Experience with Lipid-based Nutrient ... - The iLiNS Project

Experience with Lipid-based Nutrient
Supplements (LNS) for the prevention of growth
restriction, severe wasting and anemia
Seth Adu-Afarwuah, PhD
Project Manager
iLiNS, Ghana
University of Ghana, Legon

Background
• High U5 undernutrition in developing countries:
� 32% stunting ( >177 million)
�20% underweight (> 112 million)
�3.5% severely wasted (19 million)
• Lipid-based nutrient supplements (LNS) first used to
treat severe malnutrition in late 1990s.
• Recent use of LNS includes prevention of malnutrition
and micronutrient deficiencies.
• Review of effects of preventive LNS on linear growth,
severe wasting and anemia is important for guiding
future actions.
S Adu-Afarwuah, PhD
October 2010
2

Scope of review
• LNS was provided, effect directly compared
• Not for treatment of acute malnutrition
– Individual/mean pre-intervention WLZ/WHZ > 80% of
the NCHS median or > -2 SD.
• At least some participants < 5 y
• Target outcomes were: linear growth, severe
wasting, and anemia
• Studies categorized into: (a)Targeted stunted (LAZ
< -2) chn. (b) Targeted non-stunted (LAZ > - 2) chn.
S Adu-Afarwuah, PhD
October 2010
3

Assessment of effect of LNS supplementation
• Effect size*= Mean for intervention – Mean for Control
Pooled SD
– Used largest of effect sizes when >1 for linear growth
– Calculated mean (range) within groups of studies (Stunted
children vs. Non stunted children).
• % Point diff. = % for Intervention - % for Control
* Effect size (ES):
� Can be categorized as small (~0.2), medium (~0.5) or large (> ~0.8).
� The larger the ES, the larger the difference between Intervention vs Control.
� Positive value indicates intervention group has greater value of the indicator.
� Negative value indicates Control group has greater value of the indicator.
S Adu-Afarwuah, PhD
October 2010
4

Number of studies included
Number of studies
Targeted stunted children * 4
Targeted non-stunted children † 5
Total 9
No. of countries ‡ 4
* Stunted: Individual/mean pre-intervention length-for-age z score < -2 SD
† Non-stunted: Individual/mean pre-intervention length-for-age z score > -2 SD
‡ Countries: Malawi = 5; Niger = 2; Algeria = 1; Ghana = 1;
S Adu-Afarwuah, PhD
October 2010
5

a. Studies that targeted stunted children
Study Nature of intervention Report by investigator
Maleta et
al., 2004 -
Malawi
Kuusipalo
et al.,
2006),
Malawi.
S Adu-Afarwuah, PhD
October 2010
• Chn 42-60 mo old
• Mean LAZ: -3.2 (0.9) vs -3.0 (0.8)
• RUTF Vs. Maize-Soy mix (500 kcal/d)
• Folllow-up: 4 wk before supplementation,
12 during and 12 after).
• Duration: 28 wk
• Chn 6-17 mo old
• Mean LAZ: -2.4 (0.9) vs -2.3 (1.0).
• Fortified spread (22, 130, 264, 396
kcal/d milk-based or 126, 255, 386 kcal/d
soy-based) Vs. No supplementation.
• Duration: 12 wk.
• No effect on linear
growth
• Mean length gain
higher for FS ≥ 130
kcal/d.
• Hb ↑ by 10-17g/L.
• Milk-based FS 264
kcal/d had greatest
effects
6

a. Studies that targeted stunted children, cont’d
Study Nature of intervention Report by investigator
Lopriore
et al.,
2004,
Algeria
Isanaka
et al.,
2009,
Niger
S Adu-Afarwuah, PhD
October 2010
• Saharawi refugee children 36-72 mo
• Mean LAZ range: -2.73 (0.55) to -3.97 (0.70).
• Fortified spread (with/ w’out metronidazole)
(~320 kcal/d), Vs Unfortified spread
(with/w’out metronidazole), Vs. No
supplementation.
• Duration: 6 mo
• Chn 6-60 mo old in 6 Intervention Vs. 6
Non-intervention Villages
• Mean LAZ: -1.9 (1.3) Vs -2.2 (1.0)
• RUTF (500 kcal/d) for 3 mo Vs No
supplementation. 5 more mo of follow-up
with no further supplementation.
• Duration: 8 mo
• Linear growth 30%
faster in FS group at 3
mo than other two
groups
• At 6 mo, Hb ↑ in FS
was ~ 2x those of 2
groups.
• 36% ↓ in incidence
of wasting
- 58% ↓ in incidence
of severe wasting
7

