Lipid-Based Nutrient Supplement Research Network Meeting

By Sarah Style

Sarah Style is part of the ENN team working with UNHCR on the Anaemia Control, Prevention and Reduction Project

In April 2011, the International Lipid-Based Nutrient Supplements (iLiNS) Project hosted the second international LNS Research Network Meeting in Washington DC, the first of which was held in Rome in 2009. The key presentations and issues arising are summarised here.

The LNS Research Network is a group of researchers and practitioners joined by a common interest to explore the potential of Lipid-based Nutrient Supplements (LNS) to contribute to prevention of malnutrition in vulnerable populations. The key objectives of the meeting were to facilitate exchange between researchers and practitioners and share experiences on the potential of LNS in this area. Aside from poster presentations and abstracts of new, current and recent research, the majority of the meeting consisted of oral presentations. These were divided into sessions reflecting some of the key areas of research/activities involving LNS (of which a sample are highlighted below), and served to highlight some of the main learning outcomes and remaining challenges.

The first session focused on the use of LNS during the first two years of a child's life. Whilst analysis of impact on this age group is on-going, LNS studies presented showed a limited effect on growth outcomes. For example, results were presented from a study investigating the effect of complementary feeding with milk-LNS, soy-LNS and corn-soy blend (CSB) on the incidence of severe stunting amongst 6-18 month old infants in rural Malawi¹. The mean length and weight changes between groups were nonsignificant² and only the group fed milk-LNS, displayed a reduction, albeit small, in the incidence of very severe stunting after 12 months. LNS seemed to prevent further growth faltering from age 6-12 months, although this was not maintained in children 12-18m. It is thought that the timing of the intervention (height-for-age z score already low at enrolment), and the presence of infection may have played a part in reducing the potential impact of LNS (morbidity data were not presented). Further analysis is being undertaken to better understand these results.

An observational cohort study in Niger found a small but significantly higher weight gain, less decline in Mid-Upper Arm Circumference (MUAC) and lower mortality in 6-23 month old recipients of a blanket Ready-to use Supplementary Food (RUSF) distribution plus protective ration³. No difference in height gain or incidence of severe or moderate wasting among intervention groups was found. However, the study experienced a low attendance rate at distribution sites and comparability between those who received the ration and those who did not was an issue. Authors identified a need for further research on why some households attend ration distributions and others do not, as well as the ideal time for interventions to begin and the appropriate duration. Of interest, a further study (for which only the abstract was provided) found CSB and RUSF to be equally effective treatment foods for moderate acute malnutrition⁴. However the study suggested that other external factors, including sharing practices and the presence of other food aid programmes, may have had a stronger impact on recovery than the actual treatment food itself.

The second session summarised results from the Breastfeeding, Anti-retrovirals and Nutrition (BAN) study in Malawi. Research was presented on the effect of daily consumption of LNS by HIV-infected mothers on both maternal weight and the growth of their exclusively breastfed HIV-uninfected infants from 0-24 weeks of age. Mothers were randomised to receive either no LNS, or 140g per day of LNS (to meet lactation, energy and protein needs), and were then further randomized within these groups to receive maternal antiretroviral drugs (ARV), daily infant nevirapine or no postnatal ARV regimen. Outcomes included infant weight, length, and body mass index (BMI). Results found no consistent effects of the maternal supplementation on infant growth. Interestingly, maternal weight loss was largest in the ARV groups, however, the use of LNS seemed to mitigate this and act as a buffer to the ARV associated weight loss. The generalisability of the results may be limited as the mothers included in the study were relatively healthy (indicated by CD4, haemoglobin measurements and BMI) and infants weighed ?2kg at birth meaning that potential benefits may have been less than expected. It was highlighted that growth is unlikely to be impacted by maternal supplementation as supplementing the mother does not affect the breastmilk content of type II nutrients associated with growth, e.g. zinc, potassium, phosphorus and calcium.

The third session focused on LNS for refugee populations and research in this area, as well as on operational guidance for use of special nutritional products. In South Darfur, the impact of LNS (Plumpy'Doz) and an Improved Dry Ration (IDR) in blanket supplementary feeding programmes (BSFP), for preventing an increase in acute malnutrition during the 4-month hunger season was assessed⁵. In the longitudinal cohort study, children 6-36 months were randomly selected from two camps, each receiving one of the rations. Results showed that there was no statistically significant difference in mean weight-for-height z score (WHZ) between the two camps at baseline (p=0.17). However, at the final distribution, children in the camp receiving LNS had a significantly higher mean WHZ than those receiving IDR (P=0.001). Although a number of challenges were experienced including a high default rate (reducing sample size), and high staff turnover, levels of acute malnutrition were maintained at rates similar to the non-hunger period. It was suggested that LNS may be considered as a viable option for preventing malnutrition in such contexts. However further research is needed on optimising programme design, e.g. timing, duration of use, and cost-effectiveness, among other things (these areas were also highlighted by other studies as key challenges).

