Assessment of Locally-Sourced Therapeutic Foods for Children Recovering from Severe Acute Malnutrition in Karawa, Democratic Republic of the Congo Open Access

Abstract

Acute malnutrition impacts an estimated 92,000 children within IMA’s Access to Primary Healthcare Project and 11% of all children under five in the Democratic Republic of the Congo (IMA-World Health, 2017). Treatment of malnourished children is often aided by imported ready to use therapeutic foods (RUTFs) such as plumpy nut. However, availability of RUTFs are sporadic and a more sustainable approach using locally-sourced therapeutic foods is desired (IMA-World Health, 2017).

The study objectives were 1) to monitor the recovery rates of children recovering from severe acute malnutrition (SAM) and moderate acute malnutrition MAM) at the Nutritional Rehabilitation Center (NRC) of Hospital de reference de Karawa and in the community; 2) to analyze the nutritional content of therapeutic feeding recipes promoted by the ASSP project at both sites, and 3) to assess the acceptability and barriers of using therapeutic feeding recipes from locally sourced ingredients for both caregivers and children.

We collected anthropometric measurements over a 7-week period from 42 children aged 5-63 months recovering from SAM at the NRC (32) and from MAM in the communities (10). We analyzed the nutritional content of 4 locally-sourced therapeutic recipes: 2 recipes served at the NRC (locally milled corn-soy blend and rice-peanut blend) and 2 experimental recipes (hand-milled corn-peanut-coconut blend and corn-peanut-sugar cane blend). In addition, caregivers of each participant children received three short surveys: 1) a 24-hr recall diet, 2) an initial interview assessing knowledge and awareness of therapeutic foods served at the NRC and proposed in the communities, and 3) a follow-up interviews assessing acceptability to therapeutic foods given to children and willingness to continue prepare therapeutic foods at home.

In total, 32 children (76.19%) completed the study. The adjusted mean (95% CI) change in weight (kg) from baseline for male children recovering from SAM was statistically significant irrespective of the enrollment location: -0.55 kg (-0.98; -0.11) p < 0.05. Conversely, the adjusted mean (95% CI) change in weight (kg) from baseline for female children recovering from SAM was statistically insignificant irrespective of the enrollment location: -0.20 kg (-0.918, 0.518)      p > 0.05. Energy intake requirements of locally-sourced therapeutic foods served at the NRC/UNTI were found to be lower than the recommended energy intake for recovery: locally milled corn-soy blend at 241.9 kcal/serving and rice-peanut blend at 267.9 kcal/serving. at baseline, children had a history of eating fruits and vegetables (94.9%), starch and tubers (71.7%), legumes and pulse (66.7%), cereals and grains (61.5%), animals (28.2%) and other processed foods (15.3%). Also, at baseline, the average of number of meal per day being served to children was two meals with 100% of children receiving weaning foods. 39.4% of caregivers reported having heard of the locally-sourced foods served at the NRC and 21% of participating caregivers reported to like those recipes. 76.3% reported to have cooked a similar recipe and a higher proportion (94.7%) reported to be willing to cook the recipes. At the end of the study, 18 caregivers reported having put into practice at least one recommended recipes.

 

The analysis of the recovery rate of children recovering from SAM at the NRC and from MAM in the communities showed no significant improvement over the period of treatment, the nutritional content of locally-sourced foods served in the NRC did not fulfill the daily energy requirement for children recovering from SAM and MAM. 

Table of Contents

TABLE OF CONTENTS

DISTRIBUTION AGREEMENT…………………………………………….…………………………………………................i

APPROVAL…………………………………………………………………………………………………………..………......ii

ABSTRACT…………………………………………….……………………………………………………………………………...........iv

ACKNOWLEDGMENTS.....................................................................................................vii

LIST OF TABLES……………………………………………………………………………………………………….…....xi

LIST OF FIGURES…………………………………………………………………………………………………………..xii

LIST OF ABBREVIATIONS…………………….……………….………………………………………………………..........xiii

 

CHAPTER ONE

1.         INTRODUCTION.......................................................................................................1

1.1 The Problem of Malnutrition.................................................................................1

                        1.1.1 Definition and Global Burden…………………………………..…………………….....1

                        1.1.2 Developmental Consequences of Childhood Malnutrition………………....2

 

1.2 Responding to Childhood Malnutrition................................................................3

1.2.1 Global Response....................................................................................3

1.2.2 Local Interventions................................................................................3

 

           1.3 Malnutrition in the Democratic Republic of Congo..............................................3

                       1.3.1 Current Situation….................................................................................3

                       1.3.2 Country's Health System………………………………………….................4

                       1.3.3 Country Guidelines for Treating Malnutrition………………………........4

1.4 Thesis Hypothesis and Objectives…………………………………….......................6

 

CHAPTER TWO

 

2.         LITERATURE REVIEW............................................................................................8

2.1 Malnutrition..........................................................................................................8

 