. Studies that targeted non-stunted children
Study Nature of intervention Report by investigator
Phuka
et al.,
2008,
Malawi
Phuka
et al.,
2009,
Malawi
S Adu-Afarwuah, PhD
October 2010
• Chn 6 mo old
• Mean LAZ range: -1.00 (0.77) to -1.20 (1.01).
• FS50 Fortified Spread (264 kcal/d) Vs.
FS25 Fortified Spread (130 kcal/d) Vs.
Fortified corn porridge (Likuni Phala, LP)
(282 kcal/d). FS50 had 2x protein, carbo, &
fat as FS25 but same conc. of vit & min.
• Duration: 12 mo.
• Chn. 6 mo old (Phuka et al., 2008)
• FS50 (264 kcal/d) Vs. FS25 (130 kcal/d ) Vs.
Fortified corn porridge for 12 mo. Follow-up
extended by 2 y.
• Duration: 36 mo.
• 9% and 12.5% ↓ in
incidence of severe
stunting in FS25 and
FS50, resp vs LP.
• Chn on FS50, with
baseline length <
median gained 1.9 cm
more.
• 9.3% and 16% ↓ in
incidence of severe
stunting in FS25 and
FS50, resp.
• Greater diffs. for chn
stunted at baseline
8

. Studies that targeted non-stunted children, cont’d
Author Nature of intervention Report by investigator
Defourny
et al.,
2009,
Niger
Lin et al.,
2008,
Malawi
S Adu-Afarwuah, PhD
October 2010
• Blanket distribution of RUF in project
district. Chn 6-36 mo.
• RUF (~250 kcal) as supplement to usual
diet.
• Duration: 6 mo
• Chn 6 mo
• Initial mean LAZ : -1.0 (1.1) vs -1.1 (1.1).
• Fortified spread (eaten alone) Vs. Fish
power + Home prepared corn porridge)
. Energy content: 200 kcal for 6-8 mo,
300 for kcal 9-18 mo.
• Duration: 12 mo
• 85% ↓ in incidence of
severe wasting
(MUAC < 110 cm)
• Linear growth not
affected.
9

. Studies that targeted non-stunted children, cont’d
Study Nature of intervention Report by
investigator
Adu-Afarwuah
et al., 2007;
Adu-Afarwuah
et al., 2008,
Ghana
• 6 mo old
• Mean LAZ range: -0.20 (1.0) to -0.31
(1.1).
• MMN powder (Sprinkles, SP) Vs.
Ghana MMN crushable tablet (Nutritab, NT)
S Adu-Afarwuah, PhD
October 2010
Vs. LNS (Nutributter , NB) from 6 to
12 mo Vs. Non-Interventn. (NI)
children not randomized at 6 mo were
assessed at 12 mo only.
• Duration: 6 mo
• NB had greater LAZ
than NT and NT+SP
combined
• 22% ↓ in prevalence
of anemia in NB
group vs NI group.
10

Effect of LNS on linear growth: Stunted children
Author Intervention
group (n)
Maleta et
al., 2004
Kuusipalo et
al., 2006
Lopriore et
al., 2004
S Adu-Afarwuah, PhD
October 2010
Comparison group
(n)
Effect
size (ES)
ES based
on:
RUTF (30) Maize-Soy mix (31) 0.15 LAZ gain
Fortified spread
(107)
No supplementation
(18)
0.69 Length
gain
Fortified spread Unfortified spread at 0.75 Length
at 3 mo (103) 3 mo (106)
gain
Fortified spread
at 3 mo (103)
Fortified spread
at 6 mo (103)
Fortified spread
at 6 mo (103)
No supplementation
at 3 mo (45)
Unfortified spread at
6 mo (106)
No supplementation
at 6 mo (45)
0.82 “
0.55 “
0.55 “
11

Effect of LNS on linear growth: Stunted children, cont’d
Author Intervention
group (n)
Isanaka et
al., 2009
S Adu-Afarwuah, PhD
October 2010
Comparison group
(n)
RUTF (894) No supplementation
(816)
Effect
size (ES)
ES based
on:
0.14 LAZ gain
12

Effect of LNS on linear growth: Non-stunted children
Author Intervention
group (n)
Phuka et
al., 2008
Phuka et
al., 2009
Comparison
group (n)
Effect
size (ES)
ES based
on:
FS50 (54) LP (57) 0.35 Length gain
FS25 (57) LP (57) 0.22 “
FS50 (46) LP (50) 0.13 LAZ gain
FS25 (53) LP (50) -0.17 Length gain
Lin et al., Fortified spread: 6- Fish Powder: 0 Length gain
2008
12 mo (125) 6-12 mo (115)
Adu-
Afarwuah et
al., 2007),
S Adu-Afarwuah, PhD
October 2010
Fortified spread:
12-18 mo (125)
Fish Powder:
12-18 mo (115)
-0.07 Length gain
Nutributter (97) Non-interv. ( 81) 0.26 LAZ Attained
Nutributter (97) Sprinkles (96) 0.40 Length gain
Nutributter (97) Nutritab (101) 0.50 Length gain
13

Effect size for linear growth
1.05
0.8
0.55
0.3
0.05
-0.2
S Adu-Afarwuah, PhD
October 2010
Effect of preventive LNS on linear growth:
Overall effect size*
0.82
0.52 0.50
0.14
0.18
-0.17
Max Min Mean
Stunted Non-stunted All
Target for intervention
0.82
0.33
-0.17
* Results of 4 studies on stunted children and 5 on non-stunted children
14

