Effects of Ready-to-use Therapeutic Food on Malnutrition in Sub-Saharan Africa

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nBackground

nContext and rational for study

nIn the contemporary world, malnutrition is a major challenge especially among children below five years. According to World Health Organization (WHO), approximately 33 per cent of all deaths in children can be associated to malnutrition. The main factor leading to malnutrition for most people across the globe is undernourishment. Recent reports suggest that more than 2 billion individuals are expected to be suffering from malnourishment across the globe (Dibari, Bahwere, Huerga, Irena, Owino, Collins and Seal 2013). Malnutrition affects the capacity of the body to carry out various roles such as ability to enhance the immune reactions to pathological attacks. In addition, malnutrition limits the capacity of the body to recover from pathological effects. Most importantly, children are more likely to experience severe effects of malnutrition because their immune system is not fully developed (Briend and Collins 2010). Consequently, malnourished children have a high case fatality rate. In addition, malnutrition causes stunted growth, illnesses, delays in development among other negative impacts on the body.

nNature and Extent of the Problem

nRecent reports have also indicated that malnourishment is a major problem in developing nations. Many children in these countries suffer from childhood illnesses causing high rate of mortality. In these countries, a significant number of people face starvation every year. In sub-Saharan African chronic malnutrition, affect more than 43 per cent of children. According to Sunguya, et al (2012), nearly 5 million deaths of under-5 children occur every year in sub-Saharan African due to health conditions attributed to malnutrition. Other affected children suffer from stunted growth such as inability to attain expected heights (Sunguya, et al 2012). Furthermore, sub-Saharan region has the highest number of people experiencing malnutrition. For instance, there are more than 800 million individuals facing starvation across the globe, out of which 210 million are from the sub-Saharan Africa in 2015 (Briend and Collins 2010). The number has increased over the last two decades from 170 million in the 1990s to more than 200 million in the early 2000s. Sub-Saharan region is characterized by high cases of climate change, big family size, ignorance, illiteracy and corruption. Most non-profit organizations and government agencies have many challenges to deal with malnutrition (Wilford, Golden and Walker 2012). Most importantly, they have been struggling to offer nutritious, affordable and compact supplements that are resilient of bacterial contamination particularly in areas stricken by famine.

nFortunately, modern technology has provided an opportunity to establish ready-to-use therapeutic foods (RUTFs). These supplements have played a key role in effectively dealing with the problem of malnourishment. Ready-to-use-therapeutic foods targets mainly children with acute malnourishment ranging from 6 months to 59 months but who do not experience serious health complications (Briend and Collins 2010). RUTFs are very important because they offer sufficient levels of micronutrients and caloric intake. They are intended to reinstate the health status of underweight children. Similarly, they reduce the incidence of serious wasting.

nSummary of the previous relevant studies

nVarious studies on the effectiveness of RUTFs have noted that they are very useful to reduce the burden of malnutrition in sub-Saharan African especially among children less than 5 years. According to a research by Sunguya, et al (2012), RUTFs provide essential nutrients in the body since they are rich in micronutrients, energy and standardized lipids. They also contain minerals, vitamins, sugar and oil. Most significantly, they can be easily administered in affected population as they can be easily used without trained personnel. They are normally used in remote areas (Sunguya, et al 2012). Administration of RUTFs through home-based and community-based interventions has been effective in saving lives of malnourished children.

nWilford, Golden and Walker (2012) conducted a study on the effectiveness of administration of RUTFs through community-based interventions in Sub-Saharan Africa. The study recorded positive impacts (Wilford, Golden and Walker 2012). The study suggested that community-based interventions are effective in managing of wasting in children especially in outpatient care. The researcher noted that ready-to-use foods are very useful in managing moderate and severe wasting in children in Sub-Saharan Africa. The RUTFs were also attributed to high rate of recovery among these children at risk of malnutrition. Another study by Wilford et al (2012) in Malawi pointed out that RUTFs promote high rate of gaining weight among nutritional at risk children. The research evaluated the impacts of RUTFs after three months of distribution in Malawi.

nThe areas of interventions had higher number of cases malnutrition in children (Wilford et al 2012). The findings of the study demonstrated that RUTFs have a protective impact on weight-for-height ration among children. Most importantly, the results discovered that these foods supplements provide substantial decrease in the number of new cases of severe weight loss. Therefore, the study noted that RUTFs have protective effects hence it can be used to prevent cases of deaths or related diseases (Schoonees et al 2013). In under-five children, the supplements have a beneficial effect because it enhances intake of micronutrients and energy. For this reason, high intake of energy among children promotes the weight gain. Another research by (Sunguya et al 2012) suggested that gaining weight in children is associated with enhanced appetite due to higher intake of micronutrients.

