2. Moderate Acute Malnutrition (MAM) Contributes to 10% of childhood deaths under five Field Exchange 2007; 31: 3

3. Moderate Acute Malnutrition (MAM) An ineffective standard of care http://www.wfp.org/nutrition/special-nutritional-products :: accessed 6 May 2012

4. Improving the Standard of Care Parallel approaches to replacing CSB World Food Programme http://www.nutriset.fr/en/product-range/produit-par-produit/plumpy-sup.html :: accessed 6 May 2012 Journal of Nutrition 2009; 139: 773

5. Population :: Children 6-59 months old with moderate acute malnutrition (MAM) who qualify for community-based therapy (i.e., demonstrate an appetite and a reliable caretaker) -3 < Weight-for-height Z-score (WHZ) < -2 without edema Within walking distance of one of 18 rural clinic sites in southern Malawi Exclusions :: obvious chronic debilitating illness (excluding HIV & TB); recently enrolled in a therapeutic feeding program for acute malnutrition (inpatient or outpatient) Intervention :: One of two untested supplementary foods at a dose of 75 kcal/kg/d CSB++ developed by World Food Programme, manufactured in Malawi :: $0.16/d 58% maize flour, 20% de-hulled soy flour, 9% sugar, 8% milk powder, 3% oil, multivitamin mix Plumpy’Sup® developed and manufactured by Nutriset in France :: $0.38/d Peanut paste, sugar, vegetable fat, whey, soy protein isolates, maltodextrin, cocoa, multivitamin mix “Soy/whey RUSF” Comparison :: Soy-peanut ready-to-use-supplementary food (RUSF) manufactured in Malawi :: $0.22/d Peanut paste, sugar, oil, extruded soy flour, multivitamin mix (no animal source proteins) “Soy RUSF” Outcomes Primary :: adverse effects; nutritional recovery (WHZ > -2); mortality Secondary :: time to recovery; growth parameters (gains in height, weight, MUAC) Supplementary Foods for Moderate Acute Malnutrition Prospective, randomized, investigator-blinded clinical effectiveness trial

9. Supplementary Foods for Moderate Acute Malnutrition Primary Outcomes p=0.2641 RR 0.98 (0.94 - 1.02) 1.8% difference (-1.3% - 5.0%) p=0.9430 RR 1.00 (0.97 - 1.04) 0.2% difference (-2.8% - 3.2%) p=0.2352 RR 1.02 (0.99 - 1.06) 2.0% difference (-1.1% - 5.1%) 24.9 ± 17.522.5 ± 14.222.6 ± 15.0 Days to Recovery :: p = 0.0029 p=0.0289 RR 1.56 (1.05 - 2.31) 2.4% difference (0.3% - 4.5%)

10. Supplementary Foods for Moderate Acute Malnutrition Summary of findings Primary Outcomes No adverse reactions to study foods Recovery and Mortality Contrary to all previous experience with fortified blended flours, CSB++ proved comparable to ready-to-use supplementary food (RUSF) products Locally-produced RUSF without animal source protein (soy RUSF) comparable to commercial product with animal source protein (soy/whey RUSF) Secondary Findings Children receiving CSB++ …took two days longer to recover …had less weight gain and MUAC gain (but comparable height gain) …were slightly more likely to progress to marasmus HIV remains the strongest risk factor for failure to recover from MAM ART insufficient to make up the difference Default rate of only 1.3% Exceptionally low compared to prior studies and operational programs

11. Supplementary Foods for Moderate Acute Malnutrition Differences between CSB and CSB++ Increased energy density due to added oil, sugar, milk powder More phosphorus (28%), potassium (49%), vitamin B6 (316%), vitamin B12 (121%), vitamin C (141%), vitamin D (115%), zinc (43%), riboflavin (62%) Addition of vitamin K (113  g / 100 g) and pantothenic acid (7.4 mg / 100 g) Tighter specifications regarding aflatoxin and coliform contamination Reduced anti-nutrient content by including less soy beans and maize and by dehulling soy beans Animal source food included (milk powder)

12. Supplementary Foods for Moderate Acute Malnutrition A paradigm shift Cost comparison of supplementary foods studied CSB++ :: $0.03 per 100 kcal Soy RUSF :: $0.04 per 100 kcal Soy/whey RUSF :: $0.07 per 100 kcal Operational concerns about fortified blended flours :: the old dogma Requires cooking (water, firewood, dishes) :: may discourage preparation and increase spoilage Similar in taste and appearance to staple foods :: may encourage sharing Low energy density compared to RUSF :: requires children to eat large volumes of food Typical programs scoop flour out of 25-50 kg bags into family containers, whereas this study provided CSB++ in sealed 250 g plastic bags (1-2 days ration) :: may have led to decreased contamination and spillage and promoted the understanding that CSB++ is a medicinal food

16. Supplementary Foods for Moderate Acute Malnutrition HIV* as a strong predictor of failure to recover RR 1.38 (1.01-1.88) P < 0.0001 p = 0.0224 p = 0.0090