2.1.1 Overview of Malnutrition......................................................................8

2.1.2 Severe Acute Malnutrition……………………………………………………………......9

2.1.3 Causes of Severe Acute Malnutrition……………………………………..…......9

2.1.3.1 Immediate Causes…………………………………………………………....10

2.1.3.2 Underlying Causes…………………………………………………….….....11

2.1.3.3 Basic Causes……………………………………………………………….......11

            2.2 Country Nutrition Program……………………………………………………...........12

2.3 Guidelines for Admission Criteria of Malnutrition…………………………….....13

2.3.1 International Guidelines……………………………………………….......13

            2.4 Therapeutic Foods…………………………………………………………………......14

                        2.4.1 Community-Based Management of Severe Acute Malnutrition........15

                                    2.4.1.1 Standard Therapeutic Foods or RUTF……………….......15

2.4.1.2 Locally-Sourced Therapeutic Foods……………………........16

2.4.2 Nutritional Interventions……………………………………………………….......17

2.5 Study Methodology……………………………………………………………….......18

2.6 Knowledge Gap……………………………………………………………………......18

 

CHAPTER THREE               

 

3. METHODS………………………………………………………………………………….........20

3.1 Aim and Study Site……………………………………………………………….......19

3.2 Qualitative Research Approach…………………………………………………......21

3.3 Participants………………………………………………………………………......…22

3.4 Data Collection Tools…………………………………………………………….......25

3.5 Data Analysis…………………………………………………………………….....…27

3.6 Ethical Considerations…………………………………………………………….....27

3.7 Study Limitations…………………………………………………………………......28

 

CHAPTER FOUR

 

4. RESULTS………………………………………………………………………………….....…...30

4.1 Introduction……………………………………………………………………….........30

4.2 Interviews…………………………………………………………………………........31

4.2.1 24-hour Dietary Recall………………………………………………...….31

4.2.2 Initial Interviews……………………………………………………….......34

4.2.3 Follow-up and Final Visit…………………………………………….......36

4.3 Nutritional Content Analysis of Therapeutic Foods Served at UNTI………....37

4.4 Participants Nutritional Status…………………………………………………....…39

4.5 Participants' Recovery Rates…………………………………………………….......40

 

CHAPTER FIVE

 

5. DISCUSSION……………………………………………………………………………….........43

5.1 Key Findings……………………………………………………………………….......43

5.2 Limits………………………………………………………………………………........46

5.3 Recommendations………………………………………………………………......…47

           

APPENDICIES

            APPENDIX A....................................................................................................... 49

            APPENDIX B....................................................................................................... 50

APPENDIX C ………………….…………………………………………………………….………………….51

APPENDIX D ……………………………………………..…………………………………….……………..53 

REFERENCES................................................................................................................. 54

 

LIST OF TABLES

Table                                                         Title                                                                  Page

4.1                     Distribution of Participants at Karawa by Gender and Age………………...…31

4.2                       Inventory of Food Consumed During the 24-hr Dietary Recall Organized

                        by Group……………………………………………………………....................32

4.3                         Daily Number of Meal Eaten During the Most Recent 24-hr Recall by a

                        Child by Food Type…………………………………………………………......33

4.4                     Caregivers’ Perception of Therapeutic Foods Served at the UNTI……....34

4.5                     Caregivers’ Practice of Porridge at Follow-up and Final Visit…………...37

4.6                      Nutritional Analysis and % Fulfilled of Two Therapeutic Foods Served at UNTI………………………………………………………………………….........38

4.7                                    Amount of serving/g/day of Ingredients Used in Foods Served at UNTI………………………………………………………………………….......39

 4.8                                Nutritional Status of Children by Gender and Age groups at End of Study  …………………………………………………………….…......40                                                                                                    

 

LIST OF FIGURES

Figure                                                               Title                                                           Page

1.1                    World Regions Stunt Prevalence of Children under 5 years old……..……..1

1.2                    Admission Criteria for Treating Acute Malnutrition in DRC………….....…5

   2.1             UNICEF Conceptual Framework of Malnutrition…………………………...11      

2.2                   WHO Admission Criteria for Children 6-59 months with SAM…………..13

2.3                   WHO Guidelines for Management of SAM………………………………….15

3.1            Study Site, Karawa in the Democratic Republic of Congo……….…………......21

3.2                              Study Enrollment Flowchart of Participants aged 6-60 months old at Karawa……………………………………………………………………………....25

4.1                  Number of Children Consuming Food by Source…………………………….33

4.2                  Number of Caregivers Reporting Preparing a Type of Porridge……………35

4.3                  Reported Source of Information by Caregivers on Therapeutic Foods……..36

4.4                  Recovery Rate of Male Children Across Enrollment Location…………......41

4.5                  Recovery Rate of Female Children Across Enrollment Location………......42

 

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Nutrition
Keyword	Malnutrition Democratic Republic of the Congo Nord-Ubangui Province Locally-Therapeutic Foods Severe Acute Malnutrition
Committee Chair / Thesis Advisor	McFarland, Deborah, Emory University
Partnering Agencies	International Non-governmental organization (e.g., CARE, Inc.)

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