nA study conducted in Dar es Salaam investigated the effects of RUTF on HIV-positive children. The research suggested that the supplements help these children to gain weight, and improve their immunity status as compared to those who use traditional supplements. In these regard, the studies proposes that RUTFs have a positive effects in the body especially among malnourished children (Huybregts et al 2012).

nPublic Health Significance

nAccording to evidence, RUTFs provide significant benefits in public health. The supplements contain essential and adequate nutrients needed in the body. According to WHO, RUTFs provides standardized treatment based on its guideline (Irena, Mwambazi and Mulenga 2011). It has minerals such as iodine, selenium, potassium, copper, magnesium, zinc, and iron. It also offers over 500 kcal per 100 grams. Similarly, it provides proteins, and lipids to the body. They do not support growth of bacteria since it has limited content of water, which creates unfavourable climate for these microorganisms (Shewade, Patro, Bharti, Soundappan, Kaur and Taneja 2013). Additionally, they have a longer shelf life hence it can be stored for more than two years. Furthermore, RUTFs do not need cooking and they are palatable to children (Briend and Collins 2010). All these characteristics make them important in public health interventions.

nResearch questions

nPICO (population, intervention, control and outcomes) model was used to develop research questions. Population (P) will deal with a specific population suffering from a certain problem, while interventions (I) would be introduction of RUTFs (Eijkenaar, Emmert, Scheppach and Schöffski 2013). The control (C) would be an alternative supplement while outcome is the expected outcomes (O) of the intervention.

nThe research question for this study was:

nIn under-5 children suffering from acute malnutrition (P), is administration of RUTFs (I) effective in increasing intake of micronutrients and energy (O) as compared to traditional food supplements (C)?

nResearch Design and Methods

nA systematic review research design will be developed in this study, which encompasses collection of secondary data on the research topic. The study would use systematic research design as the research is aimed at utilizing comparative analysis in determining the effects of using RUTFs among children below five years (Smith, Devane, Begley and Clarke 2011). Moreover, the researcher intends to use this methodology because a comprehensive analysis of both temporary and long-lasting effects in the population will be discussed into details. Strategies such as search focus will be mainly used on academic and medical journals as well as other reports from reputable international health organizations for the purpose of systematic literature reviews in this study. In order to deliver an appropriate the investigator will be very clear and systematic and avoid instances of bias in the study (Hulley, Cummings, Browner, Grady and Newman 2013).

nPredefined search terms and exclusion and inclusion criteria will be applied aiming to avoid subjectivity and ensure rigor. Relevant medical books would also be used in this research mainly to provide shifts, definitions and meanings of terms (Eijkenaar, Emmert, Scheppach and Schöffski 2013). The study expected that journals and books could also provide an exhaustive literature review on effects of RUTFs among children below five years in Sub-Saharan Africa. Furthermore, the literature review conducted for this research, only methodology with high validity and reliability was utilized in the systematic analysis of the relevant literatures.

nThe main purpose of this study is to conduct a literature review to explore relevant and excellent studies, which will be appraised, synthesized and analysed to acquire an understanding into the effects of RUTFs among children below five years living in sub-Saharan Africa. Malnutrition especially of children under five years is a serious health concern in Sub-Saharan Africa (Khan, Kunz, Kleijnen and Antes 2011). A review of all the important literatures will play a key role to ascertain all the aspects of the research question aiming to offer in-depth information to the questions.

nStudy Methods

nThe research will identify and ascertain all relevant literature utilizing the systematic strategy using keyword searches from the medical bibliographic databases such as aMed and PubMed. Moreover, searches from recognized studies and latest editions of medical journals and reviews will collect the missed data (Smith, Devane, Begley and Clarke 2011). Most importantly, this will assist the researcher in elimination of biases. The research will not use unpublished studies in order to eliminate publications bias. Other kind of grey literatures such as UNICEF and WHO reports as well as journal articles and organization’s conference presentations that are not peer reviewed may sometimes offer extra data on the effects of RUTFs among children in Sub-Saharan Africa. Therefore, the researcher will access and appraise them before including these data in the literature review (Brownson, Baker, Leet, Gillespie and True 2010). Furthermore, the investigator will repeat searches in the website databases aiming to raise the probability of retrieving beneficial data and relevant information.

