ArticlePDF AvailableLiterature Review

Abstract

There is consensus on how to treat severe malnutrition, but there is no agreement on the most cost-effective way to treat infants and young children with moderate malnutrition who consume cereal-dominated diets. The aim of this review is to give an overview of the nutritional qualities of relevant foods and ingredients in relation to the nutritional needs of children with moderate malnutrition and to identify research needs. The following general aspects are covered: energy density, macronutrient content and quality, minerals and vitamins, bioactive substances, antinutritional factors, and food processing. The nutritional values of the main food groups--cereals, legumes, pulses, roots, vegetables, fruits, and animal foods--are discussed. The special beneficial qualities of animal-source foods, which contain high levels of minerals important for growth, high-quality protein, and no antinutrients or fibers, are emphasized. In cereal-dominated diets, the plant foods should be processed to reduce the contents of antinutrients and fibers. Provision of a high fat content to increase energy density is emphasized; however, the content of micronutrients should also be increased to maintain nutrient density. The source of fat should be selected to supply optimal amounts of polyunsaturated fatty acids (PUFAs), especially n-3 fatty acids. Among multiple research needs, the following are highlighted: to identify the minimum quantity of animal foods needed to support acceptable child growth and development, to examine the nutritional gains of reducing contents of antinutrients and fibers in cereal- and legume-based diets, and to examine the role of fat quality, especially PUFA content and ratios, in children with moderate malnutrition.
Contents
Dietary management of moderate malnutrition: Time for a change
— A. Briend and Z.W. Prinzo ................................................................................................................................. S265
Proposed recommended nutrient densities for moderately malnourished children
— M.H. Golden ....................................................................................................................................................... S267
Choice of foods and ingredients for moderately malnourished children 6 months to 5 years of age
— K.F. Michaelsen, C. Hoppe, N. Roos, P. Kaestel, M. Stougaard, L. Lauritzen, C. Mølgaard, T. Girma,
and H. Friis ............................................................................................................................................................... S343
Dietary counseling in the management of moderate malnourishment in children
— A. Ashworth and E. Ferguson ............................................................................................................................ S405
Current and potential role of specially formulated foods and food supplements for preventing
malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among
6- to 59-month-old children — S. de Pee and M.W. Bloem ...................................................................... S434
Proceedings of the World Health Organization/UNICEF/World Food Programme/United Nations
High Commissioner for Refugees Consultation on the Management of Moderate Malnutrition
in Children under 5 Years of Age — J. Shoham and A. Duffield .............................................................. S464
Guest Editors: Andre Briend and Zita Weise Prinzo
Food and Nutrition Bulletin
Food and Nutrition Bulletin, vol. 30, no. 3 (supplement)
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Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. S265
Dietary management of moderate malnutrition: Time
for a change
Introduction
All children with moderate wasting, or with moder-
ate or severe stunting, have in common a higher risk
of dying and the need for special nutritional support.
In contrast to children suffering from life-threatening
severe acute malnutrition, there is no need to feed
these children with highly fortified therapeutic foods
designed to replace the family diet. Their dietary
management should be based on improving the exist-
ing diets by nutritional counseling and, if needed, by
the provision of adapted food supplements providing
nutrients that cannot be easily provided by local foods.
Children with growth faltering would also benefit from
the same approach.
In contrast to severe acute malnutrition, management
of moderate malnutrition (defined by either moderate
wasting or stunting) has remained virtually unchanged
over the last 30 years. Two broad approaches are used.
In most situations, dietary counseling is given to fami-
lies on the assumption that they have access to all foods
needed for feeding their children but lack the knowl-
edge of how best to use them. In the context of food
insecurity, or of insufficient access to nutrient-dense
foods, food supplements, usually fortified blended
flours, are given.
Evaluation of programs for the management of
moderate malnutrition so far has yielded mixed results.
