By Daniel R. Colagiacomo
Abstract
Acute and chronic malnutrition continue to remain a critical issue of the utmost importance in many nations around the world. Although humanity has taken great strides in reducing the overarching prevalence of wasting and stunting, their global rate of prevalence continues to remain high, especially within developing nations in Asia and Africa. The development and use of ready-to-use nutritional food (RUTF) has allowed for breakthroughs to occur in the treatment of individuals suffering from acute and chronic undernutrition due to their high density of micronutrients and macronutrients, their long shelf-life, and for their ability to be easily distributed and consumed by all. Unfortunately, their high cost and high renal solute load limit their accessibility and efficacy in communities where access to safe drinking water and healthcare funding is limited. However, improving the formulation of RUTFs through adding soybean and oat to peanut-based RUTFs could potentially improve the overall nutritional value, cost, and the reception of children to therapeutic foods. Moreover, the development of tailored formulations of RUTF for specific age ranges could result in less of a burden being placed upon the kidneys as a result of the consumption of nutrient-dense RUTFs, and a decrease in the chance of the development dehydration-related conditions as a result of consuming RUTFs. More research must be done to prove whether a formulation for an RUTF based on peanut, soybean, and oat will treat acute and chronic malnutrition with greater effectiveness than an RUTF based on only peanuts.
Introduction
Childhood undernutrition, in all its forms, has imparted a deleterious impact upon communities in developing nations across the world, further perpetuating the cycle of economic ruin and food insecurity within these vulnerable areas. While global humanitarian efforts have allowed for an overall decline in the percentage of children under five years of age who are affected by conditions associated with undernutrition like wasting and stunting since 2000, the global prevalence of wasting in children under five years old continues to remain “alarmingly high” at an estimated global rate of 6.8% in 2022. This figure especially holds true within the vulnerable populations of developing nations in Asia and Africa, as in 2022, 78% of children under the age of five who were diagnosed with severe wasting lived in Asia, while the remaining 22% lived in Africa. (Levels and trends in child malnutrition 2023) Undernutrition will manifest itself within an individual as either acute malnutrition or chronic malnutrition depending on the amount of time that an affected person spends in a state of malnourishment. Both acute and chronic malnutrition are conditions that occur when one does not receive enough energy or protein to continue sustaining normal bodily function, however, one will be diagnosed with acute malnutrition if they have been malnourished for a period of less than about three to six months, and if left untreated for longer than three to six months, the afflicted individual’s condition could progress from acute malnutrition to chronic malnutrition. (Dipasquale et al., 2020) Moreover, the symptoms that could arise from acute malnutrition are usually treatable, whereas the effects of chronic malnutrition on the body are irreversible and are therefore untreatable. According to World Health Organization classification guidelines, a child can be clinically diagnosed with acute malnutrition if they exhibit symptoms of wasting by having a weight-for-height or weight-for-length less than or equal to two standard deviations below the median, and by having a BMI-for-age score greater than or equal to two standard deviations below the median. (IMCI 2017) Furthermore, severe cases of acute malnutrition are often characterized by the development of nutritional bilateral pitting oedema in the feet, which has the ability to spread up the legs and toward other parts of the body. (Prevention and management of wasting and nutritional oedema 2024) A child can be clinically diagnosed with chronic malnutrition if they exhibit signs of cognitive impairment, lack of motor skills, and from exhibiting signs of stunting by having a length-for-age or height-for-age greater than or equal to two standard deviations below the median. (IMCI 2017) (Reinhardt & Fanzo, 2014) One of the most efficient methods of treating conditions associated with undernutrition is by utilizing ready-to-use therapeutic food (RUTF) to reverse the effects of acute malnutrition and to slowly stop the affected individual’s condition from exacerbating. (Bahwere et al., 2024) Despite the fact that the development of RUTFs have allowed for great progress to be made in the eradication of undernutrition on a global scale, factors such as their high cost and high renal solute load have presented many challenges with their ability to be distributed to developing nations and to support the populations they are designed to serve. (Bazzano et al., 2017) While RUTFs have allowed for great progress to be made in the realm of treating acute and chronic malnutrition, it can be stated that changes need to be made to the formulae of RUTFs to ensure they are able to be consumed by all children with less of a risk of promoting dehydration, to further improve the nutritional balance and reception of children to RUTFs, and to safeguard the cost of treatment for acute and chronic malnutrition with RUTFs from increasing further.