nRationale for inclusion and inclusion criteria

nInclusion and exclusion criteria will be used in order to collect data from high quality peer reviewed journals providing information on the effects of RUTFs among children below five years in Sub-Saharan Africa. In addition, the criteria were applied because the greatest level of evidence can be accomplished via quality primary searches on the topic. Accessing the medical reports, academic articles and case studies on the effects of ready-to-use therapeutic foods in sub-Saharan African countries will provide important insights into how these effects can influence positive interventions. The studies of children above five years would not be included in this research (Hulley, Cummings, Browner, Grady and Newman 2013). In addition, it is anticipated that studies on diverse impacts of other supplements have been conducted in sub-Saharan region but these will be excluded from this research.

nCollection of data: Appraisal, synthesis and Analysis

nThe process of collection of data in a literature review is very important because it determines the kind of information in the study. Moreover, there are a number of methods of collection of data collection used in this kind of survey. They comprises of data assembling, synthesising and analysing (Donald, Martin‐Misener, Carter, Donald, Kaasalainen, Wickson‐Griffiths, Lloyd, Akhtar‐Danesh and DiCenso 2013). In the preliminary process of assembling, the investigator will access and read the potential abstract of the studies to ascertain their relevance and appropriateness to the research question (Smith, Devane, Begley and Clarke 2011). Consequently, the research will then be skimmed for the purpose of examination for data that provide information of applicability and value of the study. The process also enables the research to determine whether the materials could be chosen for more appraisals.

nMoreover, appraisal will then be conducted for the choses pieces of research to allow the research to understand their weaknesses, strengths, limitations, relevance and the suitability of the methodology used in those studies. The main benefit of the appraisal is that it offers an opportunity to understand whether the research offer adequate evidence or it offer an in-depth and comprehensive conclusion (Eijkenaar, Emmert, Scheppach and Schöffski 2013). Additionally, via the process of appraisal it offer an assurance that the arguments and themes identified will enable analyses and synthesise of data to establish a systematic review. The stages would be applied to assist in the analysis and synthesis of data. Similarly, they would be used to record the research details comprising date of publication, the author and the main findings (Boland, Cherry and Dickson eds. 2013).

nAfter the researches have been recorded, the data will be incorporate and synthesize the main arguments or themes that have emerged. The ideas and the arguments will then be categorized appropriately into groups. On the other hand, the produced evidence will define when the information is valid or not (Viswanathan, Ansari, Berkman, Chang, Hartling, McPheeters, Santaguida, Shamliyan, Singh, Tsertsvadze and Treadwell 2012). The main body of the literature review will deliver an in-depth evidence of how it is establishing its cases to offer an undoubted conclusion on the effects of RUTFs. The stage-by-stage process of analysis and synthesis will be useful in the literature review, as it will ensure that it develops all-inclusive inference (Brownson, Baker, Leet, Gillespie and True 2010). Most significantly, it helps to eliminate any chance of delivering fallacious ideas if the studies are not reviewed in a comprehensive and systematic manner.

nEthical consideration

nSince this literature review uses secondary data, the researcher would not be required to seek ethical approval from the ethics committee. Nonetheless, each study will be evaluated to ensure that the authors had sought an ethical approval (Higgins 2013). In addition, it ensures that they had adhered to set guidelines and standards. Most importantly, the literature review will determine whether the interests of authors and sponsors of the study are taken into consideration. Most importantly, the researcher will ensure that plagiarism is avoided in the process of systematic review (Smith, Devane, Begley and Clarke 2011). Likewise, the investigator will pay close attention on misrepresented and missing information caused by selection or publication bias. They are considered as ethical issues because they can result to inappropriate conclusions.

nRigour

nRigour of this review will be accomplished by ensuring that it is done in a systematic and open manner. The methods section describes the search terms and a rationale has been included for inclusion and exclusion criteria. Suitable appraisal tools will be used to ensure that researches are selected for quality and relevance (Viswanathan, Ansari, Berkman, Chang, Hartling, McPheeters, Santaguida, Shamliyan, Singh, Tsertsvadze and Treadwell 2012). A tally chart will display the process and depth of synthesis and analysis and a reference list will be provided. The review will ensure that that care is taking to ensure that conclusions drawn are generalizable and warranted (Khan, Kunz, Kleijnen and Antes 2011).

nLimitations

nThis work will be for a post-graduate level hence it will have some time constraints because it has to be completed within a year. The paper will include a timeframe, which will ensure that an adequate amount of time is assigned to accomplish each piece of work (Smith, Devane, Begley and Clarke 2011). At post-graduate level, the researchers’ skills and knowledge are still developing, but integrating the skills and knowledge taught on the advanced research design module will help the researcher to deliver a proposal at the appropriate academic level (Gough, Oliver and Thomas eds. 2012).

