Nutritional interventions for preventing stunting in children (birth to 59 months) living in urban slums in low- and middle-income countries (LMIC).

BACKGROUND: Nutritional interventions to prevent stunting of infants and young children are most often applied in rural areas in low- and middle-income countries (LMIC). Few interventions are focused on urban slums. The literature needs a systematic assessment, as infants and children living in slums are at high risk of stunting. Urban slums are complex environments in terms of biological, social, and political variables and the outcomes of nutritional interventions need to be assessed in relation to these variables. For the purposes of this review, we followed the UN-Habitat 2004 definitions for low-income informal settlements or slums as lacking one or more indicators of basic services or infrastructure. OBJECTIVES: To assess the impact of nutritional interventions to reduce stunting in infants and children under five years old in urban slums from LMIC and the effect of nutritional interventions on other nutritional (wasting and underweight) and non-nutritional outcomes (socioeconomic, health and developmental) in addition to stunting. SEARCH METHODS: The review used a sensitive search strategy of electronic databases, bibliographies of articles, conference proceedings, websites, grey literature, and contact with experts and authors published from 1990. We searched 32 databases, in English and non-English languages (MEDLINE, CENTRAL, Web of Science, Ovid MEDLINE, etc). We performed the initial literature search from November 2015 to January 2016, and conducted top up searches in March 2017 and in August 2018. SELECTION CRITERIA: Research designs included randomised (including cluster-randomised) trials, quasi-randomised trials, non-randomised controlled trials, controlled before-and-after studies, pre- and postintervention, interrupted time series (ITS), and historically controlled studies among infants and children from LMIC, from birth to 59 months, living in urban slums. The interventions included were nutrition-specific or maternal education. The primary outcomes were length or height expressed in cm or length-for-age (LFA)/height-for-age (HFA) z-scores, and birth weight in grams or presence/absence of low birth weight (LBW). DATA COLLECTION AND ANALYSIS: We screened and then retrieved titles and abstracts as full text if potentially eligible for inclusion. Working independently, one review author screened all titles and abstracts and extracted data on the selected population, intervention, comparison, and outcome parameters and two other authors assessed half each. We calculated mean selection difference (MD) and 95% confidence intervals (CI). We performed intervention-level meta-analyses to estimate pooled measures of effect, or narrative synthesis when meta-analyses were not possible. We used P less than 0.05 to assess statistical significance and intervention outcomes were also considered for their biological/health importance. Where effect sizes were small and statistically insignificant, we concluded there was 'unclear effect'. MAIN RESULTS: The systematic review included 15 studies, of which 14 were randomised controlled trials (RCTs). The interventions took place in recognised slums or poor urban or periurban areas. The study locations were mainly Bangladesh, India, and Peru. The participants included 9261 infants and children and 3664 pregnant women. There were no dietary intervention studies. All the studies identified were nutrient supplementation and educational interventions. The interventions included zinc supplementation in pregnant women (three studies), micronutrient or macronutrient supplementation in children (eight studies), nutrition education for pregnant women (two studies), and nutrition systems strengthening targeting children (two studies) intervention. Six interventions were adapted to the urban context and seven targeted household, community, or 'service delivery' via systems strengthening. The primary review outcomes were available from seven studies for LFA/HFA, four for LBW, and nine for length.The studies had overall high risk of bias for 11 studies and only four RCTs had moderate risk of bias. Overall, the evidence was complex to report, with a wide range of outcome measures reported. Consequently, only eight study findings were reported in meta-analyses and seven in a narrative form. The certainty of evidence was very low to moderate overall. None of the studies reported differential impacts of interventions relevant to equity issues.Zinc supplementation of pregnant women on LBW or length (versus supplementation without zinc or placebo) (three RCTs)There was no evidence of an effect on LBW (MD -36.13 g, 95% CI -83.61 to 11.35), with moderate-certainty evidence, or no evidence of an effect or unclear effect on length with low- to moderate-certainty evidence.Micronutrient or macronutrient supplementation in children (versus no intervention or placebo) (eight RCTs)There was no evidence of an effect or unclear effect of nutrient supplementation of children on HFA for studies in the meta-analysis with low-certainty evidence (MD -0.02, 95% CI -0.06 to 0.02), and inconclusive effect on length for studies reported in a narrative form with very low- to moderate-certainty evidence.Nutrition education for pregnant women (versus standard care or no intervention) (two RCTs)There was a positive impact on LBW of education interventions in pregnant women, with low-certainty evidence (MD 478.44g, 95% CI 423.55 to 533.32).Nutrition systems strengthening interventions targeting children (compared with no intervention, standard care) (one RCT and one controlled before-and-after study)There were inconclusive results on HFA, with very low- to low-certainty evidence, and a positive influence on length at 18 months, with low-certainty evidence. AUTHORS' CONCLUSIONS: All the nutritional interventions reviewed had the potential to decrease stunting, based on evidence from outside of slum contexts; however, there was no evidence of an effect of the interventions included in this review (very low- to moderate-certainty evidence). Challenges linked to urban slum programming (high mobility, lack of social services, and high loss of follow-up) should be taken into account when nutrition-specific interventions are proposed to address LBW and stunting in such environments. More evidence is needed of the effects of multi-sectorial interventions, combining nutrition-specific and sensitive methods and programmes, as well as the effects of 'up-stream' practices and policies of governmental, non-governmental organisations, and the business sector on nutrition-related outcomes such as stunting.