The review by Ann Ashworth and Elaine Ferguson
shows that the dietary advice given is often nonspe-
cific, i.e., not really different from the advice given to
well-nourished children, and that the impact of large-
scale programs is often uncertain [1]. Doubts about
the efficacy of supplementary feeding programs using
blended flours have been raised repeatedly over the
past 25 years [2, 3]
Many reasons can explain the apparent lack of effi-
cacy of these programs. Diets recommended as part of
counseling often have a low nutritional density, insuffi-
cient to promote recovery. Often, when nutrient-dense
foods are recommended, they are expensive and not
really accessible to poor families. When food supple-
ments are given, they are usually made with the cheap-
est sources of energy (cereals) and proteins (legumes)
and often have no added fat. Such supplements often
have a nutritional profile (high protein, low fat, and
high dietary fiber and antinutrient content) that does
not seem the best adapted to promote rapid growth of
malnourished children [4].
Clearly, it is time for a change. Children with mod-
erate malnutrition should get the foods that provide
all the nutrients they need for full recovery, not just
the food choice that represents the cheapest option to
provide them energy and proteins. Their efficacy to
promote recovery and their accessibility must be the
first criteria to consider when making a choice.
Improving the diets of children with moderate mal-
nutrition will not be easy to achieve. First, there are still
many uncertainties about what nutrients children with
moderate malnutrition, particularly stunted children,
need for recovery, as highlighted in the article by Pro-
fessor Mike Golden [5]. The possible negative effect of
antinutrients, which are present in high concentrations
in cereals and even higher concentrations in legumes,
will complicate the picture, as described in the article by
Kim Michaelsen and colleagues [6]. Second, diets with
higher nutrient density and lower antinutrient content,
which are more appropriate for children with moderate
malnutrition, either have a high level of animal-source
foods or have to be made from highly processed plant
foods, which makes them more expensive than cur-
rently recommended diets. Moreover, in the present
context of the emerging burden of obesity in many
poor countries, promoting diets leading to increased
weight is not satisfactory, especially in areas of high
André Briend and Zita Weise Prinzo
The authors are affiliated with the World Health Organiza-
tion, Geneva.
Please direct queries to the corresponding author: Zita
Weise Prinzo, World Health Organization, NHD, CH-1211
Genève 27, Switzerland; e-mail: weiseprinzoz@who.int.
This article reflects the personal views of the two authors
and does not necessarily represent the decisions or the poli-
cies of the World Health Organization.
S266 A. Briend and Z.W. Prinzo
stunting prevalence [7]. It is important that proposed
diets have a limited effect on deposition of fat tissue,
promote lean tissue synthesis, and lead to improved
functional outcomes, such as improved cognitive devel-
opment. In this respect, attention should be paid to the
essential fatty acid contents of diets, so far a neglected
aspect of the management of moderate malnutrition.
There are clear indications from the papers presented
at this meeting on how to improve current programs.
Dietary counseling should move away from general
“fit-for-all” recommendations and should provide
specific suggestions that are nutritionally adequate
and locally adapted. Program implementers should
make sure that the recommended diets are nutritionally
adequate and contain all nutrients needed for growth.
Adapted computer software can be used to make this
assessment more rigorous [8].
Food supplements should be considered in case of
food insecurity, or, in a context of poverty, if these
supplements represent a less expensive option for pro-
viding all nutrients needed by children. The article by
Saskia de Pee and Martin Bloem [4] presents several
possible options.
Too many uncertainties were highlighted in this
meeting to be able to propose an optimal diet for all
children with moderate malnutrition in the short term.
Enough information is available, however, to improve
the current situation and to start a process of continu-
ous evaluation and improvement of possible treatment
options for moderate malnutrition. We hope this meet-
ing will contribute to achieving these objectives, which
are within our reach and will contribute to reaching
Millennium Development Goals 1 and 4.
References
1. Ashworth A, Ferguson E. Dietary counseling in the
management of moderate malnourishment in children.
