Food Aid Research: An Update on Food Aid for Preventing & Treating Undernutrition. October 2017 Part I

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2 Food Aid Research: An Update on Food Aid for Preventing & Treating Undernutrition October 2017 Part I

3 Please Cite this Presentation as: Collins S, de Pee S, Dewey KG, El-Khour T, Michaelsen, K Rogers B. Food aid research: an update on food aid for preventing & treating undernutrition. PowerPoint slides presented at the 21 st International Congress of Nutrition, Buenos Aires, Argentina Oct 18.

4 Why are we here? 18/10/2017 IUNS 21 st International Congress of Nutrition 4

5 Food Aid Research what and why? 1. Lots of new food aid products (and changes to ingredient specifications) in past few years: Lipids, new forms of iron in premix, different dairy ingredients 2. Upsurge in research on product efficacy, effectiveness, cost-effectiveness of food aid for nutrition. 3. Need to distill new findings for donor agencies (calls for evidence-based programming), and define remaining knowledge gaps? 11/15/2017 FOOTER GOES HERE 5

6 Food Aid Research this meeting and beyond 4. This symposium part of series to share, distill and discuss science relevant to food aid programming for nutrition. 5. New empirical results emerging daily. The technologies involved in food products also improving rapidly (extrusion, packaging, microencapsulation, etc.) 6. Tufts hosts one mechanism for pulling it all together: REFINE 11/15/2017 FOOTER GOES HERE 6

7 REFINE: Research Engagement on Food Interventions for Nutritional Effectiveness Launched in October 2016 as part of FAQR Phase III Knowledge-sharing mechanism to share knowledge on effectiveness of food-supported interventions 11/15/2017 FOOTER GOES HERE 7

8 Currently on www. REFINEnutrition.org: 56 ongoing studies in 28 countries 284 publications in the REFINE library (academic and grey literature) 18/10/2017 8

9 Focus of 81 published studies (since 2011) Acceptability Adherence Composition Cost-Effectiveness Effectiveness Efficacy Product Innovation Programmatic Innovation Use /10/2017 IUNS 21 st International Congress of Nutrition 9

10 29 ongoing trials focus on: Acceptability Adherence Composition Cost-Effectiveness Effectiveness Efficacy Product Innovation Programmatic Innovation Use /10/2017 IUNS 21 st International Congress of Nutrition 10

11 For our deliberation Are the right questions being addressed? Are they being addressed in the right ways? What else should be prioritized in this research domain? Who else should be involved in such research? 18/10/2017 IUNS 21 st International Congress of Nutrition 11

12 How does dairy protein perform when it is the principal source of protein in food aid? Kim Fleischer Michaelsen Paediatric and International Nutrition Department of Nutrition, Exercise and Sports University of Copenhagen

13 Conflict of Interest Disclosure Kim F Michaelsen has received funding from USDEC, ARLA and Danish Dairy Foundation for research projects including dairy products to malnourished children

14 Why is dairy protein interesting?

15 Annu Rev Nutr. 2006;26: Convincing evidence that cow s milk stimulates linear growth from intervention studies in low-income countries Observational studies also from well-nourished populations show positive associations between milk intake and linear growth Newer reviews also supporting the effects on linear growth Dror DK, Allen LH. Dairy product intake in children and adolescents in developed countries: trends, nutritional contribution, and a review of association with health outcomes. Nutr Rev Feb;72(2):68-81 de Beer H. Dairy products and physical stature: a systematic review and meta-analysis of controlled trials. Econ Hum Biol Jul;10(3): Grasgruber et al. Major correlates of male height: A study of 105 countries. Econ Hum Biol May;21:

16 Cow s milk and growth Mainly whey? Cow s milk Protein (whey-casein) Peptides/bioactive factors Minerals - Lactose Insulin Mainly casein? IGF-I Growth Hormone Programming effect? Linear Growth Cognitive Lean development? mass accretion Immune system? Positive effect Negative effect Hoppe et al EJCN 2005