Nutrient modulation in the management of disease-induced muscle wasting: evidence from human studies.

PURPOSE OF REVIEW: In addition to being essential for movement, skeletal muscles act as both a store and source of key macronutrients. As such, muscle is an important tissue for whole body homeostasis, undergoing muscle wasting in times of starvation, disease, and stress, for example, to provide energy substrates for other tissues. Yet, muscle wasting is also associated with disability, comorbidities, and mortality. As nutrition is so crucial to maintaining muscle homeostasis 'in health', it has been postulated that muscle wasting in cachexia syndromes may be alleviated by nutritional interventions. This review will highlight recent work in this area in relation to muscle kinetics, the acute metabolic (e.g. dietary protein), and longer-term effects of dietary interventions. RECENT FINDINGS: Whole body and skeletal muscle protein synthesis invariably exhibit deranged kinetics (favouring catabolism) in wasting states; further, many of these conditions harbour blunted anabolic responses to protein nutrition compared with healthy controls. These derangements underlie muscle wasting. Recent trials of essential amino acid and protein-based nutrition have shown some potential for therapeutic benefit. SUMMARY: Nutritional modulation, particularly of dietary amino acids, may have benefits to prevent or attenuate disease-induced muscle wasting. Nonetheless, there remains a lack of recent studies exploring these key concepts to make conclusive recommendations.

Nutrition Interventions in the Lives Saved Tool (LiST).

The Lives Saved Tool (LiST) was initially developed in 2003 to estimate the impact of increasing coverage of efficacious interventions on under-5 mortality. Over time, the model has been expanded to include more outcomes (neonatal mortality, maternal mortality, stillbirths) and interventions. The model has also added risk factors, such as stunting and wasting, and over time has attempted to capture a full range of nutrition and nutrition-related interventions (e.g., antenatal supplementation, breastfeeding promotion, child supplemental feeding, acute malnutrition treatment), practices (e.g., age-appropriate breastfeeding), and outcomes (e.g., stunting, wasting, birth outcomes, maternal anemia). This article reviews the overall nutrition-related structure, assumptions, and outputs that are currently available in LiST. This review focuses on the new assumptions and structure that have been added to the model as part of the current effort to expand and improve the nutrition modeling capability of LiST. It presents the full set of linkages in the model that relate to nutrition outcomes, as well as the research literature used to support those linkages.

Improvement in Nutritional Status in Patients With Chronic Kidney Disease-4 by a Nutrition Education Program With No Impact on Renal Function and Determined by Male Sex.

