoa, to make up for
lecithin gap of essential
nutrients in com-
plementary foods,
but does not com-
pensate for low
energy intake nor
counteract impact
of antinutrients
consumed from
other foods.
continued
TABLE 3. Classification of complementary food supplements (continued)

Kind of product Nutrients and active Most appropriate
(examples) substances contained Ingredients used Impact shown or expected target groups
Good-quality comple- MNs, macrominerals, Typical commer- Impact not studied Those at risk for
mentary food to be high-quality protein, cially available More impact expected on faltering linear
prepared using boiled carbohydrates, veg- porridges, made growth as well as MN growth (6-24 mo)
water, 30 g powder etable fat from skimmed- status from porridges Impact to be
with < 120 mL water milk powder or containing milk powder confirmed
provides ~ 120 kcal soy protein, veg- rather than soy protein
etable fat, rice/ MN content varies widely
corn/wheat/oats,
sugar, MNs
Lipid-based nutrient MNs, macrominerals, Plumpy’Doz: Impact of Plumpy’Doz Those at risk for
supplements ≤ 50 g, high-quality protein, Peanut currently being studied faltering linear
i.e., high-quality nutri- high-quality oil with paste, veg- Composition is based on growth and mor-
ent and energy sup- good n-6:n-3 fatty etable fat, sugar, RUTF (Plumpy’Nut), bidity during
plement, ~ 250 kcal acid ratio, energy skimmed-milk but consumed in small highly food-inse-
(Plumpy’Doz, Indian largely from oil and powder, whey amount added to daily cure periods
RUFC) protein powder, MNs, diet
maltodextrin Question: Are all nutrient
Indian RUFC: needs met and antinu-
Chickpeas, trient effects of other
soybean oil, foods overcome?
sugar, rice flour, Indian RUFC composi-
skimmed-milk tion and production
powder, MNs, processes being final-
soy lecithin ized, subsequently to be
tested
Lipid-based nutrient MNs, macrominerals, Plumpy’Nut: Impact of Plumpy’Nut Those suffering
supplements ≤ 100 g, high-quality protein, Peanut paste, (or other RUTFs) on from moderate
i.e., high-quality nutri- high-quality oil with sugar, vegetable growth and MN status acute malnu-
ent and energy sup- good n-6:n-3 fatty fat, skimmed- has been shown among trition, i.e., in
plement, ~ 500 kcal acid ratio, energy milk powder, children suffering from targeted supple-
(Plumpy Nut, Sup- largely from oil and whey powder, severe acute malnutri- mentary feeding
plementary Plumpy, protein maltodextrin, tion who progressed programs, or for
Indian RUFCd) MNs, cocoa, through moderate acute blanket supple-
Note: Compressed bars lecithin malnutrition stage to mentary feeding
and biscuits (BP100) Supplementary normalcy of young children
can also be included in Plumpy: Note that these children in highly food-
this category Peanut paste, received no other food insecure periods
sugar, vegetable than RUTF and breast or areas
fat, whey, soy milk, if applicable,
protein isolates, during recovery
maltodextrin, Impact of Supplementary
cocoa, MNs, Plumpy currently being
lecithin studied
Indian RUFC: Indian RUFC composi-
Chickpeas, tion and production
soybean oil, processes being final-
sugar, rice flour, ized, subsequently to be
skimmed-milk tested
powder, MNs,
soy lecithin
MN, micronutrient; PUFA, polyunsaturated fatty acid; RUFC, ready-to-use food for children; RUTF, ready-to-use therapeutic food
a. Moringa oleifera leaf powder could also be considered a micronutrient supplement, but because its composition, including levels of antinu-
trients and toxic substances, is not well known, it is not included in this table.
b. Note that the Joint FAO/WHO Expert Committee on Food Additives (JECFA) norms for EDTA intake translate to a maximum of 2.5 mg
iron from NaFeEDTA for an 8-kg child.
c. Power Flour consists of barley malt but has not been fortified with micronutrients; therefore it has not been listed here.
d. When Indian RUFC is to provide 500 kcal/day, micronutrient content per 1,000 kcal of product will be lower than when providing 250
kcal/day.
Corn–soy blend from WFP* yet improved) corn–soy blend procured by WFP, except
that it also includes 5% to 10% sugar in exchange for
WFP is currently revising its specifications for corn– corn. WFP and UNICEF are discussing the improve-
soy blend and other fortified blended foods to arrive ments that will be made to corn–soy blend and also to
at mainly two products,** as follows (for more details, UNIMIX.
see de Pee et al. [28]):
» Improved corn–soy blend for general use, including Corn–soy blend from USAID
for pregnant and lactating women and people suffer-
ing from HIV/AIDS or tuberculosis, which will: The corn–soy blend procured and distributed by
– Have improved micronutrient content (more USAID complies with the USDA (US Department of
kinds, increased amounts, better bioavailability); Agriculture) Commodity Requirement CSB13 [29] and
– Use dehulled soybeans in order to make a start contains 69.5% cornmeal (“processed, gelatinized”),
with reducing fiber and phytate content and to 21.8% soybean flour (“defatted, toasted”), 5.5% soybean
reduce the content of toxins and contaminants; oil (“refined, deodorized, stabilized”), 3% micronutri-
– Have a lower maximum for aflatoxins (5 instead ents, and antioxidant premix. The declared micronutri-
of 20 ppb) and tighter specifications for microbio- ent content of corn–soy blend from USAID*** is based
logical content; on the micronutrient content of the raw materials and
– Include specifications for maximum content of the micronutrient premix, not on analysis. And, as with
heavy metals; the corn–soy blend purchased by WFP, the micro-
» Improved corn–soy blend plus milk for young (6 to nutrient specifications for the premix are currently
23 months) and moderately malnourished chil- under review as well (Liz Turner, SUSTAIN, personal
dren, which will have the same specifications as communication).
improved corn–soy blend (see above) and in addi- According to the CSB13 requirements, corn shall be
tion contain: dehulled and degermed and corn germ may be added
– Skimmed-milk powder at 8%; back to the product (maximum 10%) to replace veg-
– Sugar: up to 10% of energy; etable oil. Soybeans can be added as defatted or full-fat
– Oil (soybean): approximately 3% added before soybean flour. Defatted soybean flour shall be prepared
extrusion and up to 7% added after extrusion from dehulled soybeans, whereas dehulling is optional
(exact amount to be determined based on product for full-fat soybean flour. When full-fat soybean flour is
rancidity and shelf-life tests). used, it should be added in an amount that ensures that
The specifications for improved corn–soy blend have protein content is equivalent to use of 21.8% defatted
been finalized and will be gradually implemented in soybean flour. Vegetable oil may be added to the final
consultation with producers. For corn–soy blend plus product to ensure adequate fat content.
milk, production trials are ongoing to determine the Thus, the corn–soy blend donated by USAID con-
optimal specifications from a technological and shelf- tains less crude fiber, which is also in accordance with
life point of view. Once finalized, this product should the specifications (2% dry matter for USDA specifica-
be studied in comparison with other products (RUTF, tions and 5%, to be changed to 3%, for WFP), because
improved corn–soy blend) for its impact on growth it uses dehulled (and possibly degermed) corn, and
(linear growth as well as weight), micronutrient status, possibly dehulled soybeans (depending on whether
functional outcomes, acceptance, and length of stay in defatted or full-fat soybeans are used). For this product,
blanket or targeted supplementary feeding programs some processing steps identified in figure 3 are thus
among young (6 to 23 months) as well as moderately being taken already.
malnourished children. A comprehensive overview of the history of US
Government Food Aid Programs has been written
Corn–soy blend from UNICEF (UNIMIX) by Marchione [30]. It is noteworthy that between the
mid-1960s and the late 1980s, blended foods contained
UNIMIX, the corn–soy blend procured and distributed nonfat dry milk (corn–soy milk and wheat–soy milk)
by UNICEF, has virtually the same composition as (not but that milk was dropped from the blends when
milk surpluses became exhausted. In 2001, nonfat dry
milk was reintroduced in a number of commodities.
* WFP also distributes corn–soy blend donated by USAID
and formulated according to USDA specifications, see section Requirements for adherence to manufacturing stand-
below, ‘Corn-soy blend from USAID’. Here, we describe the ards, including micronutrient specifications, for US
specifications of corn–soy blend as purchased by WFP, to a commercial food suppliers to the food aid programs,
large extent from producers in developing countries. and their enforcement, were introduced in 1999 and
** In North Korea, WFP purchases blended foods that also
include milk powder (milk powder, corn, and soy; milk pow-
der and rice; milk powder and wheat). However, no conclusive *** Available at: http://www.usaid.gov/our_work/humanitarian
evaluation of impact is available on these operations. _assistance/ffp/cr g/downloads/fscornsoyblend.pdf.
TABLE 4. Composition and price, per daily recommended dose, of various complementary food supplements that are already being used or are in final stage of development (see S444
table 3 for classification and ingredients)
MN powders,
MN powders, 15 vitamins Plumpy’ Supplemen- Plumpy’
nutritional and minerals Soy Sprinkles MixMe Plus TopNutri Nutributter Doz, RUFC Indiaa tary Plumpy Nut
Ingredient anemia (1 g) (1 g) (10 g) (5 g) (7.5 g) (20 g) (46 g) (50 g) (92 g) (92 g)
Energy (kcal) 44 20 108 247 260 500 500
Protein (g) 3.8 3.8 2.56 5.9 5 12.5 12.5
Fat (g) 3 < 0.1 7.08 16 15.5 32.9 32.9
Lysine (mg) 400 36% excess
Malt flour (mg) 1,000
PDCAAS (%) 100
Vitamin A (µg) 300 400 400 340 400 400 100 840 840
β-Carotene (µg) 400
Vitamin E (mg) 5 5 5.6 — 6 3 18.4 18.4
Vitamin B1 (mg) 0.5 0.5 0.5 0.3 0.5 0.25 0.55 0.55
Vitamin B2 (mg) 0.5 0.2 0.5 0.7 0.4 0.5 0.25 1.66 1.66
Niacin (mg) 6 6 6.8 4 6 3.7 4.88 4.88
Pantothenic acid (mg) 2 3 1.8 2 0.5 2.85 2.85
Folic acid (µg) 160 150 90 90 80 160 75 193 193
Vitamin C (mg) 30 30 60 45 30 30 30 49 49
Vitamin B6 (mg) 0.5 0.5 0.6 0.3 0.5 0.25 0.55 0.55
Vitamin B12 (µg) 0.9 0.9 0.9 0.5 0.9 1 1.7 1.7
Calcium (mg) 385 400 320 100 387 200 276 276
Magnesium (mg) 90 16 60 40 84.6 84.6
Selenium (µg) 17 17 20 10 17 10 27.6 27.6
Zinc (mg) 5 4.1 4.1 2.5 3.8 4 9 4.1 12.9 12.9
Iron (mg) 12.5 10 6 2.5 7.7 9 9 10 10.6 10.6
Iodine (µg) 90 30 86 90 90 — 92 92
Copper (mg) 0.56 0.34 0.34 0.2 0.3 0.3 1.6 1.6
Phosphorus (mg) 230 82.13 275 75 276 276
Potassium (mg) 400 280 152 310 305 511 1022
Manganese (mg) 0.9 0.08 0.17 0.8 — —
Vitamin D (µg) 5 280 IU 5 4.9 — 2.5 15 15
Vitamin K (µg) 37.5 — 15 19.3 19.3
Biotin (µg) 18.8 — 60 60
S. de Pee and M.W. Bloem
a. The micronutrient premix that is added to Indian ready-to-use food for children (RUFC) is being modified. The composition shown here was the initial composition and has been used for the calcula-
2000. With a total US donation in 2007 of 114,000
Supplement Supplement Replacement Replacement

metric tons of corn–soy blend, 61,000 metric tons of
120?
0.41
49.2
which was donated through WFP,* good quality control
is very important.
Need and feasibility of further adjustments to

