key: cord-0051379-r5hq0k6w
authors: Akomo, Peter; Collins, Steve
title: Response to Reply - Comment on RUTF and correction of anaemia and iron deficiency in severe acute malnutrition
date: 2020-10-08
journal: Clin Nutr
DOI: 10.1016/j.clnu.2020.09.046
sha: fcfaad71ba7b58fde748256e9923e0ddecc45c7b
doc_id: 51379
cord_uid: r5hq0k6w

nan

We appreciate the reply to our Comment on ready-to-use therapeutic food (RUTF) and correction of anaemia and iron deficiency (ID) in severe acute malnutrition (SAM) 1 . The debate raises important issues about effectiveness in correction of micronutrient deficiencies during treatment of SAM.

The authors acknowledge that cow's milk inhibits iron absorption in infants but speculate that the superior performance of the milk-free RUTF in treating ID and anemia was due to the increased levels of iron and vitamin C in that product and a longer length of stay (LOS). This assertion is not consistent with our results. In our three-armed trial, the milk-free and 9.3% milk RUTFs had similar levels of iron (35.1mg/100g Vs 31.6mg/100g), both very different from the 10.5mg/100g in the 25% milk RUTF 2 . However, the milk-free product raised haemoglobin in anemic children by 2.9g/L compared to 2.3g/L and 2.2g/L in the 9.3% and 25% milk products respectively, and was significantly superior to the 9.3% product. The 9.3% product was not statistically different from the 25% product. The results on iron status for children with depleted body iron stores followed a similar pattern with greater differences in efficacy between the milk-free and 9.3% products than between the 9.3% and 25% products 2 .

These results can neither be explained by the differences in iron and vitamin C contents nor by the 3.1 days (8%) additional LOS for the milk-free product. In the presence of phytic acid, the molar ratios of phytic acid-to-iron and ascorbic acid-to-iron are superior indicators of non-heme iron absorption than absolute iron content 3, 4 . In our study, both these indicators were better in the 9.3% product compared to the 0% product. Although the TREATFOOD study found no effect on iron absorption from foods to treat MAM 5 , many studies have clearly documented the inhibitory effect of cow's milk on iron absorption 6, 7 .

Presently, less than 1 in 5 children with SAM are receiving the care they need, with grim predictions due to Covid-19 necessitating urgent action 8 . RUTF is by far the largest cost driver in the treatment of SAM, representing about 50% of the cost of care. In Malawi in 2017 the ingredient cost of the milk-free RUTF was 29% lower than for the milk-based RUTF. Since then the price of skimmed milk powder has, increased by >60% and the plant-based ingredients would now be approximately 40% lower cost. Expanding the choice of RUTF to include milk-free products not only has the potential to improve the treatment of ID and anemia but also to radically improve the coverage of SAM treatment by reducing costs and bringing competition into a market that has been dominated by a single product for 25 years.

Reply-Comment on RUTF and correction of anaemia and iron deficiency in severe acute malnutrition

Soya, maize and sorghum ready-to-use therapeutic foods are more effective in correcting anaemia and iron deficiency than the standard ready-touse therapeutic food: Randomized controlled trial

A Review of Phytate, Iron, Zinc, and Calcium Concentrations in Plant-Based Complementary Foods Used in Low-Income Countries and Implications for Bioavailability

Iron Bioavailability from a Lipid-Based Complementary Food Fortificant Mixed with Millet Porridge Can Be Optimized by Adding Phytase and Ascorbic Acid but Not by Using a Mixture of Ferrous Sulfate and Sodium Iron EDTA

Impact of food supplements on hemoglobin, iron status, and inflammation in children with moderate acute malnutrition: A 2 × 2 × 3 factorial randomized trial in Burkina Faso

Iron absorption from breast milk, cow's milk, and iron-supplemented formula: An opportunistic use of changes in total body iron determined by hemoglobin, ferritin, and body weight in 132 infants

Consumption of cow's milk as a cause of iron deficiency in infants and toddlers

Child malnutrition and COVID-19: the time to act is now