17 What are the growth components in milk? Protein DSM whey/casein- AA pattern Growth minerals e.g phosphorus, potassium, zinc Lactose Bioactive peptides Less antinutrients Permeate contains lactose and minerals

18 Undernourished children and milk lactose Grenov et al Food Nutr Bull 2016 Potential negative effects Lactose intolerance Potential positive effects Prebiotic effects Increased mineral absorption Energy density, palatability Improved growth? Convincing results from Intervention studies in piglets Cromwell et al. J Anim Sci 2008

19 Sources of lactose for food aid w/w% SMP WPC34 WPC80 WPI Lactose Lactose energy percentage Human milk 40 E% Cows milk 25 E%

20 Recommendations and specifications on dairy protein in food aid

21 Proposed nutrient composition of supplementary foods for use in the management of MAM 2012 PDCAAS >70%. Corresponds to cereal/legume mixtures, milk or animal proteins Note: The inclusion of milk improves the amino acid profile (PDCAAS) and has a specific stimulating effect on linear growth and IGF-1 levels and does not contain anti-nutrients WHO calls for additional research

22 Specifications on dairy from WFP and USAID WFP Super Cereal Plus - August w/w% DSM WFP RUSF and LNS-MQ - January 2016 RUSF and LNS-MQ PDCAAS 70%. If DSM (36% protein) used - equivalent to 10 % DSM USAID RUF December 2015 RUSF, LNS-MQ 33% protein from dairy RUTF 50% protein from dairy

23 Two recent intervention studies Steve Collins will show two more studies from his group

24 AJCN 2016 Selected Ingredients ( %w) Soy RUSF Whey RUSF Extruded Soy Flour 24.0 Whey Permeate 18.7 WPC Outcomes Soy RUSF Whey RUSF P-value Recovered % MUAC gain mm/d Weight gain g/kg/d Length gain mm/d

25 Intervention among 6-23 months old children with MAM September Funded by DANIDA, MSF-Norway, MSF-DK, WFP, USAID, ALIMA, ACF, ECHO and Arvid Nilsson s Foundation

26 Treatfood design 6-23 mo old children (n=1609) randomised to one of 12 supplements (500 kcal) for 12 weeks R Matrix Soy quality Milk (% of protein) CSB LNS Dehulled A B C Isolate D E F Dehulled G H I Isolate J K l A: CSB+ B: CSB++ I: PlumpySup??: Plumpynut

27 Primary: Treatfood outcomes Fat free mass index deuterium dilution technique Secondary: Weight, length, knee-heel length, recovery, Hb and more

28 Outcome Main Treatfood results Overall the children gained mainly fat free tissue LNS compared to CSB resulted in more lean mass. Outcome Fat-free-mass index (kg/m 2 ) LNS versus CSB Fat-free-mass index (kg/m2) (0.003, 0.163) Fat-mass index (kg/m2) (-0.023, 0.127) Effects of milk protein There was no overall effect of milk, which might be because 94% of the children were breastfed Milk protein percent 20% vs 0% ( 0.002, 0.196) p=0.055 Milk protein percent 50% vs 0% ( 0.047, 0.146) Length (cm) 0.03 ( 0.08, 0.13) 0.07 ( 0.03, 0.17) Knee-heel length (mm) 0.6 ( 0.2, 1.3) 0.7 ( 0.1, 1.4) p=0.07

29 Food Nutr Bull 2015 (supplement) - IAEA meeting High milk content of RUTFs makes it an expensive product Using lower quantities of milk seems desirable. Formulation of alternative, less expensive versions of RUTF faces difficult challenges: Uncertainties regarding protein quality, antinutrient content, and flatulence factors Formulation of alternative RUTFs will require further research on these aspects

30 Food Nutr Bull 2016 Dairy is recommended in specially formulated supplementary foods to treat children with MAM but with limited evidence and added cost There is a consistent benefit of FBF that include dairy in treatment of children with MAM Benefits of dairy in RUF require further investigation.