Effect of LNS on severe wasting: Stunted children
Author Intervention
group (n)
Isanaka et
al., 2009
S Adu-Afarwuah, PhD
October 2010
RUTF
(894)
Comparison group
(n)
No supplementation
(816)
Indicator Difference
Incidence of
WLZ < -3
- 58%
15

Effect of LNS on severe wasting: Non-stunted children
Author Intervention
group (n)
Phuka et
al., 2008
Defourny et
al., 2009)
S Adu-Afarwuah, PhD
October 2010
Comparison
group (n)
Indicator Difference
FS50 (54) LP (57) % of chn 0
FS25 (57) LP (57) with WLZ < -3 0
Fortified spread
(~60,000)
Baseline
(~60,000)
Incidence of
MUAC

Effect of LNS on Hb conc. and anemia: Stunted children
Author Intervention
group (n)
Kuusipalo
et al., 2006
Lopriore et
al., 2004
S Adu-Afarwuah, PhD
October 2010
Fortified spread
(107)
Fortified spread
at 6 mo (103)
Comparison group
(n)
No supplementation
(18)
Unfortified spread at 6
mo (106)
Indicator Difference
Effect size 0.69
Effect size 0.66
Diff in %↓ -50
Fortified spread No supplementation Effect size 0.74
at 6 mo (103) at 6 mo (45) Diff in %↓ -63
17

Effect of LNS on Hb conc. and anemia: Non-stunted children
Author Intervention
group (n)
Phuka et
al., 2008
Adu-
Afarwuah
et al., 2008
S Adu-Afarwuah, PhD
October 2010
Comparison group
(n)
Indicator Difference
FS50 (54) LP (57) Effect size 0.30
FS25 (57) LP (57) Effect size 0.16
Nutributter (97) Non-interv. ( 81) Effect size 0.59
% diff -22.1
Nutributter (97) Sprinkles (96) Effect size 0.30
% diff -8.2
Nutributter (97) Nutritab (101) Effect size 0.16
% diff -5.5
18

Effect size for change in Hb
Effect of preventive LNS on Hb: Overall effect size*
1
0.75
0.5
0.25
0
S Adu-Afarwuah, PhD
October 2010
0.74
0.69
0.65 0.59
0.30
Max Min Mean
Stunted Non-stunted All
0.74
0.45
0.15 0.15
* Results of 2 studies on stunted children and 2 on non-stunted children
19

Summary: Effect on linear growth
� Studies on effects of preventive LNS remain few (n =
9) and have been done in only three countries.
� 5 showed positive effect on linear growth
� 2 showed no effect on linear growth
� 2 did not report on linear growth
�� Effect sizes are generally modest (Mean: 0.33; Range:
-0.17, 0.82).
� Effect sizes (Mean: 0.52; Range: 0.14, 0.82) are larger
for children whose pre-intervention average LAZ was
low (< -2) than those with high LAZ.
S Adu-Afarwuah, PhD
October 2010
20

Summary : Effect on severe wasting
� Only 3 studies (1 involving stunted chn., 2 involving
non-stunted chn.) reported on severe wasting.
�� In 2 of the 3 studies, preventive LNS reduced the
incidence of severe wasting by 58%-85%
compared to no supplementation or baseline.
S Adu-Afarwuah, PhD
October 2010
21

Summary : Effect on anemia
� Only 4 studies (2 for stunted chn, 2 for non-stunted
chn) reported on hemoglobin (Hb) and anemia.
� Unlike linear growth, Effect Sizes for Hb are larger
(Mean: 0.45; Range: 0.15, 0.74).
�� Like linear growth, Effect Sizes for stunted chn. (Mean:
0.69; Range: 0.65, 0.74) are larger than those for nonstunted
chn. (Mean: 0.30; Range: 0.15, 0.59)
� Preventive LNS was associated with 50-63% drop in
anemia among stunted chn, and 6-22% among nonstunted
chn.
S Adu-Afarwuah, PhD
October 2010
22

5.0
4.0
3.0
2.0
1.0
S Adu-Afarwuah, PhD
October 2010
Cost of LNS
0.0
Malawi Ghana Malawi Niger Ghana
(2004) (2008) (2008) (2009) (2010)
USD/kg 3.0 3.5 4.0 4.5 4.0
23

General considerations
� Nutrient compositions (and in some cases concentrations) of
LNS have varied widely.
� Energy intake from LNS varied widely
� Some supplementations were probably too short to allow
detectable differences.
�� Effects of LNS could be underestimated due to inability to
include unsupplemented group in some studies.
� At least one study lacked power to detect significant
differences.
� Anthro results are nearly always reported, but only a few
studies actually reported on incidence/ prevalence of severe
wasting
S Adu-Afarwuah, PhD
October 2010
24

Overall conclusions
� Preventive LNS has positive effects on linear
growth, severe wasting and anemia that are
stronger than those of many other intervention
strategies.
� Growing cost of LNS may affect large-scale use,
unless new ways of reducing cost can be found.
S Adu-Afarwuah, PhD
October 2010
25

S Adu-Afarwuah, PhD
October 2010
THANK YOU
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