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Short Communication
Ratna C Purwestri MSc, PhD1,2,3, Veronika Scherbaum MSc, PhD1,2, Dyah A Inayati M.Phil,
1 3 4 5
PhD , Nia N Wirawan MSc , Julia Suryantan MD, MSc , Maurice A Bloem MSc ,
Rosnani V Pangaribuan MPH, PhD6, Wolfgang Stuetz MSc, PhD2, Volker Hoffmann MSc,
1 7 2 1
PhD , Matin Qaim MSc, PhD , Hans K Biesalski MD, PhD , Anne C Bellows MUP, MA, PhD
1
Institute for Social Sciences in Agriculture, Center of Gender and Nutrition, University of Hohenheim,
Stuttgart, Germany
2
Institute for Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, Germany
3
Faculty of Medicine, Study Program Nutrition, University of Brawijaya, Malang, Indonesia
4
Church World Service, Indonesia
5
Church World Service, New York
6
SEAMEO-TROPMED Regional Centre for Community Nutrition, University of Indonesia, Jakarta, Indonesia
7
Department of Agricultural Economics and Rural Development, University of Goettingen, Germany
Ready-to-Use Foods (RUFs) in the form of fortified cereal/nut/legume-based biscuits (±500 kcal and 8-10% pro-
tein per 100 g) were tested among mildly wasted children from October 2007 to June 2008, and were labelled as
RUF-Nias biscuits. This study reports on a comparison of supplementary feeding program outcomes of mildly
wasted children with weight-for-height z-score (WHZ) ≥-2 to <-1.5 SD aged ≥6 to <60 months old given locally
produced RUF-Nias biscuits within daily (in semi-urban areas) and weekly (in rural remote regions) distribution
and supervision program settings. In the Church World Service project area, all eligible children were recruited
continuously from monthly community-based screening programs and admitted into existing nutrition centers
managed by the community on Nias Island, Indonesia. Individual discharge criterion of the programs was WHZ
≥-1.5 SD. Of the index children admitted in daily programs (n=51), 80.4% reached target WHZ, which was
higher than in weekly programs (72.9%; n=48) by a similar length of stay of about 6 weeks. Weight gain of the
children in daily programs was higher (3.1±3.6 g/kg body weight/day) than in weekly programs (2.0±2.1 g/kg
body weight/day), and they achieved significantly higher WHZ at discharge. However, the majority of caretakers
preferred weekly programs due to lower time constraints. Locally produced RUF in the form of biscuits for
treatment of mild wasting among children demonstrated promising results both in daily and weekly community-
based intervention programs.
Key Words: ready-to-use foods, fortified, supplementary feeding, mildly wasted children, weight gain
Table 1. Type and frequency of activities within daily and weekly programs
Frequency of implementation
Type of regular activities
Daily programs Weekly programs
Measures regarding RUF biscuits:
local production 1-2x per week 1x per week
distribution of RUF biscuits 1x per day 1x per week
on-site RUF biscuit’intake supervision 1x per day 1x per week
Recall and monitoring on:
take-home ration of RUF biscuit’intake 1x per day 1x per week
child morbidity 1x per day 1x per week
Monitoring on child anthropometry:
weight 2-3x per week 1x per week
height 1x per month 1x per month
376 RC Purwestri,V Scherbaum, DA Inayati, NN Wirawan, J Suryantan, MA Bloem, RV Pangaribuan, W Stuetz, V Hoffmann, M Qaim, HK Biesalski and AC Bellows
Table 2. Macro and micronutrients in 100 g RUF-Nias biscuits in relation to reference data
Table 3. Selected characteristics and family socio-economic background of all eligible mildly wasted children during
admission, by daily and weekly programs†
Table 4. Anthropometric indices during admission and before discharge/program closure of mildly wasted children,
by daily and weekly programs(including those children who did not reach discharge criterion, excluding 3 default
children)†
Mothers of the index children in daily programs were be significant predictors for not reaching discharge crite-
slightly older, less likely to be engaged in on-farm activi- rion in this study setting.