Food Nutr Bull 2009;30:S406–33.
2. Beaton GH, Ghassemi H. Supplementary feeding pro-
grams for young children in developing countries. Am
J Clin Nutr 1982;35(4 suppl):863-916.
3. Navarro-Colorado C. A retrospective study of emergency
supplementary feeding programmes. Save the Children/
ENN, June 2007. Available at: http://www.ennonline.
net/pool/files/research/Retrospective_Study_of_Emer-
gency_Supplementary_Feeding_Programmes_June%20
2007.pdf. Accessed 30 May 2009.
4. de Pee S, Bloem MW. Current and potential role of
specially formulated foods and food supplements
for preventing malnutrition among 6- to 23-month-
old children and for treating moderate malnutrition
among 6- to 59-month-old children. Food Nutr Bull
2009;30:S434–63.
5. Golden MH. Proposed recommended nutrient densities
for moderately malnourished children. Food Nutr Bull
2009;30:S267–43.
6. Michaelsen KF, Hoppe C, Roos N, Kaestel P, Stougaard
M, Lauritzen L, Mølgaard C, Girma T, Friis H. Choice
of foods and ingredients for moderately malnourished
children 6 months to 5 years of age. Food Nutr Bull
2009;30:S344–405.
7. Uauy R, Kain J. The epidemiological transition: Need
to incorporate obesity prevention into nutrition pro-
grammes. Public Health Nutr 2002;5:223-9.
8. Ferguson EL, Darmon N, Fahmida U, Fitriyanti S,
Harper TB, Premachandra IM. Design of optimal
food-based complementary feeding recommendations
and identification of key ‘problem nutrients’ using goal
programming. J Nutr 2006;136:2399-404.
Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. S267
Proposed recommended nutrient densities for
moderately malnourished children
Abstract
Recommended Nutrient Intakes (RNIs) are set for healthy
individuals living in clean environments. There are no gen-
erally accepted RNIs for those with moderate malnutrition,
wasting, and stunting, who live in poor environments. Two
sets of recommendations are made for the dietary intake of
30 essential nutrients in children with moderate malnutri-
tion who require accelerated growth to regain normality:
first, for those moderately malnourished children who will
receive specially formulated foods and diets; and second,
for those who are to take mixtures of locally available foods
over a longer term to treat or prevent moderate stunting
and wasting. Because of the change in definition of severe
malnutrition, much of the older literature is pertinent
to the moderately wasted or stunted child. A factorial
approach has been used in deriving the recommenda-
tions for both functional, protective nutrients (type I) and
growth nutrients (type II).
Key words: Ascorbate, biotin, calcium, catch-up
growth, cobalamin, convalescence, copper, DRV,
essential fatty acid, folic acid, growth, iodine, iron,
magnesium, malnutrition, manganese, niacin, nutrient
density, nutrition, nutritional deficiency, nutritional
requirements, pantothenic acid, phosphorus, potassium,
protein, protein–energy malnutrition, pyridoxine, RDA,
recommendations, riboflavin, RNI, selenium, sodium,
stunting, sulfur, thiamine, vitamin A, vitamin D, vitamin
E, vitamin K, wasting, zinc
Summary
The objective is to derive nutrient requirements for
moderately malnourished children that will allow them
to have catch-up growth in weight and height, prevent
their death from nutritional disease, strengthen their
resistance to infection, allow for convalescence from
prior illness, and promote normal mental, physical, and
metabolic development.
The malnourished population will have been exposed
to nutritional stress and seasonal shortages and will
have been living in unhygienic conditions; a proportion
will have been severely malnourished. Typically, from
5% to 15% of children aged 6 to 59 months are moder-
ately wasted, and 20% to 50% are stunted in height.
There has been little published on the requirements
for the moderately wasted or stunted child per se.