General Information on RUTFs
RUTFs are specially formulated foods that are meant to be used as nutritional supplements in conjunction with other treatments to rectify macronutrient and micronutrient deficiencies in individuals suffering from acute and chronic malnutrition. RUTFs are generally shelf-stable for about two years and do not require the use of any other ingredients or equipment to prepare them for consumption, allowing them to be distributed and accessed more easily than other treatments for conditions related to undernutrition. (Bazzano et al., 2017) These therapeutic foods are usually made with a base that is high in protein and fats like peanuts, and are fortified with various vitamins and minerals, including but not limited to sodium, potassium, calcium, zinc, iodine, and vitamins A, D, E, K, C, B1, B2, B6, and B12 to ensure all the afflicted individual’s needs are accounted for and to promote weight gain in the individual. (WHO guideline on the dairy protein content in ready-to-use therapeutic foods 2021) RUTFs are also made to be a thick paste, as this ensures that all as young as six months are able to consume and digest these foods without much difficulty. (Bazzano et al., 2017) Therefore, their long shelf-life, high micronutrient, macronutrient, and caloric density, as well as their ability to be consumed anywhere without requiring fresh water or heat to prepare them make RUTFs a valuable asset in the fight against pediatric undernutrition, especially within nations plagued by conflict, drought, or famine.
Efficacy of RUTFs
As with most treatments, RUTFs have their own set of advantages and disadvantages which serve to benefit or harm their comprehensive accessibility and efficacy. One such advantage is their ability to be easily transported and stored. RUTFs are shelf-stable for up to two years after production and do not require refrigeration when in storage. (Bazzano et al., 2017) This is mainly due to the fact that RUTFs have a low water content, which strongly deters bacterial growth in the food, staving off bacterial contamination and spoilage. RUTFs are also generally packaged in single-dose pouches and are therefore able to be easily measured and distributed to individuals suffering from conditions related to undernutrition. As a result, these factors allow for RUTFs to be transported over long distances and stored without much difficulty because of the fact that they do not require refrigeration, and because they can be left in transit or in storage for extended periods of time without the possibility of them spoiling. Moreover, RUTFs can be used to treat acute and chronic malnutrition in any individual over the age of six months and they do not require the use of water or any other ingredients, or the use of any appliances to prepare them before their consumption. (Marzoog et al., 2022) (Bazzano et al., 2017) This in turn allows for RUTFs to be an accessible treatment for undernutrition related conditions for nearly the entire global population as they can be used by almost everyone, because they can be conveniently be eaten anywhere due to their portability, and because they do not need any other ingredients or appliances to be prepared for consumption, allowing for those without access to refrigeration or safe drinking water to be able to use RUTFs to treat their acute or chronic malnutrition as well. However, concerns have been raised relating to the overall efficacy of RUTFs due to their high cost and high renal solute load. Although RUTFs are easy to transport over long distances and are able to be stored for an extended period of time, the average cost of treatment for a child with undernutrition is about USD $200. (Hussein, 2021) This in turn makes it difficult for impoverished families living in war-torn or economically vulnerable areas to be able to afford treatment using RUTFs for their children without the aid of humanitarian organizations, and it further imposes a limit on the number of children that humanitarian organizations are able to fund for the treatment of acute and chronic malnutrition using RUTFs. Furthermore, RUTFs are high in protein, sodium, and potassium, which are all contributing factors as to why these foods have high renal solute loads. When consumed, RUTFs place a greater load on the kidneys than most other foods, meaning that the kidneys will require more water in order to filter the influx of nitrogenous wastes and electrolytes that are introduced into one’s bloodstream as a result of consuming nutrient dense RUTFs. (Hussein, 2021) While this may solve the issue of undernutrition in most populations, the use of RUTFs can cause the rate of incidence of dehydration related illness to rise in communities which lack the ability to obtain clean, safe, and accessible drinking water. Notwithstanding the fact that RUTFs may have their strengths and their flaws, there is still much to be done in relation to improving the overall efficacy of RUTFs through reducing their high cost and high renal solute load.