31 Conclusions and steps forward Dairy protein has a growth stimulating effect and an optimal amino acid composition, but a high cost There is increasing interest in the effect of protein quality and the need for specific amino acids in malnourished children Optimizing AA quality by combining dairy and plant protein and cereals and legumes is being explored Can addition of specific AA important for growth to foods with only plant protein match the effects of dairy on growth and other outcomes and is it an affordable solution?

32 Acknowledgements Henrik Friis Christian Fabiansen Christian Mølgaard Benedikte Grenov André Briend (Affiliated Prof at UCPH)

33 The efficacy of ready to use therapeutic foods made without milk or animal source protein Paluku Bahwere, Peter Akomo, Mwawi Mwale, Hitoshi Murakami, Chrissy Banda, Sylvester Kathumba, Chimwemwe Banda, Solomon Jere, Kate Sadler and Steve Collins Presented by Dr. Steve Collins Valid Nutrition Ireland

34 Conflict of Interest Disclosure We have received support from Ajinomoto Co. Inc. in relation to part of the results presented here.

35 Soya, Maize, Sorghum RUTF A two arm non-inferiority individually randomized controlled efficacy clinical trial Bahwere et al. Am J Clin Nutr Apr;103(4): Intention To Treat analysis Per Protocol analysis Recovery rates compared to standard Peanut Milk recipe RUTF 11/15/2017 FOOTER GOES HERE 35

36 Soya, Maize, Sorghum RUTF with amino acid A three arm non-inferiority individually randomized controlled efficacy clinical trial Bahwere et al. Am J Clin Nutr Oct;106(4): Milk free SMS RUTF 9.3% milk SMS RUTF Standard milk peanut RUTF Analysed Analysed Analysed 10 ITT analyses=433(262/171) 11 PP analysis cure rate=360(211/149) Defaulters excluded n=73(51/22) Weight gain & 12 LOS=340(196/144) Not cured excluded n=93(66/27) ITT analyses=420(253/167) PP analysis cure rate=355 (205/150) Defaulters excluded n=65(48/17) Weight gain & LOS=330(186/144) Not cured excluded n=90(67/23) ITT analyses=446(280/166) PP analysis cure rate=380(229/151) Defaulters excluded n=66(51/15) Weight gain & LOS=353 (210/143) Not cured excluded n=93(70/23) Numbers in each analysis (< 24 months / >= 24 months) 11/15/2017 FOOTER GOES HERE 36

37 Recovery rates compared to standard Peanut Milk recipe RUTF 18/10/2017 IUNS 21 st International Congress of Nutrition 38

38 Length of stay and weight velocity compared to standard Milk-Peanut RUTF 18/10/2017 IUNS 21 st International Congress of Nutrition 39

39 Impact on haemoglobin compared to standard peanut milk recipe 18/10/2017 IUNS 21 st International Congress of Nutrition 40

40 Cost comparison Soya Maize Sorghum RUTF Vs standard milk peanut RUTF 2,500 2,000 2,403 Ingredient Cost Comparsion 1,718 USD/MT 1,500 1, Stabiliser Premix Sugar Palm Stearin Vegetable oil Skimmed Milk Powder - Milk Peanut Recipe Soya Maize Sorghum RUTF 18/10/2017 IUNS 21 st International Congress of Nutrition 41

41 Other benefits of Soya Maize Sorghum RUTF compared to the standard milk peanut RUTF 10% lower sugar content Ease and safety of manufacture and use Decreased costs and working capital requirements for manufacture in developing countries Reduced aflatoxin risk from peanuts Decreased risk of allergic reaction to peanuts amongst users Decreased carbon foot print and enhanced sustainability Use of plant origin ingredients Few food miles for production and use 18/10/2017 IUNS 21 st International Congress of Nutrition 42

42 Thank you for listening Agricultural sustainability Crop diversity Economic empowerment Lower cost efficacious products 18/10/2017 IUNS 21 st International Congress of Nutrition 43