OBJECTIVE: Protein-energy wasting (PEW) is associated with increased morbidity and mortality and a rapid deterioration of kidney function in patients with chronic kidney disease (CKD). However, there is little information regarding the effect of nutrition intervention. The aims of this study were to evaluate the efficacy and safety of a nutrition education program (NEP) in patients with nondialysis dependent CKD (NDD-CKD), based on the diagnostic criteria for PEW proposed by the International Society of Renal Nutrition and Metabolism. The design of the study was a 6-month longitudinal, prospective, and interventional study. The study was conducted from March 2008 to September 2011 in the Nephrology Department of La Paz University Hospital in Madrid, Spain. SUBJECTS: A total of 160 patients with NDD-CKD started the NEP, and 128 finished it. INTERVENTION: The 6-month NEP consisted of designing an individualized diet plan based on the patient's initial nutritional status, and 4 nutrition education sessions. MAIN OUTCOME MEASURES: Changes in nutritional status (PEW) and biochemical, anthropometric and body composition parameters. RESULTS: After 6 months of intervention, potassium and inflammation levels decreased, and an improved lipid profile was found. Body mass index lowered, with increased muscle mass and a stable fat mass. Men showed increased levels of albumin and prealbumin, and women showed decreased proteinuria levels. The prevalence of PEW decreased globally (27.3%-10.9%; P = .000), but differently in men (29.5%-6.5%; P = .000) and in women (25.4%-14.9%; P = .070), 3 of the women having worsened. Kidney function was preserved, despite increased protein intake. CONCLUSION: The NEP in NDD-CKD generally improved nutritional status as measured by PEW parameters, but individual poorer results indicated the need to pay special attention to female sex and low body mass index at the start of the program.

Intentional weight loss in older adults: useful or wasting disease generating strategy?

PURPOSE OF REVIEW: Strategies for weight management in older adults remain controversial as overweight may protect them against mortality whereas weight loss may have harmful effects by promoting sarcopenia and bone loss. It has been suggested that weight management for obese older adults should focus more on maintaining weight and improving physical function than promoting weight loss. This review aims to specify whether intentional weight loss in older adults is a useful or a wasting disease generating strategy. RECENT FINDINGS: Recent randomized controlled studies have shown that a supervised, moderate caloric restriction coupled with regular exercise (both aerobic and resistance) in obese older adults do not increase mortality risk and may conversely reduce insulin resistance, metabolic complications, and disabilities without exacerbating lean mass and bone mineral density loss. SUMMARY: In obese older adults, moderate weight loss may have beneficial effects on comorbidities, functional performances, and quality of life provided that regular physical activity can be associated. An individual approach considering life expectancy, chronic comorbidities, functional status, personal motivation, and social support should be preferred. More research is needed to define the circumstances in which cautious dietary restrictions are reasonably justified in older adults. In any case, in the oldest (≥80 years) as in frail individuals, it seems reasonable to abstain from recommending weight loss.

Effectiveness and cost-effectiveness of supplemental glutamine dipeptide in total parenteral nutrition therapy for critically ill patients: a discrete event simulation model based on Italian data.

INTRODUCTION: The supplementation of alanyl-glutamine dipeptide in critically ill patients necessitating total parenteral nutrition (TPN) improves clinical outcomes, reducing mortality, infection rate, and shortening intensive care unit (ICU) hospital lengths of stay (LOSs), as compared to standard TPN regimens. METHODS: A Discrete Event Simulation model that incorporates outcomes rates from 200 Italian ICUs for over 60,000 patients, alanyl-glutamine dipeptide efficacy data synthesized by means of a Bayesian random effects meta-analysis, and national cost data has been developed to evaluate the alternatives from the cost perspective of the hospital. Simulated clinical outcomes are death and infection rates in ICU, death rate in general ward, and hospital LOSs. Sensitivity analyses are performed by varying all uncertain parameter values in a plausible range. RESULTS: The internal validation process confirmed the accuracy of the model in replicating observed clinical data. Alanyl-glutamine dipeptide on average results more effective and less costly than standard TPN: reduced mortality rate (24.6% ± 1.6% vs. 34.5% ± 2.1%), infection rate (13.8% ± 2.9% vs. 18.8% ± 3.9%), and hospital LOS (24.9 ± 0.3 vs. 26.0 ± 0.3 days) come at a lower total cost per patient (23,409 ± 3,345 vs. 24,161 ± 3,523 Euro).Treatment cost is completely offset by savings on ICU and antibiotic costs. Sensitivity analyses confirmed the robustness of these results. CONCLUSIONS: Alanyl-glutamine dipeptide is expected to improve clinical outcomes and to do so with a concurrent saving for the Italian hospital.

Cost analysis of community-based daily and weekly programs for treatment of moderate and mild wasting among children on Nias Island, Indonesia.