120?
0.33
39.6
fortified blended food
As mentioned above, one of the main issues with

corn–soy blend that make it less suitable for young
replacement replacement
0.13 (0.26
for 100 g)
malnourished children is the high content of antinu-

120?
15.6
or trients, particularly phytate, and its fiber content. A

study from 1979 documented that nitrogen absorption
and retention (indicating protein uptake) were better
from corn–soy blend made from degermed corn and
dehulled soybeans than they were from corn–soy blend
120?
0.2
24
or
made from whole cornmeal and dehulled soybean

flour or from whole cornmeal and whole soybean flour
[23]. These effects were ascribed to the higher fiber
Supplement
content. High fiber content may also reduce energy

180 (daily
6–12 mo)
intake through an effect on appetite, increased fecal

0.11
19.8
losses of energy due to reduced absorption of fat and

carbohydrate, and increased flatulence, which can have
a further negative effect on energy intake [2] and can
225 (150/yr) 225 (150/yr)
Supplement
also lead to nonacceptance of the product. Although

reduced energy uptake could be compensated for by
7.5
7.5
70
adding oil or sugar to the product, it does not improve

mineral bioavailability and also reduces micronutrient
density unless fortification levels are increased.
Supplement
b. Cost for single-dose packaging. For multidose packaging, cost could go down to US$0.008/dose.
An article by Jansen published in 1980 that reviewed

0.04?
30
more results, however, concluded that degerming corn

9
also results in loss of protein and oil from the germ

and that the higher protein content of whole corn
compensates for the slightly lower protein absorption
Supplement
related to its higher fiber content [25]. With regard

MN, micronutrient; PDCAAS, protein digestibility-corrected amino acid score
?
to the likely lower bioavailability of minerals, Jansen

said that this should be compensated by fortification.
Given the considerable losses when degermed corn
225 (150/yr) 225 (150/yr)
Supplement
meal is used (extraction rate of 65% to 75%, and thus

0.027b
a loss of 25% to 35%), the desire to produce the prod-

6.1
uct locally, and the possibility to at least dehull the

soybeans, Jansen recommended in 1980 that corn–soy
blend be composed of dehulled soybeans and whole
Supplement
maize meal, resulting in a crude fiber content of less

0.02
4.5
than 2%, and be mixed with an adequate micronutri-

ent premix.
The USDA specifications include the use of dehulled
tions in table 5D–F and table 6.
and degermed corn and dehulled defatted soybeans or

Minimum no. of doses for 6-
Product cost per dose (US$)
Total product cost (US$) for
optionally dehulled full-fat soybean flour, and up to

Supplement to or replace-
10% of corn germ may be added back to the product.

required no. of doses
ment of normal diet

Phytomenadion (µg)
Corn–soy blend purchased locally in developing coun-

Molybdenum (µg)
tries by both WFP and UNICEF, however, is made from

Chromium (µg)
to 23-mo-old
Sodium (mg)
* Details about USDA Food Aid can be retrieved from Pro-

grams and Opportunities — Food Aid — Food Aid Reports
(available at: http://www.fas.usda.gov/excredits/FoodAid/
Reports/reports.html).
Fortified blended foods Options for improving nutritional quality

Positive Negative Limited More complex and costly Worth exploring
• Can be pro- • Limited impact on complexity • Use soy protein isolates — phytasea
duced almost growth and MN status • Add dried with low phytate con- • Reduce phytate
anywhere • Fiber in nondehulled skimmed milk tent instead of dehulled by soaking forti-
• Soybeans: good maize, wheat, and to promote soybeans fied blended food
protein profile soybeans growth (10%?) • Use degermed and ingredients together
• Fortified with • Antinutrients in non- • Soybeans: dehulled maize flour with phytase before
micronutrients degermed maize as well dehulling (means discarding 25% of extrusion cooking
as in wheat and soybeans • Improve maize and altering pro- and drying (requires
• Fortified with too MN profile duction steps) equipment: condi-
few MNs and limited (more MNs • Add sugar (already tioner and dryer)
bioavailability and higher done for UNIMIX) and • Reduce phytate by
• Energy density too low amount) oil (soybean, rapeseed/ adding phytase to the
and viscosity too high canola) during processing processed dry product
for young malnourished to increase energy density • Reduce phytate by
children and essential fatty acid adding phytase to
content and compensate prepared product (i.e.,
for oil lost when soy pro- home fortification)
tein isolates rather than
soybeans are used
FIG. 3. Steps to be considered for upgrading fortified blended foods to supplementary foods of better nutritional quality for
moderately malnourished children. MN, micronutrient
whole maize as well as whole soybeans.* Option 4. Complementary food