However, with the change in definition of severe mal-
nutrition from the Wellcome classification [1] based
upon weight-for-age to one based upon weight-for-
height, reanalysis of the data shows that many of the
studies of children with less than 60% weight-for-age
included children who were moderately wasted by
modern criteria, albeit stunted. The physiological and
other data from the older literature therefore are likely
to apply to those with moderate as well as those with
severe wasting.
In order to derive the requirements of each nutrient
for moderately malnourished children, the lower and
upper boundaries were assumed to lie between the
requirement for a normal, healthy child living in a clean
environment and the requirement for treatment of a
severely malnourished child living in a contaminated
environment. The therapeutic diets used for treatment
of the severely malnourished in the developing world
have been remarkably successful and are capable of sus-
taining rates of weight gain of more than 10 g/kg/day
and returning the children to physiological normality.
The requirements for normal Western individuals
(Recommended Nutrient Intake, RNI) were used as
the minimum requirements. They were converted into
nutrient:energy densities with the use of the energy
Michael H. Golden
The author is an Emeritus Professor, Department of Medi-
cine and Therapeutics, University of Aberdeen, Aberdeen,
Scotland.
Please direct queries to the author: Michael Golden,
Pollgorm, Ardbane, Downings, Co. Donegal, Ireland; e-mail:
mike@pollgorm.net.
This publication reflects the personal views of the author
and does not necessarily represent the decisions or the poli-
cies of the World Health Organization.
S268 M. H. Golden
requirement for female children. The highest nutrient
density among the various age categories of children
was taken as a baseline.
For the growth nutrients (type II nutrients), a facto-
rial method was used to determine the increment that
should be added to allow for catch-up at 5 g/kg/day. To
this increments were added to allow those with mild
nondehydrating diarrhea to have their daily losses
replaced and to have tissue deficits replaced over a
period of about 30 days. For the type I nutrients (spe-
cific function nutrients), modest increments were added
to cover the additional oxidative and other stresses that
the subjects would be exposed to in unhygienic, pol-
luted conditions; these include smoke pollution in the
home, mild enteropathy, mild small intestinal bacterial
overgrowth, some ingestion of fungal and other toxins
arising from contaminated food and water, and recur-
rent infections such as malaria.
Two sets of requirements are suggested. First are the
requirements for rehabilitation with the use of a variety
of appropriately processed locally available foods; these
are the minimum requirements, as it is unlikely that
the optimal requirement for all nutrients can be con-
sistently reached with unfortified local foods. Second
are the optimal requirements proposed when special
complementary, supplementary, or rehabilitation foods
are being formulated to treat moderately malnourished
children. It is assumed that these foods can be fortified
with specific nutrients to achieve an optimal nutrient
density for the moderately malnourished child.
Each nutrient is considered in turn and its pecu-
liarities are considered. The nutrient:nutrient ratios
were examined to ensure that the diet would not be
unbalanced and that there would not be detrimental
interactions between the nutrients.
The results are shown in table 1. The RNI values for
healthy Western populations and the nutrient densities
in the F100 formulation used for rehabilitation of the
severely malnourished are also shown, as these repre-
sent the lower and upper boundaries within which it is
expected that the values for most nutrients needed by
the moderately malnourished will lie.