BACKGROUND: Ready-to-use food in the form of biscuits (RUF-Nias biscuit) was locally produced for rehabilitation of moderately and mildly wasted (weight-for-height z-score > or = -3 to < -1.5 SD) children on Nias Island, Indonesia. Daily programs were performed in semiurban settings, and weekly programs took place in rural areas. OBJECTIVE: To analyze the cost of daily and weekly distribution and supervision of RUF-Nias biscuit programs. METHODS: The costs of the daily and weekly programs were derived from the financial report and interviews with program implementers and participating households. Costs were calculated on the basis of total rehabilitation costs per child per day required to achieve a target weight-for-height z-score > or = -1.5 SD in daily and weekly programs. RESULTS: Institutional costs to the implementing organization were similar for both programs (approximately US $4 per child per day). The daily programs resulted in a significantly higher proportion of recovered children (78.6% vs. 65.4%) and higher weight gain (3.7 vs. 2.2 g/kg/day) than the weekly programs. About 6% to 7% of the total cost of the programs was accounted for by locally produced RUF-Nias biscuits. The social cost borne by the community for the weekly programs was about half that for the daily programs. CONCLUSIONS: The daily programs achieved better results for the implementing organization than the weekly programs; however, the weekly programs were preferred by the community because of the lower time constraints and the lower opportunity cost of time. The willingness of community and household members to invest their time in more intensive activities in the daily programs led to better program outcomes.

Improved nutrition knowledge and practice through intensive nutrition education: a study among caregivers of mildly wasted children on Nias Island, Indonesia.

BACKGROUND: Inappropriate nutrition knowledge and feeding practices of caregivers are among several important causes of persistent malnutrition problems in young children. Thus, it is essential to provide caregivers with the necessary knowledge to help them modify their feeding practices. OBJECTIVE: To examine the effectiveness of two different nutrition education methods, weekly intensive nutrition education (INE) and monthly nonintensive nutrition education (NNE), designed for caregivers of mildly wasted children (weight-for-height z-score ≥ -1.5 to < -1) aged ≥ 6 to < 60 months on Nias Island, Indonesia. METHODS: To assess the impact of the two different nutrition education approaches on nutrition knowledge and practice of caregivers with their children, respondents were assigned to receive either weekly INE (n=114) or monthly NNE (n=96). The knowledge and practice levels of the mothers in each group were assessed and compared using a pretested validated questionnaire at admission and after the intervention period. RESULTS: At admission, the knowledge and practice levels of caregivers in both groups were not statistically significantly different. After participating in the nutrition education program, the percentage of correct answers on nutrition knowledge and practice in the INE group was significantly higher than that in the NNE group. Significant improvement in knowledge and practice scores was observed in the INE group after the intervention (p < 0.001), whereas only a significant improvement in knowledge was found in the NNE group (p < .05). CONCLUSIONS: In comparison with NNE, the INE approach was significantly better in bringing about a positive change in knowledge and practice of caregivers of mildly wasted children in the study area.

Probability, plausibility, and adequacy evaluations of the Oriente Study demonstrate that supplementation improved child growth.

This article presents evidence that the high-nutrient supplement in the Oriente study (Atole) improved child growth. The evidence is presented at 4 levels. There was a causal effect of the intervention on child length, as assessed by probability analyses of the randomized, controlled trial (P < 0.05). The plausibility analyses, which included an examination of wasting, showed that the nutritional impact was due to the Atole, especially in those who were <3 y old and who suffered from diarrhea. The adequacy analyses revealed excellent biological efficacy of the Atole at the individual level. At the level of the whole population, the efficacy of impact was much less, because many children did not participate fully in the supplementation program. The external validity of the biological impact is likely to be good for populations with similar diets and medical care.

Effect of lipid-based nutrient supplement-Medium quantity on reduction of stunting in children 6-23 months of age in Sindh, Pakistan: A cluster randomized controlled trial.