A study using wheat–soy blend provided by World supplements: Compensating for shortage
Vision in Haiti found a poor impact on anemia levels of specific nutrients
[31]. If the wheat–soy blend was provided under the
Title II programs and complied with USDA specifica- Complementary food supplements can be defined as
tions, the crude fiber content was 2.5% of dry matter, food-based complements to the diet that can be mixed
as it contained partially debranned wheat [32]. This with or consumed in addition to the diet and the pur-
means that also for corn–soy blend that complies pose of which is to add nutritional value [33]. Com-
with USDA specifications it is not known whether the plementary food supplements are comparable to food
phytate content is low enough to provide for adequate fortification in the sense that they increase the intake of
mineral absorption. For young children, a maximum essential nutrients from food. However, the important
intake of total dietary fiber of 0.5 g/kg body weight differences are that complementary food supplements
has been recommended by the American Academy of can be targeted to specific vulnerable groups, as they
Pediatrics. For a 6-kg child, this would translate into are added to foods just before consumption (home or
3 g/day. When this child consumes some vegetables point-of-use fortification), and that the dosage is not
and wheat or corn in addition to one or two cups of dependent on the amount of energy consumed in a
corn–soy blend, especially when the blend is made day, i.e., one dose is added to one meal irrespective of
from whole maize and whole soybeans, the intake is meal size.
very likely higher than that. Complementary food supplements can be divided
Therefore, options to reduce fiber and phytate con- into different categories, as shown in table 3. The first
tent need to be further explored for the product pur- four categories (micronutrient powders, powdered
chased by WFP and UNICEF. The costs of degerming complementary food supplements [protein, amino
corn, due to the need for specific equipment, the loss acids, micronutrients], complementary food supple-
of 25% to 35% of the corn, and the need to compen- ments that also have active substances (enzymes), and
sate for the loss of some protein and oil, are high. This lipid-based nutrient supplements of 10-20 g) are com-
means that if degerming corn were to be done for the plementary food supplements that provide essential
products purchased by WFP and UNICEF, it should micronutrients, amino acids, fatty acids, and/or active
probably only be done for corn–soy blend that is used compounds (enzymes) but contain little additional
for young (6 to 23 months) and for moderately mal- energy. The next three categories (industrially pro-
nourished children. duced complementary foods, 45 g lipid-based nutrient
supplements [250 kcal], and 90 g lipid-based nutrient
* Note that the new specifications of WFP that will soon be supplements [500 kcal]) are foods of high nutritional
rolled out require dehulling of soy (see above), and maximum
crude fiber will be reduced from 5% to 3%.
value* that also provide a substantial amount of energy. to realize that the complementary food supplement
Because they are meant to be consumed in addition provides nutrients that would otherwise have to be
to a daily diet, even when partly replacing it, and are supplied by a much more diverse diet.
composed in such a way that they are the main source
of essential nutrients (i.e., they can be combined with Some adequacy calculations
a largely staple based diet little more than just carbo-
hydrate sources), they are included in this table on In order to determine which kinds of complementary
complementary food supplements. food supplements are most suitable to improve a typi-
Because complementary food supplements are added cal complementary feeding diet so that it is likely to
to an existing diet, the added value of a particular meet the nutrient intakes recommended by Golden
complementary food supplement depends on the com- [1] for moderately malnourished children, table 5 was
position of the diet to which it is added and the needs prepared using linear programming [38, 39]. It shows
of the target group or individual consuming it. For the typical nutrient intake of a 12- to 15-month-old,
example, micronutrient powders were originally devel- moderately underweight (7.4 kg) Bangladeshi child
oped to address nutritional anemia [34] and were then who is breastfed and receives three servings of locally
expanded to include a wider spectrum of micronutri- prepared complementary food per day, consisting
ents [35]. However, when choosing (or developing) a of rice, dhal with potatoes, oil, sugar, and dark-green
complementary food supplement to enrich the diet of leafy vegetables (a maximum of three portions per
young (6 to 23 months) or moderately malnourished day of each) and with or without fish (a maximum of
children, a commodity with additional nutrients, such two portions per day) when receiving various types of
as essential amino acids and essential fatty acids and complementary food supplements. The portion sizes
a dairy component, may be more appropriate, assum- assumed for the local foods are average sizes, and they
ing that local foods do not provide these in sufficient have been modeled to provide the energy requirement
amounts. not yet fulfilled by complementary food supplements,
Because the concept of complementary food sup- breastmilk (40% of total energy intake), and a standard-
plements is relatively new, with micronutrient powders ized portion size of rice of 150 g/day (i.e., 23% of total
developed in the late 1990s being the first, they differ energy intake). The linear programming goal was to
with regard to important ingredients, relatively few data achieve the nutrient intakes proposed by Golden [1]
exist on their impact, and depending on their purpose, and the same as those used in the article by Ashworth
only certain outcomes have yet been tested [19–22, 34, and Ferguson [3]. However, it should be noted that the
36]. However, the concept is promising, because only selection of foods for the analyses done in this article
the additionally required nutrients are added to an was more restricted than in Ashworth and Ferguson’s
otherwise local diet or basic food ration. This limits article (up to 9 vs. 24 local foods). In particular, fruits,
costs as well as interference with prevailing dietary milk, chapatti, bread, semolina, pumpkin, chicken, and
habits and sourcing of food-assistance commodities. chicken liver were not included here, as it was assumed
Programmatic experience is required to evaluate the they may not be available in the poorest households.
feasibility of their use, including prevention of shar- This makes this analysis very different from the one
ing, required social marketing messages, package presented by Ashworth and Ferguson, where a greater
design and consumer information, training needs, etc., selection of foods and somewhat different portion sizes
because the concept of a small food supplement to be were used.
consumed exclusively by a specific age group of young From table 5A to 5B (kinds of micronutrient pow-
children [35]. ders and powdered complementary food supplements)
Table 4 shows the nutrient content, sample price per and from table 5C to 5D (kinds of lipid-based nutri-
daily dose as in early 2009, estimate of the number of ent supplements), the dietary diversity is reduced by
doses required between 6 and 23 months of age or to excluding fish. Diets that included lipid-based nutri-
treat moderate malnutrition, and price of this number ent supplements had a lower dietary diversity in the
of doses (for further information on fortified com- best-fit model than diets with micronutrient powders
plementary foods and supplements see the article by or powdered complementary food supplements (table
the Infant and Young Child Nutrition Working Group 5A to 5D). The lower dietary diversity is because the
[37]). Clearly, the more nutrients and the more energy energy contribution from lipid-based nutrient sup-
the complementary food supplement contains, the plements (i.e., 12.7% to 57.5% of total energy intake)
more expensive it becomes. However, it is important partly replaced that of local foods.
For the unsupplemented restricted diet, which
* It should be noted though that the nutritional value of includes spinach, dhal, potatoes, fish (two kinds), oil,
commercially available complementary foods is very variable.
They have been listed here, because some are of high value, sugar, rice, and breastmilk, without a complementary
such as the products developed by Groupe de Recherche et food supplement, nutrient content is inadequate for
d’exchange Technologiques (GRET) (see table 8). 10 micronutrients. With a micronutrient powder with
5 micronutrients, content is inadequate for 7 micro- supplements are of the same size and composition
nutrients, and with 16 micronutrients it is inadequate irrespective of the specific age of the under-five child,
for 3, which are type II nutrients. Of all the different whether he or she is breastfed, and what the nutritional
kinds of micronutrient powders and powdered com- status is. Thus, adequacy of diet in combination with
plementary food supplements, TopNutri provides the complementary food supplements will vary among as
most complete mix of micronutrients. With decreasing well as within populations.
dietary diversity, the gap of micronutrients increases. Linear programming calculates possible solutions
When lipid-based nutrient supplements are added, to reach certain goals, such as, in this case, intake of
nutrient intake becomes more complete as compared energy, macronutrients, and micronutrients from a
with when micronutrient powders are added. However, specific set of foods that can be consumed at certain
they are still short in a number of nutrients, especially minimum and maximum amounts. However, some
vitamins E and C, potassium, magnesium, and zinc. important aspects of foods for young or moderately
This may be due to the fact that some lipid-based malnourished children discussed in this article cannot
nutrient supplements are designed for prevention yet be included in linear programming because of a
rather than for treating moderate malnutrition (i.e., lack of adequate data or because exact requirements
recommended intakes are different), and other lipid- have not yet been established. These include selenium,
based nutrient supplements are designed to completely iodine, biotin, and vitamins K and D (too variable or
meet the required nutrient intake (with exact intake to unknown content); essential fatty acids; PDCAAS, i.e.,
be varied according to energy need) rather than to be protein quality; minimum requirement for animal-
consumed in addition to a local diet and breastmilk. source food or milk; antinutrients (content in indi-
For the Indian RUFC, the micronutrient content will be vidual foods not well known and maximum intake
adjusted to be comparable to that of Plumpy’Doz when not established); and micronutrient bioavailability
providing 50 g/day and to Supplementary Plumpy (depends on factors in a meal, not a daily diet, and is
when providing 100 g/day. very complex).
The same analysis has also been done for the addi- Further, the linear programming results are very
tion of complementary food supplements to corn–soy dependent on the model parameters, which for this
blend, of which the energy density was increased by particular analysis include the list of foods, their por-
the addition of oil and sugar (table 6). For corn–soy tion sizes, and the desired nutrient intake levels. Thus,
blend, the composition as published by USDA was for households with access to a greater variety of foods
used, which is based on the micronutrient content of or with different food portion size restrictions, the
the raw ingredients and the micronutrient premix and results would differ, as was shown when results from
is a relatively complete kind of corn–soy blend. As the these analyses are compared with those for a breastfed
table shows, because complementary food supplements child in Ashworth and Ferguson [3]. Likewise, these
are not designed to be added to corn–soy blend, which results depend on the validity of the nutrient goals
is already fortified, the intake of several micronutri- modeled. In particular, estimating iron adequacy is
ents would become rather high. However for some, complex because it depends on bioavailability, which
particularly the type II nutrients, intake would still be needs to be judged separately. An additional judgment
too low, for similar reasons as mentioned above for is also required with regard to protein and fat quality
the combination of lipid-based nutrient supplements and inclusion of milk powder or another animal-source
with the local diet. It will be best either to adapt the food (in addition to breastmilk).
mew micronutrient premix formulation of corn–soy
blend (as will soon be implemented by WFP) or to
add an appropriate complementary food supplement Future option: Use of phytase
to a largely plant-source-based unfortified diet. When
adapting corn–soy blend, considerations discussed Another possible option to increase mineral bioavail-
above should also be taken into account, i.e., ingre- ability is the use of phytase to reduce phytate content,
dients and processing used, in addition to reaching by adding it during production, adding it to an end
adequate nutrient content. product as the last production step, or using it as a
The results shown should, however, be interpreted home fortificant (fig. 3). The latter two options, how-
with caution, because they are calculated for a hypo- ever, cannot yet be used at large scale because phytase
thetical child aged 1 year, weighing 7.4 kg, who is is not yet widely approved for human consumption.
breastfed, probably by a mother with suboptimal It has GRAS (Generally Regarded As Safe) status for
nutritional status herself, and lives in a food-insecure persons aged 3 years and older, but not yet for younger
household in Bangladesh. For many children, the situ- persons, and in some countries it is not permitted at
ation will be different because they are of a different all. When phytase is used during industrial process-
age, may or may not be breastfed, may have access to a ing and destroyed by a subsequent heating step, there
greater variety of foods, etc. The complementary food is no problem because the product that reaches the
consumer will not contain phytase. absorption. Promising results have been obtained from
A range of phytases is available with different pH a very recent stable-isotope trial among Swiss women
and temperature optimums; thus different phytases that assessed iron absorption from a maize porridge
can be used for phytate degradation in different wet with high phytate content to which a micronutrient
foods or in the low-pH environment of the stomach powder with low iron content of high bioavailability
[40]. To what extent phytase reduces phytate, whether and a phytase that degrades phytate both on the plate
used during food production, in prepared, wet, food and in the stomach had been added [41].
that is left to stand for a while, or in the stomach, needs Thus, it is of urgent importance to obtain GRAS
to be determined, as should the impact on mineral status for the use of phytase in foods consumed by
TABLE 5A. Comparing nutrient intake requirements as proposed by Golden [1] with the nutrient contents of a daily diet of a
13- to 15-month-old, breastfed, moderately malnourished Bangladeshi child (7.4 kg, 851 kcal/day) to which fixed amounts of
different complementary food supplements are added (see also Ashworth and Ferguson [3]). This table: Micronutrient powder
or powdered complementary food supplements with fixed amounts of breastmilk and rice, and choice of fish, spinach, dhal,
potato, onion, oil, or sugar, all with maximum intake.
Diet + MN Diet + MN Diet + soy
Diet without powder (5 powder (16 powder with Diet + MixMe Diet +
Component CFS MNs) MNs) MNs Plus TopNutri
Nutrients % of proposed intake
Protein 136 171 173 179 175 199
Vitamin A 73.a 111 123 74 122 115
Vitamin E 29 47 98 53 89 100
Vitamin C 53 101 100 43 137 112
Thiamine 77 87 185 93 180 175
Riboflavin 62 63 137 90 140 168
Niacin 140 177 260 153 248 266
Vitamin B6 87 83 156 60 144 153
Folic acid 139 159 157 100 187 149
Vitamin B12 278 530 636 408 564 658
Pantothenic acid 117 127 127 122 208 249
Calcium 100 100 100 124 191 182
Phosphorus 103 122 123 104 129 176
Magnesium 81 78 78 68 82 131
Potassium 98 104 103 91 129 115
Iron (10% bioavailability) 67 203 172 125 100 152
Zinc (moderate 32 73 66 61 57 66
bioavailability)
Copper 111 88 184 68 154 139
Manganese 483 452 453 425 483 556
Diet ingredients Amount in diet (g)
Breastmilk, 530 g 530 530 530 530 530 530
Rice, plain, boiled— 150 150 150 150 150 150
minimum 150 g
Potato, cooked 56 62 58 0 0 0
Spinach, cooked— 40 40 40 40 40 40
maximum 40 g
Onion 0 0 0 0 0 0
Lentil-dhal 80 8 12 39 80 40
Small fish with bones 15 16 16 0 19 21
Fish 0 91 91 127 46 70
Soybean oil 12 12 12 12 12 12
Gur-cane sugar 0 0 0 0 0 0
Supplement (g) 1 1 1 5 8
MN, micronutrient
a. Nutrients for which less than 100% of recommended intake is achieved are displayed in bold italics.
young children (6 to 35 months) and to test its impact i.e., whether they are ready to use or need to be pre-
on phytate degradation and mineral bioavailability in pared, how easy and hygienic is their preparation, and
this target group as well. how well they can be stored.
These aspects are important for any of the above-
discussed options, whether referring to recommenda-
Ready-to-use foods vs. to-be-prepared tions for foods prepared at home (i.e., germination,
foods: Storage and preparation storing of fresh fish or meat) or to foods provided as
food assistance (transport over considerable distance,
So far, we have considered the nutrient content, antinu- storage, cooking fuel availability).
tritional factors, and specific ingredients of specially Foods that are ready to use are extremely convenient
formulated foods for young, moderately malnourished from the point of view of storage as well as preparation
children. Another important aspect to be considered is (which is not required) and consumption. Because they
the form of these specially formulated foods that are are very energy dense and contain very little water (to
provided as part of supplementary feeding programs, prevent growth of molds and bacteria), it is important
TABLE 5B. Micronutrient powder or powdered complementary food supplements with fixed amounts of breastmilk and rice,
choice of spinach, dhal, potato, onion, oil, or sugar, all with maximum intake (i.e. no fish)
Diet + MN Diet + MN Diet + soy
Diet without powder (5 powder (16 powder with Diet + MixMe Diet +
Component CFS MNs) MNs) MNs Plus TopNutri
Protein 97.a 97 97 109 97 107
Vitamin A 73 109 122 73 122 114
Vitamin E 28 28 79 28 79 91
Vitamin C 56 103 103 56 150 118
Thiamine 78 78 176 75 176 166
Riboflavin 57 57 131 85 131 158
Niacin 106 106 189 100 189 186
Vitamin B6 87 87 160 83 160 154
Folic acid 139 225 219 133 187 184
Vitamin B12 60 60 166 60 166 166
Pantothenic acid 114 114 114 108 201 230
Calcium 50 50 50 125 129 111
Phosphorus 67 67 67 63 67 106
Magnesium 72 72 72 69 72 117
Potassium 91 91 91 89 125 100
Iron (10% bioavailability) 64 227 194 139 96 161
Zinc (moderate 27 72 64 62 49 59
bioavailability)
Copper 108 108 204 103 166 149
Manganese 466 466 466 452 466 535
Breastmilk, 530 g 530 530 530 530 530 530
Rice, plain, boiled 178 178 178 150 178 150
– minimum 150 g
Potato, cooked 62 62 62 62 62 28
Spinach, cooked 40 40 40 40 40 40
– maximum 40 g
Onion 20 20 20 20 20 0
Lentil-dhal 80 80 80 74 80 80
Soybean oil 12 12 12 12 12 19
Gur-cane sugar 0 0 0 0 0 0
Supplement (g) 1 1 1 5 8
MN, micronutrient
that those who consume them have access to clean feeding because of the difficulty for consumers of
drinking water. Where the availability of cooking fuel distinguishing between nutritious and non-nutritious
or time for food preparation is limited, providing a biscuits and the possible promotion of a habit of biscuit
RUF for an individual suffering from a special condi- consumption, which may in fact lead to consumption
tion, such as a malnourished child, will be easier than of non-nutritious, high-sugar biscuits. However, when
providing a food that needs to be prepared separately biscuits are used for feeding children with severe acute
from the family meal. In addition, a food that needs to malnutrition (BP100), used as a short-term measure for
be cooked specifically for one individual may be more reducing the risk of malnutrition under sudden situa-
likely to be shared with other family members. tions of food insecurity (BP5), or used to feed children
The same advantage applies to biscuits or com- with moderate malnutrition for a limited period of
pressed bars, which are also ready to use. There is time, these concerns do not apply. When designing
concern about using biscuits for complementary biscuits as RUF, it is important to realize that baking
TABLE 5C. Lipid-based nutrient supplements with fixed amounts of breastmilk and rice, choice of fish, spinach, dhal, small
fish with bones, potato, onion, oil, or sugar, all with maximum intake
Diet + Diet + Diet + Indian Diet + Supple- Diet +
Nutributter Plumpy’Doz RUFC mentary Plumpy Plumpy’Nut
Component (20 g) (45 g) (50 g) (90 g) (90 g)
Protein 135 127 111 89 89
Vitamin A 122 122 85 138 138
Vitamin E 39.a 91 54 197 197
Vitamin C 89 88 87 109 109
Thiamine 118 157 97 129 129
Riboflavin 114 125 87 268 268
Niacin 178 183 140 100 100
Vitamin B6 93 115 76 89 89
Folic acid 104 145 100 129 129
Vitamin B12 421 346 326 256 256
Pantothenic acid 176 179 106 165 165
Calcium 100 122 100 84 84
Phosphorus 100 115 71 69 69
Magnesium 69 87 74 63 63
Potassium 82 87 81 68 109
Iron (10% bioavailability) 148 145 159 140 140
Zinc (moderate 58 98 55 121 121
bioavailability)
Copper 92 100 102 296 296
Manganese 435 422 493 321 321
Breastmilk, 530 g 530 530 530 530 530
Rice, plain, boiled— 150 150 150 13 13
minimum 150 g
Potato, cooked 6 0 0 0 0
Spinach, cooked 40 40 40 5 5
—maximum 40 g
Onion 0 0 0 0 0
Lentil-dhal 0 0 1 0 0
Small fish with bones 10 0 5 0 0
Fish 57 66 31 0 0
Soybean oil 12 0 0 0 0
Gur-cane sugar 0 0 0 0 0
Supplement 20 46 50 90 90
RUFC, ready-to-use food for children
TABLE 5D. Lipid-based nutrient supplements with fixed amounts of breastmilk and rice, choice of spinach, dhal, potato, onion,
oil, or sugar, all with maximum intake (i.e. no fish)
Diet + Diet + Diet + Indian Diet + Supple- Diet +
Nutributter Plumpy’Doz RUFC mentary Plumpy Plumpy’Nut
Component (20 g) (45 g) (50 g) (90 g) (90 g)
Protein 97.a 100 91 89 89
Vitamin A 122 122 85 138 138
Vitamin E 28 79 48 197 197
Vitamin C 89 88 88 109 109
Thiamine 120 149 97 129 129
Riboflavin 112 124 86 268 268
Niacin 138 156 121 100 100
Vitamin B6 97 119 79 89 89
Folic acid 173 187 132 129 129
Vitamin B12 119 166 178 256 256
Pantothenic acid 170 171 103 165 165
Calcium 67 123 86 84 84
Phosphorus 73 100 57 69 69
Magnesium 68 88 74 63 63
Potassium 79 84 80 68 109
Iron (10% availability) 175 162 171 140 140
Zinc (moderate 59 101 55 121 121
availability)
Copper 112 118 113 296 296
Manganese 448 443 500 321 321
Breastmilk, 530 g 530 530 530 530 530
Rice, plain, boiled 150 150 150 13 13
– minimum 150 g
Potato, cooked 6 3 0 0 0
Spinach, cooked 40 40 40 5 5
– maximum 40 g
Onion 0 0 0 0 0
Lentil-dhal 0 46 36 0 0
Soybean oil 10 0 0 0 0
Gur-cane sugar 57 0 0 0 0
Supplement 12 46 50 90 90
RUFC, ready-to-use food for children
biscuits at up to 200°C will destroy some of the heat- Current programs for moderately
sensitive vitamins. Compressed biscuits, such as BP100 malnourished children
and BP5, do not have this problem.
For precooked dry foods that are to be prepared with Tables 7 and 8 summarize the responses received to
water to make a porridge, boiling for 5 to 10 minutes is a questionnaire on current programs for moderately
recommended in order to kill any microbes that could malnourished children that was sent to 10 UN agen-
be in the water or the food. Instant foods that only cies and donors, 20 international NGOs, 3 prominent
require adding warm water are not preferred for use pediatric associations, and 6 large national programs.
under less hygienic circumstances. The information included in this article pertains to the
responses that included provision of a food supplement.
For a more detailed description of the questionnaire,
responses received, and information about programs
providing dietary advice, see the article by Ashworth
and Ferguson [3].
TABLE 6. Nutrient requirements proposed by Golden [1] compared with nutrients provided by corn–soy blend (USDA composition, see ref 29) with oil and sugar (3 times per day
35 g CSB + 3.5 g oil + 3.5 g sugar) combined with different complementary food supplements, consumed by 13- to 15-mo-old, breastfed, moderately malnourished child (7.4 kg,
851 kcal/day)
CSB + CSB + Sup-
CSB + MN CSB + MN CSB + soy CSB + CSB + Indian plementary CSB +
CSB without powder powder powder with CSB + CSB + Nutributter Plumpy’Doz RUFC Plumpy Plumpy’Nut
Component CFS (5 MNs) (16 MNs) MNs MixMe Plus TopNutri (20 g) (45 g) (50 g) (90 g) (90 g)
Protein 112 112 112 123 112 127 106 100 93.a 90 90
Vitamin A 140 176 189 130 189 177 166 136 97 137 137
Vitamin E 110 110 161 102 161 164 90 124 91 200 200
Vitamin C 96 143 143 91 190 164 130 112 111 110 110
Thiamine 126 126 224 117 224 220 163 172 122 131 131
Specially formulated foods and food supplements
Riboflavin 98 98 172 121 172 198 142 136 99 268 268