Changes to Improve the Efficacy of RUTFs
In order to improve the comprehensive efficacy of RUTFs, changes must be made to their formulae in order to improve upon their shortcomings. Most RUTFs use peanuts as the main ingredient in their formulae as they have a high protein and fat content, which are integral macronutrients to the recovery of individuals with conditions related to undernutrition. Although peanuts have a high protein and fat content, they have a relatively lower carbohydrate content with about 16.1g of carbohydrates per 100g of peanuts. (Peanuts, all types, raw 2019) However, the addition of oats alongside peanuts in RUTFs can supplement the carbohydrates that peanuts lack as whole grain oats contain around 69.8g of carbohydrates per 100g of oats. (Oats, whole grain, steel cut 2022) The addition of oats in RUTFs can also impart a mildly sweet flavor to the food, which could possibly aid in improving the reception of RUTFs amongst children. Furthermore, peanuts contain a very low amount of the omega-3 fatty acid ALA with only around 25.34mg of ALA per 100g of peanuts. (Huang et al., 2020) On the contrary, soybean oil contains around 6.8g of ALA per 100g of soybean oil, making soybeans the superior source of ALA compared to peanuts. (Saava & Kafatos, 2015) This serves to be important as ALA is an antioxidant, meaning that it can be used by the body to support one’s immune system in regard to combating infection and disease. (Votano et al., 2021) In fact, those who suffer with conditions related to undernutrition are significantly more likely to contract infections than those who are well nourished. (Martins et al., 2011) Incorporating oat and soybean alongside peanut in RUTF also allows for manufacturing costs of RUTF to be reduced significantly since both oats and soybeans are considerably less expensive than peanuts, meaning that a blend of these ingredients will be less expensive to manufacture and have a greater nutritional content than that of an RUTF made with a base that consists of only peanut. The creation of specialized dosages of RUTFs for specific age ranges such as infants, children, and the elderly, as well as for individuals like pregnant and breastfeeding women could aid in reducing the renal solute load they place upon the kidneys. This system will allow for less nitrogenous wastes to be produced as it will allow for RUTFs to be specifically tailored to certain groups’ nutritional needs, meaning that they will receive about the right amount of amino acids their body requires when they consume the RUTF. In turn, this will reduce the amount of individuals that will experience dehydration as a result of needing to produce more urea to filter out the nitrogenous wastes produced from converting excess amino acids into energy. (MacDonald et al., 2018) Therefore, the incorporation of oats and soybeans into peanut-based RUTFs, as well as the development of a specialized dosage system for differing age ranges and individuals would most likely improve their overall efficacy in treating acute and chronic undernutrition in children, as well as in the wider population.
Conclusion
While RUTFs are effective in treating acute and chronic malnutrition in children, there is still much to be done in the realm of improving the nutritional balance of RUTFs and in creating RUTFs which specifically target the nutritional needs of children. Consequently, more research and testing must be performed to prove whether an RUTF consisting of a peanut, oat, and soybean base is able to treat conditions relating to undernutrition with greater success than an RUTF with a base that is solely made from peanuts. Thus, one can hope these changes could aid in expunging the cycle of nutrition-based disease in communities around the world.
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