Stephanie Jilcott, Scott Ickes, Alice Ammerman, Heidi Lutjens, Jennifer Myhre

1. Iterative design, implementation and evaluation of a supplemental feeding program for underweight children ages 6 – 59 months in western Uganda Stephanie Jilcott, Scott Ickes, Alice Ammerman, Heidi Lutjens, Jennifer Myhre THE UGANDA NUTRITION CONGRESS  February 19th-20th 2009  ‘The Challenges, Successes and Opportunities to Improve Nutrition’ Munyonyo Commonwealth Speke Resort Hotel Kampala, Uganda

2. Introduction • Malnutrition is a global public health problem, contributing to 50% of child deaths. • Stunted linear growth is associated with lower academic achievement and cognitive function. • Stunting prevalence in Bundibugyo (45%). • Supplemental feeding (SF) programs are one strategy to combat malnutrition/ stunting.

3. Introduction • Ready-to-use-therapeutic food (RUTF) is often used in supplemental feeding programs. • The high cost of imported RUTF has prompted attention to local RUTF/RUF (ready-to-use food) production. • Ideally RUF should be: • Made from local food sources • Made by community members • Distributed by local health workers

4. The ByokuliaBisemeye mu Bantu program In November 2007, World Harvest Mission (WHM) established a community-based supplemental feeding program that provides a locally-sourced and produced ready-to-use-food and complementary feeding education to underweight children ages 6-59 months. Inclusion criteria: Weight < 3rd percentile weight-for-age MUAC < 12cm No severe concurrent illness 10 week program provides: Weekly growth monitoring Weekly complementary feeding education 680 kcal per day RUF De-worming pill Vitamin A Multivitamin with iron

5. Aims • The BBB Program was designed to: • increase sustainability by using local food and local health workers, • increase RUF production capacity for women’s groups, • empower caregivers by providing nutrition education, • provide RUF and community-based care for underweight children.

6. Conceptual Framework

7. Purpose To describe the WHM supplemental feeding (BBB) program design, implementation, and preliminary program evaluation.

8. Methods

9. Methods Overview • Initially, WHM staff: • (1) trained local health workers to administer the program and provide nutrition information to caregivers, • (2) identified and trained local women’s groups to produce RUF (“production teams”), • (3) established the two SF programs • (4) conducted qualitative interviews with caregivers and members of RUF production teams, and • (5) examined RUF nutrient analysis.

10. Methods: Enrollment • Screening days were announced at each health center, local schools, and churches. • Eligible if: • Weight-for-age was < the lowest line (3rd percentile line) on the standard Ugandan immunization card and/or • Mid-upper arm circumference (MUAC) < 12 cm or • Referred from the WHM inpatient feeding program. • Initial enrollment target of 20 children per site. • Busunga Health Center • Busaru Health Center • Both ~2 miles from Nyahuka Health Center

11. Methods: Quantitative Data Collection and Analysis • Weight, height, MUAC, birth date, and age recorded. • Growth velocity was calculated in terms of grams per kilogram of weight gain per day • Final weight (g) – initial weight (g)/ initial weight (kg)/ # days • Growth velocities (SE) calculated using the mean function in STATA 9.0.

12. Methods: Qualitative Data Collection and Analysis • Conducted in-depth interviews with production team chairpersons • Detailed notes were taken and reviewed by investigators following the interviews. • Conducted nine structured caregiver interviews and home feeding observations.

13. Methods: Qualitative Data Collection and Analysis Production Team Chairperson Questions: • What are the benefits of being on this production team? • What are the difficult things about being on this production team? • Have there been problems on your team? • Does anyone from the community come to use the grinder? • Do you and your family enjoy the product? Caregiver Questions: • How do you prepare the BBB food? Please show me. • What do you enjoy about the BBB program? Tell me about that. • What is hard for you about the BBB program? Tell me about that. • Is there anything that you would like the BBB program to change about the food you receive? Tell me about that.

14. Methods: RUF Preparation • The RUF was prepared by roasting groundnuts and soybeans in a metal pot over a charcoal fire, then hand-grinding them. • Moringa oleifera leaves were mixed into the groundnut paste.

15. Methods: RUF Nutrient Analysis • Participants were provided 2 separate 450 g bags of roasted soybean flour and groundnut paste mixed with moringa leaf powder. • Samples of the groundnut paste and moringa powder (without the soy flour) were analyzed at the Department of Food Science and Technology, Makerere University.

