Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial

Objective: Explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition, and describe associations with survival and non-communicable disease (NCD) risk seven years post-treatment. Design: Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score (WAZ) and height-for-age z-score (HAZ). Three categorisation methods included: no categorisation, quintiles, and latent class analysis (LCA). Associations with mortality risk, and seven NCD indicators were analysed. Setting: Secondary data from Blantyre, Malawi between 2006 and 2014. Participants: A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score <70% median and/or MUAC<110 mm and/or bilateral oedema) at aged 5 to 168 months Results: Faster weight gain during treatment (g/day) and after treatment (g/kg/day) were associated with lower risk of death (aOR 0.99, 95%CI 0.99 to 1.00; and aOR 0.91, 95% CI 0.87 to 0.94 respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0.02, 95%CI 0.00 to 0.03) and larger HAZ (6.62, 95%CI 1.31 to 11.9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0.02, 95%CI 0.01 to 0.03), an indicator of later life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/day during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. Conclusions: A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.

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“…Programmes for moderate malnutrition are important in this prevention role, limiting and monitoring further weight loss (42) .…”

Section: Discussionmentioning

confidence: 99%

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi ‘ChroSAM’ cohort

Lelijveld

Cox

Anujuo

et al. 2023

Public Health Nutr.

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“…Furthermore, Family MUAC is designed to increase demand for nutrition treatment services but does not necessarily increase service availability and accessibility. Early referral could generate demand for an unavailable service: MAM service coverage is historically low and difficult to quantify (Brown et al, 2019 ), and there lacks global consensus on optimal MAM treatment (Lelijveld et al, 2019 ). Any programme that encourages self‐monitoring and self‐referral should therefore also aim to ensure treatment availability for the identified condition.…”

Section: Discussionmentioning

confidence: 99%

Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic

Wrabel

Stokes‐Walters

King

et al. 2022

Maternal & Child Nutrition

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The COVID-19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community-based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid-upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow-up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well-accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID-19 disruptions; however, challenges included long-term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme.Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi-year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences.

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“…Admission weight deficit is less easy to control – though this finding does reiterate the need for prevention and proactive case finding to catch children early in their deterioration. Programmes for moderate malnutrition are important in this prevention role, limiting and monitoring further weight loss (48).…”

Section: Discussionmentioning

confidence: 99%

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: A secondary analysis of the Malawi ‘ChroSAM’ cohort

Lelijveld

Cox

Anujuo

et al. 2022

Preprint

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Background: Rapid catch-up growth after prenatal undernutrition is associated with increased risk of non-communicable diseases (NCDs) in high-income countries. Severe malnutrition treatment programmes in low- and middle-income countries promote rapid post-malnutrition growth (PMGr) as desirable. Our aim was to explore patterns of PMGr during and in the year following treatment, and describe associations with survival and NCD risk seven years post-treatment. Methods: Secondary data analysis from a cohort of children treated for severe malnutrition in Malawi in 2006/7. Six definitions of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score (WAZ) and height-for-age z-score (HAZ). Three categorisation methods included: no categorisation, quintiles, and latent class analysis (LCA). Associations with mortality risk, and with eight NCD indicators were analysed visually using scatter plots and boxplots, and statistically using simple and multivariable linear regression. Findings: Faster weight gain was associated with lower risk of death (g/day during treatment aOR 0.99, 95%CI 0.99 to 1.00, p=0.04; after treatment g/kg/month aOR 0.91, 95% CI 0.87 to 0.94, p<0.001). In survivors, it was associated with greater hand grip strength in some instances (g/day during treatment 0.02, 95%CI 0.00 to 0.03, p=0.007) and larger HAZ 7-years post-discharge (adjusted Δ WAZ per day during treatment 6.62, 95%CI 1.31 to 11.9, p=0.02), both indicators of better health. However, faster weight gain in treatment was also associated with increased waist:hip ratio (adjusted g/day during treatment 0.02, 95%CI 0.01 to 0.03, p=0.003), a key indicator of later life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/day during treatment, and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. Conclusion: We found a complex pattern of benefits and risks associated with faster PMGr with a possible trade-off between short- and long-term benefits/risks. Peripheral versus visceral weight distribution in particular requires further exploration. Both initial weight deficit and rate of weight gain have important implications for future health. Because conclusions from observational studies can go only so far, future randomised intervention trials are needed.

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Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial

Cited by 14 publications

References 23 publications

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi ‘ChroSAM’ cohort

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi ‘ChroSAM’ cohort

Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: A secondary analysis of the Malawi ‘ChroSAM’ cohort

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