It should be emphasized that there are many uncer-
tainties involved in deriving these first estimates of the
TABLE 1. RNIs for normal children, nutrient contents of F100 and RUTF (used for treating children with severe acute
malnutrition [SAM]), and proposed RNIs for children with moderate acute malnutrition (MAM) living in contaminated
environments, expressed as nutrient:energy densities (amount of nutrient/1,000 kcal)
Nutrient
Gravi-
metric
unit
RNIs for
normal children F100 and
RUTF for
SAM
Proposed RNIs for MAMa
FAO OtherbFood
Supple-
ment SI unit Food
Supple-
ment
Protein
Protein g 22.3 — 28.4 24 26
Nitrogen g 3.6 — 4.6 3.9 4.2 mmol 275 300
Minerals
Sodium mg 978 434 550
maximum
550
maximum
mmol 24 24
Potassium mg 1,099 2,400 1,400 1,600 mmol 36 41
Magnesium mg 79 112 175 200 300 mmol 8.3 12.5
Phosphorus mg 450 634 762 600 900 mmol 19 29
Sulfurcmg 0 0 0 0 200 mmol 0 5.6
Zinc mg 12.5 16.5 22.3 13 20 µmol 200 310
Calcium mg 595 820 1,009 600 840 mmol 15 21
Copper µg 892 2,749 680 890 µmol 11 14
Iron mg 17.8 17.8 24d9 18 µmol 160 320
Iodine µg 201 201 190 200 200 µmol 1.6 1.6
Selenium µg 17.8 29.7 55 30 55 nmol 380 700
Manganese mg 1.2 0.69 1.2 1.2 µmol 22 22
Chromium µg 10.8 0 0 11 nmol 0 210
Molybdenum µg 16.6 0 0 16 nmol 0 170
Vitamins, water
soluble
Thiamine
(vitamin B1)
µg 523 523 700 600 1,000 mmol 2.0 3.3
continued
S269
Recommended nutrient densities
TABLE 1. RNIs for normal children, nutrient contents of F100 and RUTF (used for treating children with severe acute
malnutrition [SAM]), and proposed RNIs for children with moderate acute malnutrition (MAM) living in contaminated
environments, expressed as nutrient:energy densities (amount of nutrient/1,000 kcal) (continued)
Nutrient
Gravi-
metric
unit
RNIs for
normal children F100 and
RUTF for
SAM
Proposed RNIs for MAMa
FAO OtherbFood
Supple-
ment SI unit Food
Supple-
ment
Riboflavin
(vitamin B2)
µg 595 595 2,000 800 1,800 mmol 2.1 4.8
Pyridoxine
(vitamin B6)
µg 595 732 700 800 1,800 mmol 4.7 10.7
Cobalamin
(vitamin B12)
ng 966 966 1,000 1,000 2,600 nmol 745 1,930
Folate µg 167 167 350 220 350 nmol 500 795
Niacin mg 6.4 8.4 10 8.5 18 µmol 70 145
Ascorbate
(vitamin C)
mg 45 74 100 75 100 µmol 425 570
Pantothenic
acid
mg 2.7 2.7 3 2.7 3 µmol 12.3 13.7
Biotin µg 9.7 9.7 24 10 13 nmol 40 53
Vitamins, fat
soluble
Retinol (vita-
min A)
µg 595 743 1,500 960 1,900 µmol 3.3 6.6
Cholecalciferol
(vitamin D)
µg 7.4 10.9 30 7.4 11 nmol 19 29
Tocopherol
(vitamin E)
mg 8.9 8.9 22 11.5 22 µmol 27 51
Phytomenadione
(vitamin K)
µg 16.1 16.1 40 20 40 nmol 44 89
Essential fatty
acids
N-6 fatty acid g 5 5 5
N-3 fatty acid g 0.85 0.85 0.85
Others
Choline mg — 223 — 223 223 —
Histidine mg — 430 — 430 430 —
Isoleucine mg — 575 — 575 575 —
Leucine mg — 1,245 — 1,245 1,245 —
Lysine mg — 1,190 — 1,190 1,190 —
Methionine +
cystine
mg — 575 — 575 575 —
Phenylalanine
+ tyrosine
mg — 1,125 — 1,125 1,125 —
Threonine mg — 655 — 655 655 —
Tryptophan mg — 175 — 175 175 —
Valine mg — 776 — 776 776 —
FAO, Food and Agriculture Organization; RNI, Recommended Nutrient Intake; RUTF, ready-to-use therapeutic food
a. The recommendations for moderately malnourished children are divided into two components. The first component (Food) is the amount
that should be in the diet when programs are based on a mixture of local foods to treat the moderately malnourished without general
fortification of the diet. The second component (Supplement) is the suggested nutrient density that should be achieved in the diet when
specially fortified supplementary foods are used in a program to treat moderately malnourished or convalescent children.
b. Highest of the values given by other authorities: see table 45 for details.
c. The sulfur should be in addition to that derived from protein.
d. Iron is only added to RUTF, not to F100
S270 M. H. Golden
nutrient requirements for the moderately malnour-
ished. As new data become available, it is anticipated
that the proposed nutrient requirements will be incre-
mentally refined and expert opinion will converge.
