title: A Randomized Controlled Trial Offering Higher- Compared with Lower-Dairy Second Meals Daily in Preschools in Guinea-Bissau Demonstrates an Attendance-Dependent Increase in Weight Gain for Both Meal Types and an Increase in Mid-Upper Arm Circumference for the Higher-Dairy Meal.
abstract: BACKGROUND
  Controversy remains over the most effective approaches to prevent childhood malnutrition.
  
  
  OBJECTIVE
  We tested the feasibility and effectiveness of delivering ready-to-use supplementary foods (RUSFs) as a second daily meal in preschool children aged 3-5 y in Guinea-Bissau, and compared RUSFs with different levels of dairy protein.
  
  
  METHODS
  This study was a 3 mo cluster-randomized controlled pilot trial of 2 RUSFs differing in dairy protein in 533 boys and girls from 9 preschools. Children receiving RUSFs were compared with wait-listed controls, and all students received a daily school lunch. The RUSFs were delivered 5 d/wk for 3 mo and contained 478 kcal and 11.5 g protein per 92-g daily serving. Deliveries included a ready-to-use supplementary food with 15% of protein from dairy sources (RUSF-15%) or one with 33% of protein from dairy sources (RUSF-33%). Intention-to-treat (ITT) and per-protocol analyses (>50 d of RUSF consumption) were conducted. Changes in the weight-for-age z score (WAZ) and height-for-age z score were primary outcomes. Additional outcomes included changes in mid-upper arm circumference (MUAC), hemoglobin, and retinol binding protein.
  
  
  RESULTS
  Baseline anthropometry was not different between groups (WAZ, -0.48 ± 1.04) and increased significantly over time (P < 0.01) with no effects of the RUSFs in ITT analyses. However, children consuming RUSFs for >50 d had a significantly greater increase in WAZ relative to the increase in controls (+0.40 and +0.32 for RUSF-15% and RUSF-33%, respectively, compared with +0.24 in controls, P < 0.01 and P < 0.05, respectively). RUSF-33%, but not RUSF-15%, also eliminated a decrease in MUAC observed in controls (-0.01 cm in RUSF-33% compared with -0.34 cm in controls, P < 0.05). The only difference between RUSF-15% and RUSF-33% was a mean decrease in hemoglobin in children receiving RUSF-15% (-0.5 compared with -0.002 g/dL, P = 0.05).
  
  
  CONCLUSIONS
  Implementation of 2-meal preschool feeding programs is feasible in low-income countries, and there are measurable benefits relative to 1-meal programs in children attending preschool regularly. In addition, MUAC and hemoglobin measurements indicate that meals with 33% compared with 15% of protein from dairy may help prevent wasting and anemia.
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA;
authors.forename: Payal
authors.initials: P
authors.lastname: Batra
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA; Global Food & Nutrition Inc., Washington, DC; and.
authors.forename: Nina
authors.initials: N
authors.lastname: Schlossman
authors.affiliation: International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau.
authors.forename: Ionela
authors.initials: I
authors.lastname: Balan
authors.affiliation: International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau.
authors.forename: William
authors.initials: W
authors.lastname: Pruzensky
authors.affiliation: International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau.
authors.forename: Adrian
authors.initials: A
authors.lastname: Balan
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA;
authors.forename: Carrie
authors.initials: C
authors.lastname: Brown
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA;
authors.forename: Madeleine G
authors.initials: MG
authors.lastname: Gamache
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA;
authors.forename: Molly M
authors.initials: MM
authors.lastname: Schleicher
authors.affiliation: International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau.
authors.forename: Augusto Braima
authors.initials: AB
authors.lastname: de Sa
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA;
authors.forename: Edward
authors.initials: E
authors.lastname: Saltzman
authors.affiliation: Global Food & Nutrition Inc., Washington, DC; and.
authors.forename: Lauren
authors.initials: L
authors.lastname: Wood
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA; susan.roberts@tufts.edu.
authors.forename: Susan B
authors.initials: SB
authors.lastname: Roberts
mesh_terms: D001132:Arm; D002675:Child, Preschool; D016000:Cluster Analysis; D003611:Dairy Products; D004041:Dietary Fats; D004044:Dietary Proteins / Q000008:administration & dosage; D002149:Energy Intake; D005260:Female; D006169:Guinea-Bissau; D006801:Humans; D008297:Male; D044342:Malnutrition / Q000453:epidemiology*; D062407:Meals; D018977:Micronutrients / Q000008:administration & dosage / Q000172:deficiency; D010865:Pilot Projects; D015995:Prevalence; D015430:Weight Gain
chemical_list: D004041:Dietary Fats; D004044:Dietary Proteins; D018977:Micronutrients
keywords: Guinea-Bissau; HAZ; RUSF; WAZ; anemia; dairy; preschool; protein; retinol binding protein; undernutrition