BACKGROUND: Chronic childhood malnutrition, or stunting, remains a persistent barrier to achieve optimal cognitive development, child growth and ability to reach full potential. Almost half of children under-five years of age are stunted in the province of Sindh, Pakistan. OBJECTIVE: The primary objective of this study was to test the hypothesis that the provision of lipid-based nutrient supplement-medium-quantity (LNS-MQ) known as Wawamum will result in a 10% reduction in risk of being stunted at the age of 24 months in the intervention group compared with the control group. DESIGN: A cluster randomized controlled trial was conducted in Thatta and Sujawal districts of Sindh province, Pakistan. A total of 870 (419 in intervention; 451 in control) children between 6-18 months old were enrolled in the study. The unit of randomization was union council and considered as a cluster. A total of 12 clusters, 6 in each study group were randomly assigned to intervention and control group. All children received standard government health services, while children in the intervention group also received 50 grams/day of Wawamum. RESULTS: Children who received Wawamum were found to have a significantly reduced risk of stunting (RR = 0.91, 95% CI; 0.88-0.94, p<0.001) and wasting (RR = 0.78, 95% CI; 0.67-0.92, p = 0.004) as compared to children who received the standard government health services. There was no evidence of a reduction in the risk of underweight (RR = 0.94, 95% CI; 0.85-1.04, p = 0.235) in the intervention group compared to the control group. Statistically significant reduction in anaemia in the intervention group was also found as compared to the control group (RR = 0.97, 95% CI; 0.94-0.99, p = 0.042). The subgroup analysis by age, showed intervention effect is significant in reduction of risk of stunting in younger children of aged 6-12 month (RR = 0.83, 95% CI; 0.81-0.86, p = <0.001) and their older peers aged 13-18 month- (RR = 0.90, 95% CI; 0.83-0.97, p = 0.008). The mean compliance of Wawamum was 60% among children. CONCLUSIONS: The study confirmed that the provision of Wawamum to children 6-23 months of age is effective in reducing the risk of stunting, wasting and anaemia. This approach should be scaled up among the most food insecure areas/households with a high prevalence of stunting to achieve positive outcomes for nutrition and health. This study was registered at clinicaltrials.gov as NCT02422953. Clinical Trial Registration Number: NCT02422953.

Dietary Protein and Muscle Mass: Translating Science to Application and Health Benefit.

Adequate consumption of dietary protein is critical for the maintenance of optimal health during normal growth and aging. The current Recommended Dietary Allowance (RDA) for protein is defined as the minimum amount required to prevent lean body mass loss, but is often misrepresented and misinterpreted as a recommended optimal intake. Over the past two decades, the potential muscle-related benefits achieved by consuming higher-protein diets have become increasingly clear. Despite greater awareness of how higher-protein diets might be advantageous for muscle mass, actual dietary patterns, particularly as they pertain to protein, have remained relatively unchanged in American adults. This lack of change may, in part, result from confusion over the purported detrimental effects of higher-protein diets. This manuscript will highlight common perceptions and benefits of dietary protein on muscle mass, address misperceptions related to higher-protein diets, and comment on the translation of academic advances to real-life application and health benefit. Given the vast research evidence supporting the positive effects of dietary protein intake on optimal health, we encourage critical evaluation of current protein intake recommendations and responsible representation and application of the RDA as a minimum protein requirement rather than one determined to optimally meet the needs of the population.

Alternative Ready-To-Use Therapeutic Food Yields Less Recovery Than the Standard for Treating Acute Malnutrition in Children From Ghana.

BACKGROUND: Only 20% of children with severe acute malnutrition (SAM) have access to ready-to-use therapeutic food (RUTF), and RUTF cost limits its accessibility. METHODS: This randomized, double-blind controlled study involved a clinical equivalence trial comparing the effectiveness of an alternative RUTF with standard RUTF in the home-based treatment of uncomplicated SAM and moderate malnutrition in Ghanaian children aged 6 to 59 months. The primary outcome was recovery, equivalence was defined as being within 5 percentage points of the control group, and an intention-to-treat analysis was used. Alternative RUTF was composed of whey protein, soybeans, peanuts, sorghum, milk, sugar, and vegetable oil. Standard RUTF included peanuts, milk, sugar, and vegetable oil. The cost of alternative RUTF ingredients was 14% less than standard RUTF. Untargeted metabolomics was used to characterize the bioactive metabolites in the RUTFs. RESULTS: Of the 1,270 children treated for SAM or moderate malnutrition, 554 of 628 (88%) receiving alternative RUTF recovered (95% confidence interval [CI]=85% to 90%) and 516 of 642 (80%) receiving standard RUTF recovered (95% CI=77% to 83%). The difference in recovery was 7.7% (95% CI=3.7% to 11.7%). Among the 401 children with SAM, the recovery rate was 130 of 199 (65%) with alternative RUTF and 156 of 202 (77%) with standard RUTF (P=.01). The default rate in SAM was 60 of 199 (30%) for alternative RUTF and 41 of 202 (20%) for standard RUTF (P=.04). Children enrolled with SAM who received alternative RUTF had less daily weight gain than those fed standard RUTF (2.4 ± 2.4 g/kg vs. 2.9 ± 2.6 g/kg, respectively; P<.05). Among children with moderate wasting, recovery rates were lower for alternative RUTF, 386 of 443 (87%), than standard RUTF, 397 of 426 (93%) (P=.003). More isoflavone metabolites were found in alternative RUTF than in the standard. CONCLUSION: The lower-cost alternative RUTF was less effective than standard RUTF in the treatment of severe and moderate malnutrition in Ghana.