The particular forms of the nutrients (salts and
purity), which can affect taste, availability, dietary inter-
action, acid–base balance, efficacy, and cost, that should
be taken into account in formulating any supplemen-
tary foods or fortification are considered. The effects of
antinutrients that affect absorption and availability or
directly damage the intestine, as well as a more detailed
discussion of the essential fatty acids, are considered in
the companion article by Michaelsen et al. [2].
A summary of the derived nutrient requirements is
given in table 1 expressed as nutrient densities (nutri-
ent/1000 kcal). The derived nutrient requirements
expressed in absolute units are given in the appendix
(table 46).
Introduction
National and international RNIs are derived from
experimental data from normal, healthy individuals
living in a clean, secure environment and developing
and growing normally.
In the developing world, most individuals do not live
in such a clean, secure environment. One could argue
that the RNIs do not apply to much of the worlds popu-
lation. In general, the environment is unhygienic; the
children have recurrent infections, drink contaminated
water, are exposed to smoke pollution from cooking
fires, eat food containing fungal and bacterial toxins,
and subsist on a limited range of crops grown in the
immediate vicinity of their homes. Their growth and
development are retarded. In such circumstances, it is
likely that the requirements for nutrients are higher than
for those living in safe, secure environments. The reality
is that the diets of these children are much poorer than
those of children living without such stresses, where
food comes from a wide variety of sources. When they
get an infection and lose their appetite, there is an acute
loss of weight; this is so for all children in all societies.
However, in impoverished households there is no sub-
sequent catch-up growth during convalescence. The
diets are of insufficient quality to replace the nutrients
lost during the illness and to allow the children to return
to normal. From 5% to 15% of the world’s children are
wasted (low weight-for-height), with the peak prevalence
being between 6 and 24 months of age; 20% to 40% are
stunted (low height-for-age) by the time they reach 2
years of age.
There are no internationally agreed RNIs for such
children; although there have been published recom-
mendations, there has been no justification for the
levels chosen [3–5]. The Food and Agriculture Organiza-
tion/World Health Organization (FAO/WHO) and the
Institute of Medicine (IOM) have addressed this need in
their reports but have not proposed any changes to the
RNIs for such circumstances. However, agreed recom-
mendations are needed in order to plan programs, treat
moderate malnutrition, prevent deterioration, and assess
the diets of those who are living in stressful environments
or are at risk for malnutrition. The recommendations for
healthy Western populations are based upon relatively
extensive experimental data; these RNIs give a neces-
sary benchmark from which to start [6–14]. However,
for many essential nutrients, there are major gaps in the
data upon which the RNIs are based. This is particularly
true when deficiency in the West is not encountered
in the healthy (e.g., potassium, magnesium, phospho-
rus) or the emphasis is on excess intake (e.g., sodium);
these nutrients become critically important when there
are abnormal losses from the body, for example, with
diarrhea or enteropathy, and in the malnourished. Defi-
ciencies of these same nutrients are usually reported
by those caring for patients with gastroenterological
disease or requiring parenteral nutrition. For many other
nutrients, their bioavailability from the complex matrix
of foodstuffs commonly consumed where malnutrition
is common is unknown [15]. Furthermore, for children
in the age group from 6 to 59 months, there are few
direct experimental measurements, and RNIs have been
assessed either by extrapolation from older age groups or
from the composition of breastmilk [16]. The resulting
judgments for normal children differ from committee to
committee, sometimes quite dramatically.