Complementing this, was a second presentation on refugee settings which described the development of operational guidance (OG) outlining the recommended stages and available tools for planning, implementing, monitoring and evaluating interventions to reduce micronutrient deficiencies and malnutrition in refugee populations⁶. Compiled by ENN on behalf of UNHCR, the guidance is aimed at health and nutrition staff from UNHCR and implementing partners, to meet the needs and challenges involved in using relatively new products and approaches, including LNS in refugee settings. The guidance is in the process of finalisation and will be updated as and when necessary to ensure that the current version reflects the latest developments in product availability and use. Challenges in developing these guidelines include identifying an appropriate duration of use for these products, the potential for interaction of iron and malaria and the potential for adverse effects on breastfeeding practices. These are areas that will require future collaboration with others to resolve.

Following this, the use and sharing of LNS in the diet was discussed, with experiences being shared from Malawi, Niger and Ghana. Acceptability of LNS to children and mothers was a key focus of this session. LNS was found to be acceptable as a breastmilk replacement to un-infected infants aged 6-12 months of HIVinfected mothers⁷; mothers reported that their children liked the taste, that it helped maintain health without breastmilk, and promoted weight gain. In general, other studies consistently reported that LNS was well liked by caregivers and their children, and that a range of positive benefits of the supplement to their children were frequently perceived, for example increased health and appetite. One study found challenges with children's acceptance of 'regular' complementary food, e.g. maize porridge, when LNS was no longer provided. However, where possible, caregivers overcame this by diversifying the diet and substituting the porridge with locally available ingredients, for example. Although many women believed that LNS increased their child's appetite, for some households this was also a concern, as they did not always have enough food to meet this increased appetite. Some study participants reported concerns with packaging that was difficult to open and the organoleptic properties (specifically taste, odour and texture) of the LNS⁸. A study reporting some sharing of the LNS found that this was largely linked to social norms and sensitisation⁹. The importance and benefit of providing relevant counselling and education through a trusted source was emphasised¹⁰.

The final session focused on issues related to the regulation and marketing of LNS. Studies in the resource poor setting of Niger explored people's willingness to pay for LNS, which is taken to reflect acceptance of the product and its potential for regular consumption under 'real' conditions. Results indicated that a low cost, subsidised market based system for delivery of the product may be possible, dependent on identification of appropriate distribution systems¹¹. Also highlighted, was the need for amendments to the Codex Guidelines on Formulated Supplementary Foods for Older Infants and Young Children (IYCF) to include new products such as LNS and other formulated complementary foods. This will help ensure that their production and use conform to WHO/UNICEF's Global Strategy on IYCF. The need for improved regulation and guidance for the appropriate marketing of complementary food supplements (CFS) was also emphasised.

Whilst only a sample of the presentations and research shared have been covered above, the meeting provided an invaluable opportunity to share and learn from the many activities being carried out using LNS to improve malnutrition. A number of key learning outcomes and challenges were highlighted. Although the evidence remains thin, the randomised control trials (RCTs)/observational studies on LNS impact undertaken thus far have not yet yielded compelling evidence of impact and it may not always be feasible to conduct RCTs, given the continuing food crisis in many countries. Indications are that the:

• Use of LNS should not be a stand-alone option but requires appropriate water, sanitation and hygiene, health and other programmatic inputs.
• Good counselling and education on promotion of breastfeeding and appropriate complementary feeding practices should also accompany LNS interventions.
• Interaction between nutrition and infection needs to be further addressed.
• Dosage and composition requirements need to consider the potential for unintentional breastmilk displacement, sharing and cost issues.
• Clarity is needed as to whether LNS is positioned as a medicine or a food.

Evidently a number of challenges remain and there is a need for continued research to further investigate the efficacy and cost-effectiveness of LNS in different contexts, as a method of preventing malnutrition among vulnerable populations.

A full meeting report is available from the iLiNS Project at http://www.ilins.org/

¹Maleta et al. The effect of complementary feeding with lipid based nutrient supplements on incidence of very severe stunting among 6 to 18 month old infants in rural Malawi.

²p=0.47 and p=0.13 respectively: preliminary findings, and authors plan further analysis.

³Grellety E et al. Potential benefits of a preventative distribution: results of an observational cohort study during the hunger gap in Niger, 2010.

⁴Karakochuk C et al. CSB and RUSF are equivalence in their effect on the recovery of moderately malnourished children 6-60 months of age in southern Ethiopia: a cluster-randomised equivalence trial.

⁵Boyd et al. Preventing Malnutrition: Operational research using two blanket distribution approaches in two internally displaced persons camps of South Darfur, Sudan.

⁶See news piece in this issue of Field Exchange.

⁷Parker ME, Bentley ME, Adair L, van der Horst CM et al. Using LNS to replace breast-milk among HIV-positive population in Malawi: Results of the Breastfeeding, Antiretrovirals and Nutrition (BAN) Study.

⁸Klevor MK, Dewey KG et al. Experiences with the use of LNS (Nkatepa) by pregnant and lactating women in Ghana.

⁹Cohuet S, Marquer C, Grais RF et al. Intra-household use and acceptability of RUSF distributed in Niger between July and December 2010.

¹⁰Parker ME, Bentley ME, Adair L, van der Horst CM et al. Using LNS to replace breastmilk among HIV-positive population in Malawi: Results of the Breastfeeding, Antiretrovirals and Nutrition (BAN) Study.

¹¹Tripp K, Perrine C, Hartz R, Jefferds ME et al. Formative research for the development of a market-based home fortification program for young children in Niger.