Niacin 170 170 253 158 253 258 195 185 150 102 102
Vitamin B6 81 81 155 75 155 166 109 118 80 89 89
Folic acid 185 271 266 171 233 227 194 192 143 130 130
Vitamin B12 179 179 284 168 284 280 212 225 235 260 260
Pantothenic acid 190 190 190 178 278 315 237 204 136 168 168
Calcium 195 195 195 256 273 251 179 190 149 88 88
Phosphorus 56 56 56 52 56 99 63 88 49 69 69
Magnesium 13 13 13 13 13 66 22 46 35 60 60
Potassium 24 24 24 24 58 48 37 49 50 65 107
Iron (10% bioavailability) 233 396 363 291 266 324 301 238 245 145 145
Zinc (moderate 51 96 88 84 74 84 78 109 65 121 121
bioavailability)
Copper 179 179 276 166 238 232 181 156 151 299 299
Manganese 382 382 382 376 382 468 375 365 424 314 314
Breastmilk 530 530 530 530 530 530 530 530 530 530 530
Soybean oil 10 10 10 9 10 10 8 5 5 0 0
Gur-cane sugar 10 10 10 9 10 10 8 5 5 0 0
Corn–soy blend 101 101 101 92 101 97 79 53 49 3 3
Supplement 1 1 5 5 8 20 45 50 90 90
CFS, complementary food supplement; MN, micronutrient; CSB, corn-soy blend.
a. Nutrients for which less than 100% or more than 200% of recommended intake is achieved are displayed in bold italics.
S453
TABLE 7. Fortified blended food mixtures provided by organizations implementing supplementary feeding programs for
children with moderate acute malnutrition
No. of Corn–
Organizations implementing and children/ soy blend Oil (g/ Sugar (g/
locationa yrb (g/day) day) day) Additional information
Action Contre la Faim (USA) 42,000 180-200 20 20 Mixed before distribution.
East and Central Africa Target: 1,000 kcal/day. Also
Tajikistan providing vitamin A capsules,
iron/folic acid, mebendazole
Concern 16,500 200 20 20 In case of pipeline break of WFP,
West Darfur maize/soybean mixture pur-
Democratic Republic of the Congo) chased locally, but unfortified
Concern 5,000 200 30 30
South Sudan
Concern ? 250 25 15
Niger
Food for the Hungry 57,000 400 31
Bolivia
Democratic Republic of the Congo
Kenya
GOAL ? 277 33 mL
Ethiopia
GOAL ? 357
Malawi
Helen Keller International 40,000
Niger 250 25 15
Burkina Faso 200 20 15
Mali 250 25 20
Save the Children (UK) 30,000 Different ratios
6 African countries
Afghanistan
continued
The majority of programs provide fortified blended Most organizations that answered the question on
food, especially corn–soy blend, to moderately mal- target intake from the corn–soy blend mixture for the
nourished children, who are mostly wasted. Table 7 malnourished child stated that this was 1,000 kcal/day
shows the number of children reached with a mixture (equivalent to 200 g of corn–soy blend + 20 g of oil +
of corn–soy blend + oil + sugar by reporting programs. 20 g of sugar), while at the same time they said that they
The total amounts to more than 550,000. Considering provided the corn–soy blend mixture as a take-home
that many more programs are implemented, it can be ration that was likely to be shared. Considering that
estimated that at least 2 million moderately wasted the energy needs of a moderately malnourished 6.7-kg
children receive corn–soy blend (or wheat–soy blend) child 12 to 15 months of age with a weight gain target
every year. of 5 g/kg/day are 770 kcal/day and that many children
The majority of programs add oil and sugar to the for- also receive breastmilk, a target intake of 1,000 kcal/
tified blended food, usually by mixing it with the food day from corn–soy blend is excessively high for many
just before distribution (including oil reduces shelf-life), moderately wasted children and is also not possible to
but sometimes by handing out the three commodities attain for a child who consumes three or four meals per
separately.* The ratio of corn–soy blend:oil:sugar day of 35 g dry weight each. However, unfortunately,
varies, as was also observed in the Save the Children little is known about actual intakes of corn–soy blend
(UK) review of supplementary feeding programs preparations by different age groups of moderately
by Navarro-Colorado [27]. On average, the ratio is wasted children. Some programs provided family food
10:1:1, and approximately 1,000 kcal/day is provided. rations or a supply of corn–soy blend for siblings to
limit sharing of the corn–soy blend mixture that was
* UNIMIX (corn–soy blend provided by UNICEF) already provided to the moderately wasted child.
contains sugar, usually 10% in exchange for corn. A number of organizations provided other kinds
TABLE 7. Fortified blended food mixtures provided by organizations implementing supplementary feeding programs for
children with moderate acute malnutrition (continued)
No. of Corn–
Organizations implementing and children/ soy blend Oil (g/ Sugar (g/
locationa yrb (g/day) day) day) Additional information
GTZ–UNHCR 7,955 250 25 20
Kenya
International Rescue Committee— ? 270 25 UNIMIX already contains sugar.
UNHCR (UNIMIX) Target: 1,000–1,200 kcal/day
Kenya
Médecins sans Frontières (Spain) 3,532 300 40 20 Reflects program June 2007–
Uganda April 2008
Planned to change to RUFs in
May 2008
UNHCR 1,000 250 40 20
Djibouti
UNHCR 2,000 229 29 29
Uganda
UNHCR 2,671 120 20 20 Target: 1,000 kcal/day
Tanzania
UNICEF 350,000 250 25 15 Families or siblings receive
Niger another ration, to maximize
intake of the supplementary
feeding ration by the target
child. Target: 1,200 kcal/day
Replaces other foods in the diet
Valid Different ratios, depending on
Ethiopia organization supported
Sudan
Zambia
Malawi
GTZ, Gesellschaft für Technische Zusammenarbeit; RUF, ready-to-use food; UNHCR, United Nations High Commissioner for Refugees
a. It should be noted that most of the corn–soy blend (or wheat–soy blend) distributed by the organizations listed below is donated either by
the World Food Programme, which has received it from the United States or purchased it from local producers in a range of countries, or
by UNICEF.
b. Most organizations provided the number of beneficiaries for supplementary feeding programs in 2007.
of food supplements (table 8). Some (reaching about with moderate acute malnutrition (Médecins sans
200,000 children) provided a mixture of fortified staple, Frontières, Action Contre la Faim WFP, Project Peanut
pulse, oil, and sugar (UNICEF Uganda, Church World Butter in Malawi) or even to prevent malnutrition
Service Indonesia, Bangladesh National Nutrition Pro- [42]. A rough estimate of the number of children with
gram, and Action Contre la Faim Myanmar), some of moderate acute malnutrition receiving a lipid-based
which was locally produced, or BP5 (UNICEF Uganda). RUF is a maximum of 50,000 per year. Note that most
Some provided a supplement that also included milk lipid-based RUF is in the form of RUTF and is provided
and still had to be cooked, such as the fortified blended to children suffering from severe acute malnutrition.
food mixtures (DREAM for HIV-positive children in
African countries and GRET in Burkina Faso, Mada-
gascar, and Vietnam). World Vision in Niger promoted Further programmatic considerations
home preparation of a local peanut paste mixed with
dried moringa leaf concentrate for mildly malnour- Much of the discussions of this Consultation focused
ished children and provided the corn–soy blend mix- on the nutrient and food needs of individual malnour-
ture to moderately malnourished children (see table 8 ished children, which are a function of the percentage
for details). A few organizations use lipid-based RUFs of lean body mass that they should gain and the desired
such as Supplementary Plumpy, Indian RUFC, peanut/ weight gain, which are in turn dependent on the indi-
soybean paste, Plumpy’Doz, or Plumpy’Nut for children vidual’s nutritional status (stunted, wasted, or both) as
well as on whether a specific food will be provided or Access to, affordability of, and distribution of
whether the diet should be changed. However, from a specially formulated foods
programmatic point of view, it will rarely be feasible to
really tailor the treatment to the individual moderately Because treatment of severe acute malnutrition is con-
malnourished child. sidered a right of the child and is too costly for most
In targeted programs that identify the individual families (about US$50 for one child’s treatment with
malnourished (usually wasted) child, weight and RUTF), it is generally provided by the public sector
height measures will be taken, a target for weight gain (governments or humanitarian agencies). For moder-
will be set, and the caretaker will be provided with ate malnutrition, however, the situation depends on the
dietary advice and complementary food supplements target group, the commodities, and the context.
or special foods. The programs have no control over For preventive purposes, complementary food
the diet consumed. Also, giving specific advice and dif- supplements such as micronutrient powders, pow-
ferent amounts of commodities to individual children dered complementary food supplements, and lipid-
depending on their needs is challenging, especially based nutrient supplements of 20 g/day or less, can
when working with community volunteers rather than be taken,with a product cost (subject to change) of
medically or nutritionally qualified personnel or when US$0.02 to US$0.12/day. Although they should be
workload is high. Furthermore, the number of different used by the majority of children who consume too
commodities and their quantities should be limited to few animal-source foods and fortified complementary
reduce errors. foods, they cannot be afforded by all households [43].
With the current development of new concepts and Ways are sought to target different socioeconomic
products for different types of malnutrition, many groups in a country in different ways with the same
questions arise about what programs to implement or product, which may be packaged differently for this
how to modify ongoing programs, and what advice or purpose, so that wealthier households can cross-subsi-
commodities to use. Although these program-related dize poorer households and public sector organizations
questions will be the subject of a follow-on meeting can buy and distribute to the poorest. The use of vouch-
to be organized by WHO and partner organizations ers for specific groups that are targeted for specific
towards the end of 2009, some of them need to be public programs is also considered [44].
answered now, even though it is clear that guidance
is likely to change as more products and information Preventive or curative approach
about their use and impact become available. Table 9
suggests response options that can be considered for Based on the successful treatment of severe acute
food-assistance programs to prevent and treat moder- malnutrition with RUTF, attention now focuses on the
ate and mild child malnutrition (wasting, stunting). treatment of moderate acute malnutrition, the guide-
Which choice to make will depend on many factors, lines for which are similar to those for prevention of
including: wasting and growth-faltering among children aged 6
» What is likely to have the best impact; to 23 months. Also, as explained by Golden [1], when
» Logistical considerations, such as the accessibility of treating children with moderate acute malnutrition,
the area and presence and capacity of implementing weight gain should be due mainly to increase in lean
partners; tissue and hence should also result in linear growth
» Availability of preferred commodities within the (note that many wasted children are also stunted).
desired time frame; Among non-wasted children, it is better to prevent
» Human capacity for designing, supervising, imple- stunting between conception and 24 months of age
menting, and evaluating the program; than to treat stunting after it has occurred [45].
» Funding for the program. Thus, a good strategy for a population would be to
In situations of severe food insecurity where blanket focus on preventing malnutrition through programs
supplementary feeding programs are implemented for that target pregnant and lactating women and children
young children and pregnant and lactating women, aged 0 to 23 months, and on treatment of moderate
often also for reasons of logistics and safety, foods could and severe wasting among children under 5 years of
be provided of which the composition is as recom- age. The former can also be considered treatment of
mended for treating moderate malnutrition, because a population; i.e., based on the prevalence of stunting
these are designed to be inherently safe for nonmal- among 2- to 5-year-olds, the younger children receive
nourished individuals. Because of the larger number blanket treatment to reduce their risk of becoming mal-
of beneficiaries, blanket feeding of high-quality and nourished. Ruel et al. [46] conducted a trial in which
more expensive food supplements comes at a higher they compared two populations; in one population all
commodity cost. However, at the same time, money is children aged 6 to 23 months received a monthly supply
saved because there is no need to identify and follow of fortified blended food and oil, and in the other
individual moderately malnourished children. population all children aged 6 to 59 months suffering
from moderate acute malnutrition received a monthly What appropriate preventive measures are depends
supply of the same. Three years later, the population on the adequacy of the local diet, i.e., which dietary
levels of malnutrition were lower in the former than gap has to be filled, and on the accessibility of required
in the latter group, and the authors concluded that foods. For treating moderate acute malnutrition, locally
the former strategy was more effective for combating available foods can be used where accessible [3]. Where
undernutrition. this option is not very feasible, processed and fortified
TABLE 8. Other foods provided to moderately malnourished children