Growth Components of Cow's Milk: Emphasis on Effects in Undernourished Children.

BACKGROUND: Cow's milk is a core ingredient in foods for prevention and treatment of undernutrition in children. It promotes growth, but there is limited knowledge of which components in milk have growth-stimulating effects. OBJECTIVE: To discuss the growth-stimulating effects of milk in undernourished children with emphasis on protein, lactose, and minerals. METHODS: We reviewed literature on dairy and growth in undernourished children. RESULTS: Cow's milk has a specific stimulating effect on linear growth, even in well-nourished children, and it may stimulate weight gain and muscle accretion in wasted children. Dairy protein has high protein quality scores with no major differences between whey protein concentrate and dried skimmed milk. Lactose has potential growth-stimulating effects, and the high content of potassium, phosphorus, magnesium, and zinc in milk is also likely to stimulate growth. Furthermore, a high dairy content reduces the amount of antinutrients from plant protein. CONCLUSIONS: Dairy protein, lactose, and bioavailable minerals all have potential growth-stimulating effects, which make cow's milk an important ingredient in foods for undernourished children. Different dairy ingredients vary with regard to protein amount and quality, content of lactose, and minerals, and thereby growth stimulating effects. This should be taken into consideration when deciding which dairy ingredient to use. Challenges include the relatively high cost of dairy. Therefore, future studies should include cost-effectiveness analysis and assessment of the desirable content of each growth-promoting milk component.

Mitigated Impact of Provision of Local Foods Combined with Nutrition Education and Counseling on Young Child Nutritional Status in Cambodia.

BACKGROUND: In Cambodia, stunting and wasting affect, respectively, 32% and 10% of children 0⁻59 months while 55% are anemic. Our research aims to assess the efficiency of two local foods combined with nutritional education and counseling (CEN) activities as compared to CEN alone on improving child nutritional status and dietary intake. METHODS: A cluster-randomized controlled trial was conducted in Soth Nikum area over a six-month period among children 6⁻23 months (n = 360) assigned to receive either moringa +CEN, cricket +CEN or CEN alone. Anthropometric measurements were performed and hemoglobin and ferritin levels assessed. RESULTS: Overall, no significant increase in the mean length/height-for-age z-score was observed, although a small increase of the weight-for-length/height was noted in intervention groups. Hemoglobin and ferritin mean values increased in all groups. The degree of satisfaction of energy, proteins, iron, and zinc requirements improved in all groups, but to a greater extent in the intervention groups and more children were healthy. CONCLUSION: Our research shows no significant impact of the provision of two local foods combined with CEN on the improvement of child nutritional status as compared to CEN alone. However, children consuming them better fulfilled their energy, iron, and zinc requirements and were healthier.

Wasting and intestinal barrier function in children taking alanyl-glutamine-supplemented enteral formula.