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nReferences

nBoland, A., Cherry, M.G. and Dickson, R. eds., 2013. Doing a systematic review: A student’s guide. Sage.

nBriend, A. and Collins, S., 2010. Therapeutic nutrition for children with severe acute malnutrition: summary of African experience. Indian pediatrics, 47(8), pp.655-659.

nBriend, A. and Collins, S., 2010. Therapeutic nutrition for children with severe acute malnutrition: summary of African experience. Indian pediatrics, 47(8), pp.655-659.

nBrownson, R.C., Baker, E.A., Leet, T.L., Gillespie, K.N. and True, W.R., 2010. Evidence-based public health. Oxford University Press.

nDibari, F., Bahwere, P., Huerga, H., Irena, A.H., Owino, V., Collins, S. and Seal, A., 2013. Development of a cross-over randomized trial method to determine the acceptability and safety of novel ready-to-use therapeutic foods. Nutrition, 29(1), pp.107-112.

nDonald, F., Martin‐Misener, R., Carter, N., Donald, E.E., Kaasalainen, S., Wickson‐Griffiths, A., Lloyd, M., Akhtar‐Danesh, N. and DiCenso, A., 2013. A systematic review of the effectiveness of advanced practice nurses in long‐term care. Journal of Advanced Nursing, 69(10), pp.2148-2161.

nEijkenaar, F., Emmert, M., Scheppach, M. and Schöffski, O., 2013. Effects of pay for performance in health care: a systematic review of systematic reviews. Health policy, 110(2), pp.115-130.

nGough, D., Oliver, S. and Thomas, J. eds., 2012. An introduction to systematic reviews. Sage.

nHiggins, J.P.T., 2013. Green S. Cochrane handbook for systematic reviews of interventions version 5.1. 0. The Cochrane Collaboration, 2011. 2011-03-20)[2013-5-19]. http://www. cochrane-handbook, org.

nHulley, S.B., Cummings, S.R., Browner, W.S., Grady, D.G. and Newman, T.B., 2013. Designing clinical research. Lippincott Williams & Wilkins.

nHuybregts, L., Houngbé, F., Salpéteur, C., Brown, R., Roberfroid, D., Ait-Aissa, M. and Kolsteren, P., 2012. The effect of adding ready-to-use supplementary food to a general food distribution on child nutritional status and morbidity: a cluster-randomized controlled trial. PLoS Med, 9(9), p.e1001313.

nIrena, A.H., Mwambazi, M. and Mulenga, V., 2011. Diarrhea is a major killer of children with severe acute malnutrition admitted to inpatient set-up in Lusaka, Zambia. Nutrition journal, 10(1), p.1.

nKhan, K., Kunz, R., Kleijnen, J. and Antes, G., 2011. Systematic reviews to support evidence-based medicine. Crc Press.

nSchoonees, A., Lombard, M., Musekiwa, A., Nel, E. and Volmink, J., 2013. Ready‐to‐use therapeutic food for home‐based treatment of severe acute malnutrition in children from six months to five years of age. The Cochrane Library.

nShewade, H.D., Patro, B.K., Bharti, B., Soundappan, K., Kaur, A. and Taneja, N., 2013. Effectiveness of indigenous ready-to-use therapeutic food in community-based management of uncomplicated severe acute malnutrition: a randomized controlled trial from India. Journal of tropical pediatrics, p.fmt039.

nSmith, V., Devane, D., Begley, C.M. and Clarke, M., 2011. Methodology in conducting a systematic review of systematic reviews of healthcare interventions. BMC medical research methodology, 11(1), p.1.

nSunguya, B.F., Poudel, K.C., Mlunde, L.B., Otsuka, K., Yasuoka, J., Urassa, D.P., Mkopi, N.P. and Jimba, M., 2012. Ready to Use Therapeutic Foods (RUTF) improves undernutrition among ART-treated, HIV-positive children in Dar es Salaam, Tanzania. Nutrition journal, 11(1), p.1.

nViswanathan, M., Ansari, M.T., Berkman, N.D., Chang, S., Hartling, L., McPheeters, M., Santaguida, P.L., Shamliyan, T., Singh, K., Tsertsvadze, A. and Treadwell, J.R., 2012. Assessing the risk of bias of individual studies in systematic reviews of health care interventions.

nWilford, R., Golden, K. and Walker, D.G., 2012. Cost-effectiveness of community-based management of acute malnutrition in Malawi. Health policy and planning, 27(2), pp.127-137.