Organizations
implementing and Food ration provided,
location ingredients Target group Comments
UNICEF Corn–soy blend + oil + sugar, or 50,000–70,000 moderately
Uganda BP5 when these ingredients are malnourished children
not available
Church World Wheat–soy blend and recipes, Children with moderate acute
Service with demonstration, such as malnutrition on Nias and
Indonesia cake, meatballs, etc., and forti- West Timor Islands
fied food from Kids Against
Hunger, made of rice, soybean
flour, dried vegetables, salt,
maltodextrin, dextrose, hydro-
lyzed soy protein, soybean oil,
and MNs
BNNP 20 g roasted rice, 10 g roasted 91,435 children/yr, 150 kcal/
Bangladesh lentils, 5 g molasses, 3 mL oil day for underweight 6- to
(total 150 kcal) 11-mo-olds and 300 kcal/
day for underweight 12- to
23-mo-olds
Action Contre la Fortified mixture of 125 g rice, 11,650 children/yr, moderately A study was planned for 2nd half
Faim (France) 125 g yellow beans, and 50 g malnourished < 5 yr of 2008, to compare impact
Myanmar sugar, with 43 g oil added just of this mixture with that of
before distribution. Instant Plumpy’Doz and Supplemen-
food, requires adding hot tary Plumpy
water. Locally produced
World Vision 3 different treatment groups So far, in 2008: Depending on the amount of
Niger receiving different foods under Zogala Nut consumed and the
different schemes: composition of the local diet,
Severe acute malnutrition: RUTF #12,929 < –3 Z scores (W/H < the foods consumed by the
70%) or MUAC < 110 mm mildly malnourished may be of
Moderate malnutrition: corn– # 1,167 –3 and –2 Z scores similar nutritional value as the
soy blend (250 g) + oil (25 g) (70% < W/H < 80%) corn–soy blend/oil/sugar diet
+ sugar (15 g), referred to as #560 –2 and –1 Z Scores (80% The source of nutrient con-
“therapeutic food” < W/H < 85%) and stunted tent of Zogala Nut has not
Mild malnutrition: PD/Hearth + All received MNs (vitamin A, been specified and is likely
locally made food supplement iron/folic acid, zinc, vitamin to vary because it is locally
Zogala Nut (leaf powder from C) prepared (most MNs are from
Moringa oleifera [25%], peanut 23,000 healthy children the leaf concentrate, i.e., no
paste [55%], sugar [10%], enrolled in growth fortification)
peanut oil [10%], and iodized monitoring Numbers of mildly and moder-
salt) ately malnourished are very
small compared with those
with severe acute malnutrition
DREAM A variety of mixes, e.g., 70 g 3,000 children who are HIV+
9 African coun- corn–soy blend/wheat–soy or born to HIV+ mothers/yr
tries: all pro- blend, 5 g oil, 8 g sugar, 25 g
grams related to skimmed-milk powder
HIV/AIDS)
continued
TABLE 8. Other foods provided to moderately malnourished children (continued)