ties, and had almost similar education level as those in
weekly programs. Family income in semi-urban areas DISCUSSION
was only slightly higher than those in the rural remote All eligible mildly wasted children participating in the
regions. A high proportion of respondents (84.3 and daily programs gained more weight than those in weekly
95.8%) in daily and weekly programs were categorized as programs (3.1 and 2.0 g/kg/day, respectively) within a
poor families by earning less than US$1.25/day of Pur- similar duration of stay (±6 weeks) (Table 4). The results
chasing Parity Power (PPP);9 however the difference was are comparable to weight gain and proportion of recov-
not significant (Table 3). Income data was derived from ered observed in Malawian mildly wasted children con-
average cash money earned per month, and did not in- suming RUTF (3.1 g/kg/day, 58% recovered children)
clude household valuable assets, agriculture production, and higher than the children who consumed corn-soy
savings or aids. blend (1.4 g/kg/day, 22% recovered children) in commu-
As shown in Table 4, children assigned in daily pro- nity-based programs.4 As nearly all macro and micronu-
grams demonstrated better weight gain than those in trients (based on a 24-h dietary recall) were below the
weekly intervention groups (3.1 and 2.0 g/kg/day respec- recommended nutrient intake for Indonesian well-
tively) although the average duration of stay was similar nourished children (data not shown), the role of RUF-
for both programs (42.7 and 43.5 days). As many as Nias biscuits was to fill the gap and rehabilitate mild
80.4% (41/51) of the children in daily and 72.9% (35/48) cases of wasting.10
of those in weekly programs reached discharge criterion. Height-for-age z-score and height gain of our study
Within program period, the children in both programs children during individual discharge was not clearly af-
suffered from mild diarrhea, respiratory infection and fected by the RUF-Nias biscuit intervention, similar to the
fever with mostly 1-2 episodes (data not shown). Weight study result in Malawi.3 This could possibly be due to the
gain (in g/kg/day) of children at program discharge shorter duration of stay (about 37 days) of children who
showed significant positive correlation with good compli- reached discharge criterion in the respective programs
ance in consuming RUF biscuits (ß=0.337, p=0.031). (data not shown).
Furthermore, based on logistic regression analysis, chil- In this study, randomization could not be applied in our
dren who did not comply with RUF-Nias biscuit con- distinctive study areas because it was often impossible to
sumption had about 30 fold higher risk of not reaching perform daily programs in rural remote regions, where the
discharge criterion. Other risk factors were not shown to nutrition center was far away from the respondent’s
378 RC Purwestri,V Scherbaum, DA Inayati, NN Wirawan, J Suryantan, MA Bloem, RV Pangaribuan, W Stuetz, V Hoffmann, M Qaim, HK Biesalski and AC Bellows
houses. Daily programs were performed in semi-urban Despite the differences in socio-cultural, as well as
areas, that are relatively densely populated and near pub- geographical settings, the vast majority of mildly wasted
lic facilities (including health facilities), enabling daily children in daily and weekly programs achieved accept-
meeting for supervision and evaluation of RUF-Nias bis- able weight gain, and a high proportion in both programs
cuits consumption. In more rural villages, only a weekly reached discharge criterion within a relatively short pe-
program was possible; supervision and home visits were riod of intervention (about 6 weeks). Thus, treatment of
found more difficult to carry out. mild wasting with RUF-Nias biscuits seems to be feasible
The daily programs also recorded a slightly higher even in the less supervised weekly programs.
compliance rate and RUF biscuit’s intake among mildly
wasted children than in weekly programs (see Table 4). ACKNOWLEDGEMENTS
One explanation is that daily programs enabled supervi- Special thanks go to DAAD, DSM Nutritional Product Ltd-
sion and monitoring on-site consumption of 30-40% of Basel, Eiselen Foundation, Neys-van Hoogstraten Foundation
and CWS Indonesia for its kind and financial contribution. We
the daily portion of RUF-Nias biscuits, in contrast to only
greatly appreciate the cooperation of all voluntary workers,
about 5-10% portion in the weekly programs. Addition-
women and their children in the intervention area in Nias. We
ally, the analysis of consumed take-home ration of RUF- are also thankful to Prof Hans-Peter Piepho for statistical advice,
Nias biscuits relied on the accuracy of mothers’/caregivers’ as well as Dr. Saskia de Pee and Dr. Jee-Hyun Rah for review-
recall of children’s RUF intake. Daily recall of RUF-Nias ing an earlier draft of this manuscript.
biscuits consumption could be assessed more precisely
than in the weekly programs, wherein the past seven days AUTHOR DISCLOSURES
were harder to recapture. Similarly, the health status of The authors declared no conflict of interest in regard to this
the children, which was not significantly different be- paper.
tween the two programs, was also more closely monitored
in the daily than in weekly programs. Despite a slightly REFERENCES
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RUF for mildly wasted children 379
Short Communication
Ratna C Purwestri MSc, PhD1,2,3, Veronika Scherbaum MSc, PhD1,2, Dyah A Inayati M.Phil,
1 3 4 5
PhD , Nia N Wirawan MSc , Julia Suryantan MD, MSc , Maurice A Bloem MSc ,
Rosnani V Pangaribuan MPH, PhD6, Wolfgang Stuetz MSc, PhD2, Volker Hoffmann MSc,
1 7 2 1
PhD , Matin Qaim MSc, PhD , Hans K Biesalski MD, PhD , Anne C Bellows MUP, MA, PhD
1
Institute for Social Sciences in Agriculture, Center of Gender and Nutrition, University of Hohenheim,
Stuttgart, Germany
2
Institute for Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, Germany
3
Faculty of Medicine, Study Program Nutrition, University of Brawijaya, Malang, Indonesia
4
Church World Service, Indonesia
5
Church World Service, New York
6
SEAMEO-TROPMED Regional Centre for Community Nutrition, University of Indonesia, Jakarta, Indonesia
7
Department of Agricultural Economics and Rural Development, University of Goettingen, Germany
關鍵字:即食補充品、強化、補充餵食、輕度消瘦兒童、體重增加