OBJECTIVE: We examined the effect of a diet supplemented with alanyl-glutamine (AG) or placebo glycine (G) on intestinal barrier function and growth in children in northeastern Brazil. PATIENTS AND METHODS: One hundred seven children ages 7.9 to 82.2 months with a weight-for-age (WAZ), height-for-age (HAZ), or weight-for-height (WHZ) z-score less than -1 were studied. From July 2003 to November 2004, 51 study patients received AG (24 g/d) and 56 received G (25 g/d; isonitrogenic concentration) control for 10 days. Lactulose/mannitol excretion ratio was used as a measure of intestinal permeability and was performed on days 1 and 10 of nutritional supplementation. Weight and height were measured on days 1, 10, 30, and 120 of the protocol. RESULTS: The patients were similar on admission with regard to age, sex, birth weight, nutritional status, lactulose/mannitol ratio, and serum concentrations of glutamine and arginine. The percentage of lactulose urinary excretion significantly improved (decreased) in children receiving AG for 10 days but not in those receiving glycine controls. AG significantly increased cumulative change over 120 days in WHZ and WAZ scores but not HAZ scores after adjustment for age and season in comparison with the placebo glycine group. CONCLUSIONS: Children tolerated AG-supplemented enteral formula well, and it significantly improved cumulative WHZ and WAZ over 120 days in comparison with children in the placebo glycine group. The data also suggested a beneficial effect of AG in the barrier function paracellular pathway, albeit with reduced mannitol excretion. Thus, although the effect of AG on reduced mannitol concentration requires clarification, AG appears to improve nutrition and barrier function.

Evaluation of Nutrition Interventions in Children in Conflict Zones: A Narrative Review.

Food and nutrition insecurity becomes increasingly worse in areas affected by armed conflict. Children affected by conflict, or in war-torn settings, face a disproportionate burden of malnutrition and poor health outcomes. As noted by humanitarian response reviews, there is a need for a stronger evidence-based response to humanitarian crises. To achieve this, we systematically searched and evaluated existing nutrition interventions carried out in conflict settings that assessed their impact on children's nutrition status. To evaluate the impact of nutrition interventions on children's nutrition and growth status, we identified published literature through EMBASE, PubMed, and Global Health by using a combination of relevant text words and Medical Subject Heading terms. Studies for this review must have included children (aged ≤18 y), been conducted in conflict or postconflict settings, and assessed a nutrition intervention that measured ≥1 outcome for nutrition status (i.e., stunting, wasting, or underweight). Eleven studies met the inclusion and exclusion criteria for this review. Five different nutrition interventions were identified and showed modest results in decreasing the prevalence of stunting, wasting, underweight, reduction in severe or moderate acute malnutrition or both, mortality, anemia, and diarrhea. Overall, nutrition interventions in conflict settings were associated with improved children's nutrition or growth status. Emergency nutrition programs should continue to follow recent recommendations to expand coverage and access (beyond refugee camps to rural areas) and ensure that aid and nutrition interventions are distributed equitably in all conflict-affected populations.

Beta-hydroxy-beta-methylbutyrate supplementation and skeletal muscle in healthy and muscle-wasting conditions.

Beta-hydroxy-beta-methylbutyrate (HMB) is a metabolite of the essential amino acid leucine that has been reported to have anabolic effects on protein metabolism. The aims of this article were to summarize the results of studies of the effects of HMB on skeletal muscle and to examine the evidence for the rationale to use HMB as a nutritional supplement to exert beneficial effects on muscle mass and function in various conditions of health and disease. The data presented here indicate that the beneficial effects of HMB have been well characterized in strength-power and endurance exercise. HMB attenuates exercise-induced muscle damage and enhances muscle hypertrophy and strength, aerobic performance, resistance to fatigue, and regenerative capacity. HMB is particularly effective in untrained individuals who are exposed to strenuous exercise and in trained individuals who are exposed to periods of high physical stress. The low effectiveness of HMB in strength-trained athletes could be due to the suppression of the proteolysis that is induced by the adaptation to training, which may blunt the effects of HMB. Studies performed with older people have demonstrated that HMB can attenuate the development of sarcopenia in elderly subjects and that the optimal effects of HMB on muscle growth and strength occur when it is combined with exercise. Studies performed under in vitro conditions and in various animal models suggest that HMB may be effective in treatment of muscle wasting in various forms of cachexia. However, there are few clinical reports of the effects of HMB on muscle wasting in cachexia; in addition, most of these studies evaluated the therapeutic potential of combinations of various agents. Therefore, it has not been possible to determine whether HMB was effective or if there was a synergistic effect. Although most of the endogenous HMB is produced in the liver, there are no reports regarding the levels and the effects of HMB supplementation in subjects with liver disease. Several studies have suggested that anabolic effects of HMB supplementation on skeletal muscle do not occur in healthy, non-exercising subjects. It is concluded that (i) HMB may be applied to enhance increases in the mass and strength of skeletal muscles in subjects who exercise and in the elderly and (ii) studies examining the effects of HMB administered alone are needed to obtain conclusions regarding the specific effectiveness in attenuating muscle wasting in various muscle-wasting disorders.