Organizations
implementing and Food ration provided,
location ingredients Target group Comments
GRET in collabo- Developed complementary foods for feeding young children GRET supports local enterprises
ration with IRD, (6–23 mo) to prevent malnutrition to produce fortified infant food
Montpellier Target population ~ 150,000 children. Recommended consump- and to sell it to the poor at
Madagascar tion 70–140 g/day from the following mixtures: adapted price
Vietnam Madagascar: maize, rice, soybeans, peanuts, sugar, salt, MNs, Note that 5 of 6 mixtures contain
Burkina Faso α-amylase α-amylase (to reduce viscosity),
Vietnam: rice, soybeans, sugar, milk powder, sesame, salt, MNs 3 contain milk powder, and
(produced by very-low-cost extrusion cooking) staple (maize, rice, millet, or
Burkina Faso 1: millet, soybeans, sugar, sesame, cowpeas, milk sorghum) is the main ingredi-
powder, salt, MNs, α-amylase ent in all. No studies available
Burkina Faso 2: millet, soybeans, peanuts, sugar, salt, MNs, on impact
α-amylase
Burkina Faso 3: sorghum, millet, soybeans, sugar, peanuts,
monkey bread, salt, MNs, α-amylase
Burkina Faso 4: maize, soybeans, sugar, peanuts, milk powder,
salt, MNs, α-amylase
Project Peanut 125 g peanut/soybean paste 2,000 moderately malnour- This has replaced the use of
Butter providing 75 kcal/kg/day and ished children/yr corn–soy blend, oil, and sugar
Malawi 1 RDA of all MNs. The paste is in these operations
made from 25% whole roasted
soybeans, 20% soybean oil,
26% peanut paste, 27% sugar,
and 2% MNs
WFP Supplementary Plumpy, 90 g/day Targeted distribution to mod-
Ethiopia erately wasted children < 5 yr
Somalia in Ethiopia and Somalia
Myanmar Improved corn–soy blend with Blanket distribution to chil-
milk powder dren < 2 yr in Somalia
Indian RUFC + Plumpy’Doz Blanket distribution to chil-
dren < 2 yr affected by
Myanmar cyclone
Action Contre la Supplementary Plumpy, 2 × 90 5,000 children in 2007, mod- Questionnaire response says that
Faim g/day erately wasted (WH ≥ 70% it is complementary to the diet,
Sudan and < 80% and/or MUAC ≥ not a replacement However, it
South Darfur 110 and < 120 mm (6–18 mo provides 1,000 kcal/day for 6-
old), only during hunger gap to 18-mo-old children (!)
Jun-Oct 2007
Médecins sans 2 sachets Plumpy’Nut/child/day, 10,000 moderately malnour- This replaced the use of corn–soy
Frontières i.e., 1,000 kcal/day ished children/yr blend, oil, and sugar in these
(Suisse) MSF Suisse operations
Niger
Sudan
Somalia
Médecins sans Children with moderate and 2006: 60,000 cases of moderate The preventive distribution in
Frontières severe acute malnutrition acute malnutrition and 5,000 2007 reduced case load of mod-
(France) treated with Plumpy’Nut of severe acute malnutrition erate acute malnutrition and
Niger (2006) Blanket distribution severe acute malnutrition and
of Plumpy’Doz during lean limited the burden on health-
season (2007) as preventive care system of identifying
measure and following malnourished
individuals
BNNP, Bangladesh National Nutrition Program; GRET, Groupe de Recherche et d’exchange Technologiques; IRD, Institut de Recherche
pour le Développement; MN, micronutrient; MUAC, mid-upper-arm circumference; PD/Hearth, Positive Deviance/Hearth Program; RDA,
recommended dietary allowance; RUFC, ready-to-use food for children; RUTF, ready-to-use therapeutic food; WH, weight-for-height; WFP,
World Food Programme
foods or complementary food supplements can be or moderately malnourished children:

