Effect of malted sorghum-based porridge on nutritional status of moderately malnourished breastfed infants and young children aged 6 to 18 months in Arua, Uganda.

Abstract

Moderate acute malnutrition (MAM) among infants and young children (IYC) has a negative impact on their immature digestive system and requires an energy rich, nutrient dense supplementary food to reverse the condition and promote catch up growth and development. In this study, a malted sorghum-based porridge (MSBP) was formulated using locally available ingredients. It was subsequently used as a supplementary food in the management of IYC with MAM to determine whether it could serve as an alternative supplementary porridge when compared to fortified corn soy blend (CSB+), the standard care for managing IYC with MAM in Uganda. The effect of MSBP supplementation, in conjunction with nutrition education, on the nutritional status of IYC with MAM was determined. In addition, maternal knowledge regarding appropriate complementary feeding and hygiene practices were determined before the supplementation intervention commenced (baseline), as well as after the completion of the three month intervention period. In addition, the study also determined maternal perceptions regarding the MSBP versus CSB+, as well as perceived barriers encountered in the course of the intervention. Hence the study developed an acceptable energy rich and nutrient dense MSBP for managing MAM. The MSBP was formulated (using estimated values generated by NutVal software) from malted sorghum flour and extruded soy-maize flour. Four formulations estimated to meet the specifications of a supplementary food for treatment of IYC with MAM (in accordance with World Health Organisation criteria), were subsequently assessed for consumer acceptability. Analysis of variance was used to compare the acceptability scores and viscosity level of four different MSBP formulations to test for significant differences between mean scores. The four formulations had significantly different (p<0.05) acceptability scores for flavour, taste, mouth feel, sweetness and overall acceptability. The best formulation had significantly (p<0.05) higher mean acceptability scores. In addition, the best MSBP formulation had a significantly (p<0.05) higher energy and nutrient content than CSB+. At a flour rate of 25%, this formulation also had the best energy density, protein density and viscosity of 1.6kcal/g, 4g/100kcal and 2809cP respectively. The results showed that a quarter sorghum malt mixed with three quarters of extruded soy-maize, produced an energy rich, nutrient dense MSBP with acceptable sensory attributes at optimal viscosity. The best formulated MSBP met the energy, protein and viscosity level requirements for the management of IYC with MAM. To evaluate the efficacy of MSBP in alleviating malnutrition among IYC with MAM, the intervention component of the study established maternal socio-demographic characteristics and associated complementary feeding practices at baseline. A cross sectional community assessment was conducted among 204 randomly sampled breastfeeding mothers of IYC aged 6 to 18 months with MAM in four out of eighteen sub counties in Arua district, Uganda. Multivariate logistic regression analysis showed that maternal level of education as well as that of the head of the household, were significantly associated with IYC minimum meal frequency (p=0.003) and (p=0.023) respectively. In addition, maternal care, determined in terms of the preparation of food such as porridge especially for the IYC, was also significantly associated with minimum meal frequency (p<0.001) and with the IYC food intake meeting that of a minimum acceptable (p=0.004). These findings suggested that optimal complementary feeding practices in terms of minimum dietary diversity, minimum meal frequency and minimum acceptable diet were not met by the majority of IYC with MAM. The baseline study was followed by evaluating the effect of MSBP and CSB+ in combination with nutrition education, on the anthropometric status and blood haemoglobin levels of IYC aged 6 to 18 months diagnosed with MAM. A double blind cluster randomised control trial was conducted with 204 mother-IYC pairs, with a cluster consisting of nine to ten pairs per parish where mothers consented to participate (Appendix B, p197). A daily ration of 150g of either MSBP or CSB+ was fed to IYC for ninety days. Weekly anthropometric measurements (weight, length and mid-upper arm circumference) of IYC were conducted, whereas haemoglobin levels were determined only at baseline and at the end of the study. A comparison between mean anthropometric outcomes namely weight gain, length gain, length-for-age z-scores, weight-for-age z-scores, length-for-weight z-scores, and mean blood haemoglobin levels in the treatment (MSBP) and control (CSB+) groups were determined using the independent t-test. Proportions of the anthropometric and haemoglobin levels in the treatment and control groups were determined using the z-test. At three months, the mean weight-for-age z-score of IYC in the treatment group was significantly higher than in the control group (p=0.01). The change in mean blood haemoglobin levels was significantly smaller in the treatment group when compared to that of the control group (p=0.01). No significant difference was observed in the proportion of IYC who recovered from MAM between the treatment group and control group (p=0.055). Thus, MSBP supplementation of IYC with MAM resulted in comparable recovery rates to CSB+ in terms of weight-for-length and improved blood haemoglobin levels. Therefore, MSBP could be considered as an alternative to CSB+ in the management of breastfed IYC with MAM. The effect of nutrition education on the feeding and hygiene practices of mothers with IYC with MAM being supplemented with either MSBP or CSB+, was also determined. A cross-sequential study using a pre-test-post-test design was used among the 204 mothers in the 24 clusters. Mothers’ knowledge, complementary feeding and hygiene practices were analysed as mean scores before and after the intervention. The paired t-test was used to determine the differences between baseline and end line mean scores for knowledge and practices. Mothers’ mean knowledge scores regarding complementary feeding in terms of dietary diversity and meal frequency were significantly higher at end line compared to baseline (p<0.001). Maternal practices regarding food safety and water quality was significantly higher at end line compared to baseline (p<0.001). Thus, nutrition education of mothers in combination with supplementing their IYC with either MSBP or CSB+, improved meal frequency, dietary diversity, water quality, and food safety. Lastly, maternal perceptions and barriers experienced while using either MSBP or CSB+ to manage their IYC with MAM was determined via qualitative research techniques. A qualitative study using, focus group discussions (FGD) and in depth interviews (IDI) was conducted among mothers a week after completion of the three months supplementation period. One hundred eight mothers were purposively sampled to participate in 12 focus group discussions. This was followed by selecting 48 mothers to participate in IDI. Five FGD were conducted with mothers whose IYC were fed CSB+, while the remaining seven FGD included mothers whose IYC were fed with MSBP. The qualitative data on maternal perceptions and barriers were analysed using an inductive approach. The results showed that both MSBP and CSB+ were perceived as being responsible for IYC weight gain, reduction in illness, improved appetite, glowing healthy skin, and improved active play. Hence, mothers had positive attitudes towards using MSBP and CSB+. Collectively, the perceived barriers mothers encountered during the supplementary feeding intervention included household chores, limited time to feed IYC regularly, limited household income and household food insecurity in addition to minimal social support from household members. Mothers believed in the use of MSBP and CSB+ in the management of their IYC with MAM and were satisfied with the health benefits such as weight gain and improved appetite observed among their IYC. However, factors contributing to maternal stress should be addressed by improving household food security status and the distribution of an even workload among household members so that IYC with MAM can reap maximum benefits from supplementary food interventions. Overall, this study provided an opportunity to gather additional evidence regarding the use of a locally formulated energy rich, nutrient dense supplementary porridge MSBP with suitable consumer acceptability, energy content and nutrient density in the management of IYC with MAM. Nevertheless, nutrition service providers of supplementary foods in the management of IYC with MAM should endeavour to educate mothers on potential barriers they may encounter in the course of intervention strategies for the management of MAM. This should include potential socio-care barriers, in addition to emphasising the health and nutrition benefits of the supplementary foods for their IYC.