The Second International Conference on Nutrition: Implications for Hidden Hunger.

The Second International Conference on Nutrition (ICN2) was jointly organized by the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) and was held at the FAO Headquarters in Rome, Italy, from 19 to 21 November 2014. The ICN2 was a high-level intergovernmental meeting that focused global attention on addressing malnutrition in all its forms: undernutrition, including micronutrient deficiencies, overweight, and obesity. The ICN2 was held to specifically address the persistent and unacceptably high levels of malnutrition. Despite much progress in reducing hunger globally, 795 million people remain undernourished, over 2 billion people suffer from various micronutrient deficiencies, and an estimated 161 million children under 5 years of age are stunted, 99 million underweight, and 51 million wasted. Meanwhile, more than 600 million adults are obese. Global problems require global solutions. The ICN2 brought together national policy-makers from food, agriculture, health, education, social protection and other relevant sectors to address the complex problem of malnutrition through a multi-sectoral approach. Two outcome documents - the Rome Declaration on Nutrition and the Framework for Action - were endorsed by participating governments at the Conference, committing world leaders to establishing national policies aimed at eradicating malnutrition in all its forms and transforming food systems to make nutritious diets available to all. The Rome Declaration on Nutrition is a political statement of 10 commitments for more effective and coordinated action to improve nutrition, while the Framework for Action is a voluntary technical guide of 60 recommendations for the implementation of the political commitments. This chapter provides information on the ICN2 and its outcomes as well as follow-up activities. Emphasis is placed on the Rome Declaration on Nutrition and the Framework for Action, with special focus on hidden hunger problems that have to be addressed through different interventions and a multi-sectoral approach.

Beta-hydroxy-beta-Methylbutyrate and its use in athletics.

Nutritional supplements are widely used by patients and athletes around the world for many different reasons. Many companies are thriving on this billion-dollar industry with little proof that these substances do what they are reported or suggested to do. Beta-hydroxy-beta-methylbutyrate (HMB) is a relatively new supplement on the ergogenic landscape. Studies of HMB supplementation have shown minimal gains in strength and lean body mass in specific populations, mainly untrained athletes and patients with wasting syndromes. HMB use in those athletes involved in regular high-intensity exercise has not been proven to be beneficial when multiple variables are evaluated. Unlike other ergogenics, with HMB no adverse events have been reported in association with short-term use. Despite these findings, HMB cannot be recommended as an ergogenic until further studies in larger groups reproduce early data. This review summarizes current literature on HMB, and provides the reader with information to better educate and treat patients and athletes.

Role of Integrated Outreach Activities in Improving Nutritional Status among Under-Five Children in Yemen.

This paper intends to review the feasibility of scaling-up nutrition activities through integrated outreach activities to respond to development challenges. Evaluating the efficiency and effectiveness of current packages of outreach services during the period of 2006-2014 is the aim of this review for better access to basic and social services and economic opportunities in Yemen. The two components of health system performance are related to: (i) the levels of coverage for health interventions; and (ii) financial risk protection, with a focus on equity. In this sense, Yemen's intervention coverage indicators of the health-related MDGs, such as immunization, integrated management of childhood illnesses (IMCI), reproductive health (RH) and disease control including non-communicable diseases (NCDs) have shown good progress. Yet, malnutrition is still highly prevalent among under-five children in the country. Coverage indicators of the outreach approach in Yemen, which started in 2006, indicate a strong role of the integrated services in reaching under-five children of the most vulnerable communities with basic health services including preventive and curative ones. As well, these activities respond to the financial risk protection challenges with enhancing efficiency in the provision of health services. Considering that nutrition is part of the package of integrated outreach services, inter-related measures of universal coverage in Yemen are to be addressed together with setting the impact indicators for essential health services coverage targeting the neediest populations. Coverage of health services encompasses the full targeted population in the most malnutrition-affected areas, especially the west coast of the country, for intervention and for the age group these services are directed to.