Children who need to replenish the tissues that have
been lost while developing moderate malnutrition or
who need to have catch-up growth during convalescence
from illness will have higher requirements for nutrients
laid down in growing tissue than normal children.
Children living in hostile environments will also require
higher intakes of “protective” nutrients than those who
are not under stress. Normal children gain weight and
height at a slow pace relative to other mammals; thus,
the increments in nutrient intake required for growth
over those required for maintenance in the normal child
are quite modest. However, the malnourished child will
need to grow at an accelerated rate to catch up. In these
circumstances, the requirement for growth becomes a
higher proportion of the total requirement and the bal-
ance of nutrients changes; a richer, more nutrient-dense
diet is needed to enable functional tissue to be synthe-
sized more rapidly than normal.
General considerations in the derivation of
RNIs for moderately malnourished children
The effects of giving modern therapeutic diets to
severely wasted children are dramatic. The children
regain their appetites and ingest enough of the diet to
gain weight at up to 20 times the normal rate of weight
S271
Recommended nutrient densities
gain; indeed, the Sphere Project standards require an
average rate of weight gain of more than 8 g/kg/day
[17]. However, with the older diets, when emphasis
was placed upon energy density, the children did not
regain physiological or immunological normality; thus,
delayed hypersensitivity [18], thymic size [19], sodium
pump function [20], glucose tolerance [21], renal con-
centrating ability [22], and muscle size [23] remained
abnormal after treatment. Even though they gained
weight rapidly and reached normal weight-for-height,
they had a deficit of functional tissue and an excess of
fat tissue; they were relatively obese [24–28] because
the balance of nutrients was not correct to allow
appropriate amounts of lean tissue to be synthesized.
When the limiting growth nutrient” was added to the
diet, the children would regain more functional tissue
and their physiology and immunity would improve
[29–31], presumably until the next essential nutrient
limited further growth. With the modern diets based
upon the F100 formula, they regain physiological and
biochemical normality [32, 33].
These observations raise a critical point. Weight gain,
of itself, does not indicate a return to physiological,
biochemical, immunological, or anatomical normality.
Indeed, consuming “empty calories” that do not contain
all the nutrients in the correct balance necessary to
regain functional tissue results in the deposition of the
excess energy as adipose tissue. In this way, an inad-
equate diet may well convert a thin, undernourished
individual into an obese, undernourished individual*;
this was often the experience with the older diets used
to treat malnutrition and with attempts to treat stunted
children with energy supplements alone [34]. Indeed,
many overweight children are stunted in height,
indicating that they have had a chronic deficiency of
nutrients required for growth [35, 36]. We should not
rely only on an observed rate of weight gain or final
body weight-for-height when we judge the adequacy of
diets or supplementary foods. It is likely that acceler-
ated growth in height is a better indicator of nutritional
adequacy for a child than weight gain.
Nevertheless, the composition of the modern diets
for treating severe malnutrition (F100 [37–40] and the
derivative ready-to-use therapeutic foods (RUTFs)
[41]) gives a probable upper limit to the nutrient
intakes that are likely to be required by the moderately
malnourished or convalescent child living in a hostile
environment.
Thus, for any new recommendations for the moderately
* Obesity is only “overnutrition” in terms of energy. Obese
individuals can be undernourished in terms of many essential
nutrients; the empty calories are laid down as fat because
energy per se cannot be excreted, but coincidental low in-
takes of essential nutrients results in many obese persons
being undernourished. It is misleading to think of obesity as
“overnutrition”; nutrition is much more than simple energy
intak e.
malnourished, the requirements for most nutrients are
likely to lie somewhere between the requirements for
a normal child living in a clean, safe environment (the
RNIs) and a severely malnourished child recovering in
a hostile environment (F100 formula).