16. Results

17. Results: Production Team interviews • Production team chairpersons reported the benefit of increased knowledge of healthy foods to feed young children: “Being on the production team, we have learned how to care for our families.” • An additional benefit to having a production team in the community was an increase in community members’ motivation to cultivate groundnuts and soybeans for grinding. 

18. Results: Production Team interviews • Chairpersons noted the challenge of grinding and lack of acceptable financial incentives for production. For instance, one older production team member said: “Grinding is hard for some of us. We are becoming old.” • Regarding financial incentives, teams noted a preference for getting paid directly for the work instead of in-kind compensation initially provided: “We are working for free with no allowance…it is making some members leave the work.”

19. Results: Caregiver interviews/ observations • Caregivers often prepared the BBB supplement as a dilute sauce for staple food versus using as RUF. • Educational message added to encourage caregivers to use a 2:1 ratio of BBB supplement to staple. • Often, the BBB supplement components were not consumed together, affecting nutrient composition. • Educational message added to educate caregivers on importance of mixing groundnut paste and soy flour bags together immediately after returning home.

20. Results: Nutrient analysis per 100 grams BBB RUF Comparative selective nutrient analysis per 100 grams of soy flour, BBB peanut paste, total BBB food supplement (soy flour plus BBB paste), commercial ready-to-use therapeutic food (Plumpy’nut) and USAID corn soy blend. Source: Jilcott, Ickes, Myhre & Ammerman. Mater Child Health J, 2009. Nutrient analysis performed by Dr. Archileo N. Kaaya, Department of Food Science and Technology, Makerere University, Kampala, Uganda.

21. Results: Growth Velocities Characteristics and growth velocities for children enrolled in the 5-week (cycles 1 and 2) and 10-week (cycles 3-5) BBB program Mean (SE) = 7.4(7.3) g/d Mean (SE) = 2.5 (0.6) g/kg/d

22. Conclusions

23. Conclusions • The BBB program model is a promising strategy for community-based care of moderately malnourished children. • BBB supplement had similar protein and energy density as commercial RUTF. • Chairpersons and caregivers appreciate the program.

24. Conclusions • To draw comparison with similar programs, we calculated mean daily weight gain (SD) after the program duration changed to 10-week cycles (4 and 5) • BBB program participants gained 7.4(7.3) g/day. • Maleta et al (2004): 3.3 (3.4) g/day during 12-week supplementation with 500 kcal/d of RUTF. • Flax et al (2008): 11.9 (6.0) g/day with 12-week supplementation with 250 kcal/d of RUTF.

25. Conclusions • The program was altered to address findings of preliminary analyses: • Production teams changed to the small business model, providing financial incentive for continued RUF production. • Educational messages regarding RUF preparation were emphasized to improve caregiver feeding practices.

26. Limitations and Strengths • Limitations: • Study was not powered to detect a particular effect. • The interpretation of modest growth velocities is complicated by the wide age range of participants. • It is impossible to separate out the effects of all program components. • No standard quality control measures for RUF production. • Strengths: • Use of weight-for-age criteria to enroll children, as it is easily comprehended by local health workers. • BBB supplement had no trace of aflatoxin and no caregivers have reported peanut allergies. • High energy density of the BBB supplement.

27. Conclusions & Next Steps • Future efforts are needed to educate caregivers on correct RUF use, explore how RUF is incorporated into the local diet, and improve commercial viability of this energy-dense supplemental food in local markets. • See Scott Ickes’ poster: “FEEDING PRACTICES AND CONSUMPTION OF LOCALLY PRODUCED READY-TO-USE-FOOD AMONG UNDERWEIGHT CHILDREN AGES 6-59 MONTHS”

28. Acknowledgments • We would like to acknowledge the hard work of World Harvest Mission Agriculture Extension Agents Batisibwa Geofrey, Tugume Lamech, Kentaro Pauline, and Baguma Charles, and WHM staff, Karen Masso, Pat Abbot, Sarah Reber, Nathan Elwood. • Many thanks to staff and community health workers at Busunga and Busaru Health Centers. • We are also grateful for the hard work of BBB production teams and caregivers.

29. Acknowledgments • Roey Rosenblith of Village StartUp • Jeff Rose of Full Belly Project • Bert Rivers of Compatible Technology Incorporated