WHZ and MUAC Overlap but Identify Different Children As Acutely Malnourished, and Diagnosis Is Sensitive to Child Sex. Insights From Burkina Faso and Sierra Leone

Objectives To examine differences in outcomes when using MUAC and/or WHZ to identify wasted children by sex in Burkina Faso and Sierra Leone. Methods Spearman's correlation was calculated to examine the relationship between MUAC and WHZ. Kappa Statistics were calculated to examine the agreement between MUAC and WHZ in identifying wasted children. Sensitivity and specificity of WHZ using MUAC as benchmark for identifying wasting was calculated. Results There were 6112 children total in Burkina Faso (51% male); 2650 children total in Sierra Leone (43% male). In Burkina Faso, the correlation between MUAC and WHZ for both sexes was significant (lowest r = 0.79, p < 0.001; highest r = 0.86, p < 0.001). Agreement between the two measures in identifying wasted children was fair for female (k = 0.29, p < 0.001), but poor for male children (k = 0.16, p < 0.001). Sensitivity analysis revealed that WHZ identified the same MAM and SAM children more often for males (MAM: 40%–68%; SAM: 25%–100%) than females (MAM: 25%–61%; SAM: 13%–80%). Specificity analysis revealed that WHZ identified non-malnourished children similarly for both sexes (male: 86%–96%; female: 94%–98%). In Sierra Leone, the correlation between MUAC and WHZ was high in relation to both sexes (r = 0.78, p < 0.001). Agreement between the two measures in identifying wasted children was fair for both sexes (k = 0.24, p < 0.001). Sensitivity analysis showed that WHZ identified the same MAM and SAM children more often for males (MAM: 33–66.7%; SAM: 20–100%) than females (MAM: 15–33%; SAM: 9–50%). Specificity analysis showed that WHZ identified non-malnourished children for both sexes similarly (MAM: 75%–100%; SAM: 94%–100%). Conclusions Poor overlap was found between MUAC and WHZ in diagnosing wasted children, and high sensitivity of these measures to sex of child. Both measures should be used together to inclusively identify all wasted children for treatment. Funding Sources United States Agency for International Development's Bureau for Humanitarian Assistance (USAID/BHA) and legacy Office of Food for Peace (FFP).

Behavioral Factors Related to Use of Specialized Nutritious Foods in a MAM Treatment Program in Sierra Leone

Objectives This analysis describes differences in household-level use of four specialized nutritious foods (SNFs) for treatment of moderate acute malnutrition (MAM) in children 6–59 months of age in Sierra Leone and explores whether these behaviors influenced recovery. Methods From 4/2017 to 11/2018, sub-samples of caregivers whose children were enrolled in a supplemental feeding program (SFP) for a MAM treatment study were randomly selected for in-depth interviews and in-home observations. This was a cluster-randomized trial of 2653 children with MAM in Sierra Leone evaluating cost-effectiveness of 4 SNFs: Super Cereal Plus w/amylase (SC + A), Corn-soy Blend Plus w/oil (CSB + w/oil), Corn-soy-whey Blend w/oil (CSWB w/oil), and Ready-to-Use Supplementary Food (RUSF). Caregivers received bi-weekly isocaloric distributions of 1 of the 4 SNFs until recovery or up to 12 weeks. The purpose of the in-depth interviews was to understand caregivers’ experiences with the SFP and the SNF which they received. In-home observations gathered information about observed behaviors related to SNF use over 5 consecutive days. Descriptive statistics were calculated and stratified by study arm and by outcome to explore: consumption of the SNF by the target child, sharing and selling, and diversion of other household foods. Results A total of n = 949 caregivers completed an in-depth interview. Of these, n = 323 also had an in-home observation. Observed consumption of the SNF was high in all study arms (>60%), with no discernible differences among arms. Consumption of the study food by anyone other than the beneficiary child (i.e., sharing) was similar across arms (9–12% reported, 19–27% observed), with the lowest reported and highest observed in RUSF. Very few reported giving the SNF away or selling it to others (<1%). Sharing and displacement did not differ by recovery status, but children who recovered were observed consuming the SNF more often than those who failed (82% vs. 46%). Conclusions Sharing of the SNF was common among all arms but did not affect likelihood of recovery. Ensuring adequate consumption of the SNF by the beneficiary child is critical for effectiveness. Qualitative data can expand on these findings. Funding Sources Office of Food for Peace, United States Agency for International Development.

Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit

Background: Global food insecurity persists despite continued international attention, necessitating evidence-based food assistance interventions that adequately address nutritional concerns. In June 2018, the US Agency for International Development’s Office of Food for Peace through the Food Aid Quality Review (FAQR) project sponsored a “Food Assistance for Nutrition Evidence Summit” to share evidence relevant to policy and programmatic decision-making and to identify critical evidence gaps. Objective: This article presents 4 priority areas to advance nutrition in the international food assistance agenda generated through presentations and discussions with the food assistance community at the Evidence Summit. Methods: Priority areas were identified after the Evidence Summit using a combination of FAQR team discussions, review of presentations and official notes, and supporting literature. Results: Key priority areas to advance nutrition in the international food assistance agenda are as follows: (1) increase research funding for food assistance in all contexts, paying particular attention to emergency settings; (2) research and adopt innovative ingredients, technology, and delivery strategies in food assistance products and programs that encourage long-term well-being; (3) redefine and expand indicators of nutritional status to capture contextual information about the outcomes of food assistance interventions; and (4) augment communication and collaboration across the food assistance ecosystem. Conclusions: These priorities are critical in a time of increased humanitarian need and will be key to fostering long-term resilience among vulnerable groups.

Agriculture and Food Aid in US Policymaking during the Cold War

In the 20th century, US policymakers often attempted to solve domestic agricultural oversupply problems by extending food aid to foreign recipients. In some instances, the United States donated food in times of natural disasters. In other instances, the United States offered commodities to induce foreign governments to support US foreign policy aims or to spur agricultural modernization. These efforts coalesced during the 1950s with the enactment of Public Law 480, commonly known as the Food for Peace program, which provided for a formal, bureaucratic mechanism for the disbursement of commodities. Throughout the second half of the 20th century, successive presidential administrations continued to deploy commodities in advance of their often disparate foreign policy objectives.

Self-Reported Adherence to Ration Guidance During Preparation or Feeding of Four Specialized Foods May Not Predict Recovery from Moderate Acute Malnutrition (MAM) (P10-143-19)

Objectives Fortified blended flours (FBFs) require preparation with boiling water, sometimes with fortified vegetable oil (FVO), using prescribed quantities and ratios. Lipid-based nutrient supplements (LNS) are ready-to-eat, individually packaged, and prescribed for consumption without adding other ingredients/foods. This study assessed compliance with recipe and ration instructions and whether this influenced treatment effectiveness for moderate acute malnutrition (MAM). Methods A cluster-randomized clinical-effectiveness trial in Sierra Leone compared four isocaloric foods in treating children 6–59 mos with uncomplicated MAM: Corn-Soy Blend Plus with FVO (CSB +), Corn-Soy Whey Blend with FVO (CSWB), Super Cereal Plus with amylase (SC + A), or ready-to-use-supplementary food (RUSF). Caregivers were advised bi-weekly by trained nurses on ingredients, quantities, and daily rations. A random sub-sample participated in in-depth interviews on ingredients used at the last preparation. Respondents were categorized in two ways: (for FBFs) using too little, the correct amount or too much or (for RUSF) correct if eaten without other food; or using the recommended ratios of ingredients. Unadjusted logistic regression evaluated the relationship between compliance and graduation from treatment. Results Graduation rates among 958 respondents: 70% CSB + , 67% CSWB, 66% SC + , and 66% RUSF. Reported use of correct ingredients was: 99% of CSB +, 97% of CSWB, and 99% of SC + A and 86% RUSF reported eating without mixing. Reported use of correct amount of flour: 34% in CSB + , 27% in CSWB, and 43% in SC + A of those, 95% in CSB + and 96% in CSWB also used the correct amount of oil. Among all caregivers, 86% in CSB + and 92% in CSWB used the correct amount of oil. In unadjusted models, the relationships between compliance behaviors and graduation were not statistically significant. Conclusions Reported use of correct ingredients was high for all study foods; among FBFs, amount of flour was often different from the recommendation while amount of oil was often correct. Further research may explain apparent low importance of emphasizing ration guidance when designing information, education, and communication for MAM treatment programs. Funding Sources Office of Food for Peace, Bureau for Democracy, Conflict, and Humanitarian Assistance, U.S. Agency for International Development.