made available through subsidies or for-free distribu- » Improving the current standard of fortified blended
tion. Such foods can be produced locally or imported, foods by reducing phytate content by dehulling
depending on ingredient availability, local producer and/or degerming of corn and soybeans, improving
capacity, and packaging facilities. micronutrient premix specifications, and adding
When specially formulated foods are used for treat- milk powder, sugar, and oil;
ing moderate acute malnutrition, the results should » Modifying the RUTF recipe to develop RUSF (ready-
preferably be obtained more quickly than when the diet to-use supplementary food) using local foods as
is modified, because delivery of such products incurs much as possible and limiting costs, for example,
program costs, and there is a greater expectation of the by reducing milk content, replacing some dairy
foods’ being a treatment (the argument that the food is protein with soy protein (extracts), using chickpeas
a treatment for the specific child should also prevent or sesame instead of peanuts, and making biscuits or
sharing with other household members). When treat- bars instead of a lipid-based food;
ment relies on dietary changes, it will hopefully result » Development of complementary food supplements
in a change of the diet of all young children in the that add the nutrients, ingredients, and active com-
family that is maintained for a longer period of time. pounds to diets that are not contained in adequate
amounts.
Different categories of complementary food supple-
Discussion and conclusions ments can be distinguished, ranging from micronutrient
powder, powdered complementary food supplements
Many of the recommendations for dietary management of protein, amino acids, and/or enzymes and micro-
of moderate malnutrition in children, including the use nutrients, to lipid-based nutrient supplements that
of specific food supplements, also apply to children range from 20 to 90 g/day (120 to 500 kcal/day) and
aged 6 to 23 months who are at risk for becoming mal- typically contain milk powder, essential oil, peanut
nourished because they live in populations with a high paste, sugar, and micronutrients. Some complementary
prevalence of stunting as well as wasting. Therefore, food supplements are primarily used for prevention of
most of what is discussed in this article is applicable to malnutrition (≤ 20 g/day), whereas others (≥ 40 g/day)
young children (6 to 23 months) as well as to moder- are used for blanket or targeted supplementary feeding
ately malnourished children (weight-for-height z-score of malnourished individuals or populations with a high
< –2 and ≥ –3 or height-for-age z-score < –2). prevalence of malnutrition.
Important foods for young and/or malnourished Although we know what nutrients are required,
children include breastmilk, staples (for energy and which antinutrient contents should be reduced, and
some micronutrients), animal-source foods (good what foods should ideally be used, choosing effective,
sources of protein, minerals, and some vitamins), available, appropriate, and cost-effective foods is a
legumes or lentils (particularly for protein), vegetables challenge. This is due to a number of factors, including
and fruits (for vitamins, minerals, and vitamin C to the following:
enhance nonheme iron absorption), oil (for energy and » The fact that as yet, only a few of the above-men-
essential fatty acids), and a source of iodine such as salt tioned specially formulated foods and food supple-
(but high sodium intake in moderately malnourished ments have been assessed in terms of their impact
children is not desirable). Particularly important com- on recovery from moderate malnutrition, i.e., length
ponents of the diet are protein quality, essential fatty and weight gain, functional outcome, immunity,
acid content, bioavailability of micronutrients, and and micronutrient status. Thus, there is an urgent
limited antinutrient content, as well as high energy and need for studies that determine the impact of new or
nutrient density. modified foods for treating moderate malnutrition in
These requirements are difficult to fulfill when a diet comparison to fortified blended foods and RUTF;
includes few animal-source foods and fortified foods. » The availability of RUTF is limited, and it is prefer-
A largely plant-based diet with few fortified foods is entially used for treating severe acute malnutrition;
disadvantageous, because of a relatively high content » Milk appears to be an essential food that comes at
of antinutrients, lower bioavailability of certain micro- a relatively high cost compared with staples and
nutrients (iron, vitamin A), and the lack of specific soybeans;
nutrients and active compounds contained in animal- » The need for high-quality, nutritious foods for young
source foods. Breastfeeding is an important source of children is not yet understood by all development
several nutrients, but also needs to be complemented partners, which limits commitment and funding.
by animal source foods and fortified foods. Also, many of the modified or new foods or com-
When the diet is largely based on plant sources, plementary food supplements are a new concept, both
three main options can be considered for modifica- for consumers and for program implementers; thus,
tion or development of food commodities for young experience with their introduction, distribution, and
TABLE 9. Current response options for food-assistance programs to prevent and treat moderate and mild child malnutrition
(wasting, stunting)
Intervention Potential target groups Considerations
Blanket supplementary feed- All young children, espe- Blanket supplementary feeding of all children < 2 yr is
ing where the prevalence of cially those < 2 yr probably more effective than targeted supplementary
malnutrition is high, i.e., ≥ feeding of underweight children < 5 yr [43]. When pos-
30% underweight or ≥ 15% sible, improved fortified blended foods (which have better
wasted among children MN profile and, when possible, include milk powder,
< 5 yr sugar, and oil) should be used. Alternative to be explored:
staple for general population with additional comple-
mentary food supplements that provide 250–500 kcal for
children 6–23 mo or 6–35 mo of age
Targeted supplementary Children < 5 yr with moder- RUTF (500 kcal/day), new RUF commodity (500 kcal/day),
feeding (appropriate where ate acute malnutrition complementary food supplements (250 kcal/day) + staple,
blanket feeding is not nec- improved fortified blended food with skimmed-milk
essary due to lower malnu- powder, oil, and sugar, or standard fortified blended food
trition prevalence) mixed with sugar and oil
Home fortification using Young children (< 5 yr) Home-fortification commodities can be used when the
complementary food sup- who cannot meet their quality of the primary diet is insufficient. Depending on
plements such as MN needs from the general the age group, prevailing malnutrition rate, and diet, a
powder, lipid-based nutri- food ration or from the selection of the most appropriate complementary food
ent supplements, and pow- local diet that is within supplements can be made
dered complementary food their means (i.e. available,
supplements affordable, acceptable)
Cash transfers or vouchers Vulnerable households in May be particularly suited for urban and periurban areas.
to obtain nutritious foods settings where food is To maximize impact on nutrition, collaboration with pri-
or complementary food available in markets and vate sector should ensure availability of specific nutritious
supplements capacity for implementing commodities to which the vouchers provide access. Eligi-
programs exists bility for receiving a voucher can be linked to conditional
cash transfer or food-for-work programs. Collecting
vouchers and reimbursing shopkeepers requires reason-
ably functioning markets and administrative systems [44]
MN, micronutrient; RUF, ready-to-use food; RUTF, ready-to-use therapeutic food
use needs to be built. Use of new products