Variables determining the increments needed for the
moderately malnourished child
The derivation of recommendations for the moderately
malnourished to have catch-up growth depends upon
five variables:
» The amount of new tissue that needs to be synthesized
to achieve a normal body composition;
» The time available for the child to recover;
» The composition of the new tissue in terms of the
ratio of adipose to lean tissue (and skeletal tissue) that
should be deposited to achieve functional normality;
» The extent of any initial nutrient deficit or excess in the
body tissues brought about by physiological adapta-
tion to the malnourished state;
» Whether there are likely to be changes in nutrient
availability due to intestinal abnormalities or ongoing
pathological losses in the moderately malnourished
child.
Each of these variables affects the desirable daily intake
of the nutrients essential for replenishing and synthesiz-
ing new tissue. When individual nutrients are being
considered, the effect of each of the variables needs to
be examined.
Nevertheless, there are considerable uncertainties
in attempting to derive nutrient requirements for the
moderately malnourished child. Indeed, there are uncer-
tainties in the derivation of the RNIs for normal, healthy
children; for some nutrients, the extant data are not suf-
ficient to set RNIs, and therefore Adequate Intakes (AIs),
which are observed intakes of American children that
have no apparent detrimental effect on health, are used.
The uncertainties also include the degree of wasting and
stunting that has to be corrected, the initial deficits of
the tissues themselves and the body stores of nutrients
that need to be corrected, the composition of the tissue
that needs to be deposited, the rate of weight or height
gain that is achievable (the length of time over which
recovery should take place), and the effect of changes
in intestinal function in children with moderate mal-
nutrition on the absorption of nutrients from the diet,
as well as the effect of intercurrent infections, diarrhea,
accompanying chronic infections, and environmental
pollution on nutrient requirements. Each of these factors
is potentially of critical importance in determining the
quality of recover y of the malnourished child and should
be considered in setting requirements. However, reli-
able and quantitative data are lacking for many of these
considerations. Thus, it is likely that there will be many
points upon which experts’ opinions diverge. The present
article is deliberately conservative. For example, even if a
S272 M. H. Golden
mean rate of weight gain of 5 g/kg/day is not frequently
achieved in a group of children under traditional treat-
ment, there will be individuals within the group who
will achieve greater rates of weight gain, and the current
treatment itself may be limiting the rate of recovery.
Thus, it is reasonable to set the requirements at levels
that permit such a rate of recovery, and not to set them at
levels that restrict the weight gain or physiological recov-
ery of some of the children with moderate malnutrition.
Similarly, for body composition, if the deficit is mainly
of adipose tissue, then the nutrient density requirements
for its replacement will be relatively modest, and giving
a diet that is more nutrient dense will have no detri-
mental effect. On the other hand, if the deficit is mainly
of functional tissue, setting the requirements at a level
that would allow mainly for adipose tissue synthesis
would fail to return some of the children to normality
and might promote obesity. The RNIs, in the presence
of such uncertainty, should be set at a level that will not
compromise groups of children and yet are achievable
both with mixtures of local foods and with fortified
foods, where the fortification is not elevated to a level
that would pose a hazard if the fortified food was taken
exclusively. As with the RNIs for healthy children, set-
ting the RNIs for malnourished children will necessarily
involve value judgments and compromises to be made,
but it must be understood that the degree of uncertainty
is much higher than with normal, healthy children and
the consequences of underestimating the requirements
are more likely to lead to death.
As new data become available, it is anticipated that
the proposed nutrient requirements will be incremen-
tally refined and expert opinion will converge.
Rates of tissue accretion
The wasted child should be able to replenish both the
lean and the fat tissues within a reasonable period of
time to reach the normal range of weight-for-height.
It is usual for these children to have several episodes of
acute illness each year. If most children with moderate
malnutrition are to regain normality before the next
attack of acute illness, it is reasonable for such children to
regain their weight deficit in 30 days or less. If the deficit
is between –2 z-scores (just moderately malnourished)
and –1 z-score (the lower limit of normal and the upper
limit for mild was