It is important to note that the nutrient densities pro-
posed by Golden [1] for specific nutrients are based on With the increasing development of products for
the assumption that the densities for other nutrients are preventing or treating different forms of malnutrition,
also realized. For example, a higher intake of zinc than there is a need for guidance on expected impact and on
the RDA could affect copper metabolism except when when, how, and for whom they can be used. The Con-
copper intake is increased concurrently. Thus, when sultation agreed that if it is expected that a new com-
diets, with or without inclusion of special foods or modity has a better impact than currently used fortified
complementary food supplements, meet the proposed blended food, it can be used in programs, provided that
requirements for some but not for other nutrients, this the product is acceptable to the beneficiaries, while at
may have negative consequences for the status of the the same time its impact is studied under controlled
nutrient(s) of which too low amounts are consumed. circumstances (which could be in another location).
Programs that use a new product should collect data to
monitor the time needed for recovery of children with
Recommendations moderate malnutrition, when the product is used for
treatment, or on the occurrence of new cases of malnu-
In order to move forward with the development and trition if it is used for prevention. Preferred comparison
use of special food commodities for young and/or treatments for a study under controlled circumstances
malnourished children, steps need to be taken in the are the current fortified blended foods and RUTF; the
following areas: latter is an adequately fortified, nutrient-rich therapeu-
tic food. Outcome indicators should include indicators
of physiological, immunological, cognitive, and body
compositional recovery as well as simple weight gain
(see also the Proceedings of the Consultation [47]). more effectively with regard to product development,
production capacity, and distribution?
Product development » Although the why of improved nutrition program-
ming for young and for moderately malnourished
Urgent questions and issues to be addressed for the children is clear, and the most suitable dietary options
development of new foods and complementary food for different contexts are becoming clear, much
supplements include the following: experience needs to be gained with how to advocate
» How much milk is required for optimal growth at for, design, and implement modified programs. This
different ages? involves issues such as the following:
» Could a different combination of nutrients and – Advocacy at global and national levels about why
active compounds achieve the same effect as milk modification of programs and commodities is
powder? proposed;
» The use of phytase for human consumption needs to – Program design: exchanging commodities or
be permitted for young children also, and its impact modifying programs?
on mineral bioavailability and digestibility should be – Acceptability and awareness of new commodities
assessed. among communities;
» The contents and effects of specific antinutrients – How are very similar commodities that are simul-
need to be determined taneously distributed, such as corn–soy blend
» Food-composition tables need to include the con- for general use and corn–soy blend with milk
tents of a wider range of micronutrients, active for young or malnourished children, used at the
compounds, including fibers, and antinutrients. household level?
– Can RUF for an individual child be provided with
Way forward for programs staples for general use by the family or should the
RUF ration be doubled?
Programs need to be adapted based on the newly – Evaluation of program data about the use and
proposed nutrient requirements for moderately mal- impact of new products.
nourished children [1], the use of existing ingredients
[2], the development of new foods and complementary
food supplements (this article), improved understand- Acknowledgments
ing about which dietary changes to recommend and
how [3], and increasing experience with production The authors thank Elaine Ferguson for the analyses of
and use of new products in existing or modified pro- nutrient intake when using different complementary
grams. The following are some program-related issues food supplements; André Briend, Kim Michaelsen, Zita
that will need to be addressed in the near future: Weise Prinzo, and Klaus Kraemer for their insightful
» How can production capacity for new, especially comments; and the respondents to the questionnaire
ready-to-use, products be increased? for their time and responsiveness for their time and
» How can the public and private sectors collaborate responsiveness to further queries.
References
1. Golden MH. Proposed recommended nutrient densities efficacy and effectiveness of complementary feeding
for moderately malnourished children. Food Nutr Bull interventions in developing countries. Maternal Child
2009;30:S267–343. Nutr 2008;4:24–85.
2. Michaelsen KF, Hoppe C, Roos N, Kaestel P, Stougaard 6. Zimmermann MB, Hurrell R. Nutritional iron defi-
M, Lauritzen L, Mølgaard C, Girma T, Friis H. Choice ciency. Lancet 2007;370:511–20.
of foods and ingredients for moderately malnourished 7. Hoppe C, Molgaard C, Michaelsen KF. Cow’s milk and
children 6 months to 5 years of age. Food Nutr Bull linear growth in industrialized and developing coun-
2009;30:S344–405. tries. Annu Rev Nutr 2006;26:131–73.
3. Ashworth A, Ferguson E. Dietary counseling in the 8. Hoppe C, Jacobsen S, Molgaard C, Friis H, Sangild PT,
management of moderate malnourishment in children. Michaelsen KF. The use of whey protein or skimmed
Food Nutr Bull 2009;30:S406–33. milk powder in fortified blended foods for vulnerable
4. World Health Organization. Complementary feeding of groups; a literature review. J Nutr 2008;138:145S–61S.
young children in developing countries. A review of cur- 9. Hotz C, Gibson RS. Traditional food-processing and prepa-
rent scientific knowledge. 1998. Available at: http://www. ration practices to enhance the bioavailability of micronu-
who.int/nutrition/publications/infantfeeding/WHO_ trients in plant-based diets. J Nutr 2007;137:1097–100.
NUT_98.1/en/index.html. Accessed 29 June 2009. 10. Hurrell RF, Juillerat MA, Reddy MB, Lynch SR, Dassenko
5. Dewey KG, Adu-Afarwuah S. Systematic review of the SA, Cook JD. Soy protein, phytate, and iron absorption in
humans. Am J Clin Nutr 1992;56:573–8. 25. Jansen GR. A consideration of allowable fibre levels
11. Hurrell RF, Reddy MB, Juillerat MA, Cook JD. Degradation in weaning foods. Food Nutr Bull 1980;2. Available at:
of phytic acid in cereal porridges improves iron absorption http://www.unu.edu/unupress/food/8F024e/8F024E09.
by human subjects. Am J Clin Nutr 2003;77:1213–9. htm#A%20consideration%20of%20allowable%20
12. Davidsson L, Galan P, Cherouvrier F, Kastenmayer P, fibre%20levels%20in%20weaning%20foods. Accessed
Juillerat MA, Hercberg S, Hurrell RF. Bioavailability in 30 May 2009.
infants of iron from infant cereals: effect of dephytiniza- 26. Méance S, Achour L, Briend A. Comparison of starch
tion. Am J Clin Nutr 1997;65:916–20. digestibility of a blended food prepared with and with-
13. Ciliberto MA, Sandige H, Ndekha MJ, Ashorn P, Briend out extrusion cooking. Eur J Clin Nutr 1999;53:844–8.
A, Ciliberto HM, Manary MJ. Comparison of home 27. Navarro-Colorado C, Mason F, Shoham J. Measuring
based therapy with ready-to-use therapeutic food with the effectiveness of supplementary feeding programmes
standard therapy in the treatment of malnourished in emergencies. Humanitarian Practice Network Paper,
Malawian children: a controlled, clinical effectiveness no 63. September 2008. Available from: http://www.odi.
trial. Am J Clin Nutr 2005;81:864–70. org.uk/resources/details.asp?id=2496&title=measuring-
14. Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam effectiveness-supplementary-feeding-programmes-
A. Management of severe acute malnutrition in children. emergencies.Accessed 15 June 2009.
Lancet 2006;368:1992–2000. 28. de Pee S, van Hees J, Heines E, Graciano F, van den
15. Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt Briel T, Acharya P, Bloem MW. Ten minutes to learn
M, Saboya M, Walsh A. Key issues in the success of about nutrition programming. Sight and Life Magazine
community-based management of severe malnutrition. 2008;3(suppl):1–44. Available at: http://www.sightandlife
Food Nutr Bull 2006;27:S49–82. .org/images/stories/pageimages/content/magazine
16. World Health Organization/UNICEF/World Food Pro- /03_2008/supplement_10_minutes_to_learn.pdf.
gramme/United Nations Standing Committee on Nutri- Accessed 30 May 2009.
tion. Joint statement on community-based management 29. United States Department of Agriculture (USDA), Farm
of severe malnutrition. 2007. Available at: http://www. Service Agency (FSA). USDA Commodity Requirements.
who.int/nutrition/topics/statement_commbased_ CSB13. Corn–soy blend for use in export programs.
malnutrition/en/index.html. Accessed 30 May 2009. Available at: http://www.fsa.usda.gov/FSA/webapp?are
17. Patel M, Sandige HL, Ndekha MJ, Briend A, Ashorn P, a=home&subject=coop&topic=pas-ex-cr. Accessed 30
Manary MJ. Supplemental feeding with ready-to-use May 2009.
therapeutic food in Malawian children at risk of mal- 30. Marchione TJ. Foods provided through US government
nutrition. J Health Popul Nutr 2005;34:351–7. emergency food aid programs: policies and customs
18. Defourny I, Harczi G, Seroux G, Kader I. Management governing their formulation, selection and distribution.
of moderate malnutrition with RUTF in Niger. Field J Nutr 2002;132:2104S–11S.
Exch 2007;31:2–4. 31. Menon P, Ruel MT, Loechl CU, Arimond M, Habicht
19. Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend J-P, Pelto G, Michaud L. Micronutrient sprinkles reduce
A, Dewey KG. Randomized comparison of 3 types of anemia among 9- to 24-mo-old children when delivered
micronutrient supplements for home fortification of through an integrated health and nutrition program in
complementary foods in Ghana: effects on growth and rural Haiti. J Nutr 2007;137:1023–30.
motor development. Am J Clin Nutr 2007;86:412–20. 32. United States Department of Agriculture (USDA), Farm
20. Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Service Agency (FSA). USDA Commodity Requirements.
Briend A, Dewey KG. Home fortification of comple- WSB15. Wheat–soy blend for use in export programs.
mentary foods with micronutrient supplements is well Available at: http://www.fsa.usda.gov/FSA/webapp?are
accepted and has positive effects on infant iron status in a=home&subject=coop&topic=pas-ex-cr Accessed 30
Ghana. Am J Clin Nutr 2008;87:929–38. May 2009.
21. Lin CA, Manary MJ, Maleta K, Briend A, Ashorn P. An 33. Nestel P, Briend A, de Benoist B, Decker E, Ferguson
energy-dense complementary food is associated with a E, Fontaine O, Micardi A, Nalubola R. Complementary
modest increase in weight gain when compared with food supplements to achieve micronutrient adequacy
a fortified porridge in Malawian children aged 6-18 for infants and young children. J Pediatr Gastroenterol
months. J Nutr 2008;138:593–8. Nutr 2003;36:12–22.
22. Phuka JC, Maleta K, Thakwalakwa C, Cheung YB, Briend 34. Zlotkin SH, Schauer C, Christofides A, Sharieff W,
A, Manary MJ, Ashorn P. Complementary feeding with Tondeur MC, Hyder SMZ. Micronutrient sprinkles to
fortified spread is likely to reduce the incidence of severe control childhood anaemia. PLoS Med 2005;2:e10. Avail-
stunting among 6–18 month old rural Malawians. Arch able at: www.plosmedicine.org. Accessed 30 May 2009.
Pediatr Adolesc Med 2008;162:619–26. 35. de Pee S, Kraemer K, van den Briel T, Boy E, Grasset
23. Matilsky DK, Maleta K, Castleman T, Manary MJ. C, Moench-Pfanner R, Zlotkin S, Bloem MW. Quality
Supplementary feeding with fortified spreads results criteria for micronutrient powder products. Food Nutr
in higher recovery rates than with corn/soy blend in Bull 2008;29:232–41.
moderately wasted children. J Nutr 2009 Feb 18. [Epub 36. de Pee S, Moench-Pfanner R, Martini E, Zlotkin S,
ahead of print] Darnton-Hill I, Bloem MW. Home fortification in
24. Instituto de Investigacion Nutricional, Graham GG, emergency response and transition programming:
MacLean WC. Digestibility and utilization of extrusion- experiences in Aceh and Nias, Indonesia. Food Nutr
cooked corn-soy blends. Baltimore, MD, USA: US Bull 2007;28:189–97.
Agency for International Development, 1979. 37. Infant and Young Child Nutrition Working Group:
Formulation subgroup of the ten year strategy to and morbidity of children aged 6 to 60 months in Niger.
reduce vitamin and mineral deficiencies. Formulations JAMA 2009;301:277-85.
for fortified complementary foods and supplements: 43. Save the Children (UK). Running on empty. Poverty
Review of successful products for improving nutritional and child malnutrition. Briefing, May 2007. Available
status of infants and young children. Food Nutr Bull from http://www.savethechildren.net/media/publica-
2009;30:239–54. tions/2007/20070630_Running_On_Empty_Briefing.
38. Briend A. Trial and error methods, “expert” guessing pdf. Accessed 15 June 2009.
or linear programming? Formulating sound nutritional 44. Valpiani N, Thorne-Lyman AL, de Pee S, Godfrey S,
recommendations for complementary feeding. SCN Gentilini U, Bloem MW. Mitigating the impact of high
News 2003;27:36–9. food prices on nutrition and health in Latin America
39. Ferguson EL, Darmon N, Fahmida U, Fitriyanti S, and the Caribbean: considerations for a short-term
Harper TB, Premachandra IM. Design of optimal food- strategy. CAB rev: Perspectives in Agric, Vet Sc, Nutr,
based complementary feeding recommendations and Nat Res 2008;81 (doi: 10.1079/PAVSNNR20083081).
identification of key “problem nutrients” using goal 45. Victora CG, Adair L, Fall C, Hallal PC, Martorell R,
programming. J Nutr 2006;136:2399–404. Richter L, Sachdev HS. Maternal and child undernutri-
40. Rimbach G, Pallauf J, Moehring J, Kraemer K, Minihane tion: Consequences for adult health and human capital.
AM. Effect of dietary phytate and microbial phytase Lancet 2008;371:340–57.
on mineral and trace element bioavailability—a litera- 46. Ruel MT, Menon P, Habicht J-P, Loechl C, Bergeron G,
ture review. Current Topics in Nutraceutical Research Pelto G, Arimond M, Maluccio J, Michaud L, Hankebo
2008;6:131–44. B. Age-based preventive targeting of food assistance and
41. Troesch B, Egli I, Zeder C, Hurrell RF, de Pee S, Zim- behaviour change and communication for reduction of
mermann MB. Optimization of a phytase-containing childhood undernutrition in Haiti: a cluster randomized
micronutrient powder with low levels of highly bioavail- trial. Lancet 2008;371:588–95.
able iron for in-home fortification of complementary 47. Shoham J, Duffield A. Proceedings of the World Health
foods. Am J Clin Nutr 2009;89:539–44. Organization/UNICEF/World Food Programme/United
42. Isanaka S, Nombela N, Djibo A, Poupard M, van Beck- Nations High Commissioner for Refugees Informal
hoven D, Gaboulaud V, Guerin PJ, Grais RF. Effect Consultation on the Management of Moderate Malnu-
of preventive supplementation with ready-to-use trition in Children under 5 Years of Age. Food Nutr Bull
therapeutic food on the nutritional status, mortality, 2009;30:S464–74.

Saskia de Pee and Martin W. Bloem: Food and Nutrition Bulletin

Uploaded by

Copyright:

Available Formats

Saskia de Pee and Martin W. Bloem: Food and Nutrition Bulletin

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Saskia de Pee and Martin W. Bloem: Food and Nutrition Bulletin

Uploaded by

Copyright:

Available Formats

Current and potential role of specially formulated

foods and food supplements for preventing

Saskia de Pee and Martin W. Bloem

Abstract many antinutrients, no milk (important for growth),

Among relatively food-secure populations (i.e., those

Local diet: Issues Modification options

TABLE 3. Classification of complementary food supplements

TABLE 3. Classification of complementary food supplements (continued)

Supplement Supplement Replacement Replacement

Need and feasibility of further adjustments to

As mentioned above, one of the main issues with

malnourished children is the high content of antinu-

or trients, particularly phytate, and its fiber content. A

made from whole cornmeal and dehulled soybean

content. High fiber content may also reduce energy

intake through an effect on appetite, increased fecal

losses of energy due to reduced absorption of fat and

also lead to nonacceptance of the product. Although

adding oil or sugar to the product, it does not improve

An article by Jansen published in 1980 that reviewed

more results, however, concluded that degerming corn

also results in loss of protein and oil from the germ

related to its higher fiber content [25]. With regard

to the likely lower bioavailability of minerals, Jansen

meal is used (extraction rate of 65% to 75%, and thus

a loss of 25% to 35%), the desire to produce the prod-

uct locally, and the possibility to at least dehull the

maize meal, resulting in a crude fiber content of less

than 2%, and be mixed with an adequate micronutri-

and degermed corn and dehulled defatted soybeans or

Total product cost (US$) for

optionally dehulled full-fat soybean flour, and up to

10% of corn germ may be added back to the product.

ment of normal diet

Corn–soy blend purchased locally in developing coun-

tries by both WFP and UNICEF, however, is made from

* Details about USDA Food Aid can be retrieved from Pro-

Fortified blended foods Options for improving nutritional quality

whole maize as well as whole soybeans.* Option 4. Complementary food

Riboflavin 98 98 172 121 172 198 142 136 99 268 268

TABLE 8. Other foods provided to moderately malnourished children

TABLE 8. Other foods provided to moderately malnourished children (continued)

foods or complementary food supplements can be or moderately malnourished children:

use needs to be built. Use of new products

You might also like