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Background: Balanced energy protein (BEP) supplementation in pregnant women in low-and middle-income countries may reduce the risk of stillbirth and low birth weight. Objectives: The objective of this study was to assess the adherence to and acceptability of a corn-soy blend (CSB) BEP product among pregnant women in rural Ethiopia. Methods: This formative study was conducted from October to November 2018 among pregnant women in the rural Amhara region of Ethiopia prior to initiation of a clinical effectiveness study (ISRCTN: 15116516). We assessed adherence and acceptability of a micronutrient-fortified CSB BEP supplement among 40 pregnant women during a 4-wk utilization period. Acceptability was assessed using a 7-point Likert-style scale about the hedonic characteristics of the BEP product at 2 wk and 4 wk. Adherence was assessed by weekly monitoring and empty sachet counts for BEP consumption over 4 wk. Results: Adherence to the BEP was, on average, 89% over the month-long pilot. The BEP product was rated favorably (mean Likert score >6 of 7) for the following domains: color, taste, odor, and likeability at mid and endpoints. Women found the product convenient to eat [mean (standard deviation [SD] = 5.9 (1.0))] and filling (mean (SD) = 6.1 (1.5) out of 7). Scores on acceptability and perception of the product remained stable throughout the duration of use. A majority of women (63%) reported consuming the BEP as a snack to supplement meals and splitting the serving over 2 or more sessions (68%). A quarter of respondents reported sharing the supplement with family members. Conclusions: Adherence and acceptability of the CSB BEP product were high among this population in rural Amhara, Ethiopia. This formative data was important to select the final product and shape the counseling and delivery of BEP in the parent study.

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The effective management of the 33 million children with moderate acute malnutrition (MAM) is key to reducing childhood morbidity and mortality. In this review, we aim to evaluate the effectiveness of specially formulated foods (SFFs) compared to non-food-based approaches to manage MAM in children >6 months old. We conducted a search on ten databases until 23 August 2021 and included five studies, covering 3387 participants. Meta-analysis of four studies comparing SFFs to counselling or standard of care showed that SFFs likely increase recovery rate, reduce non-response, and may improve weight-for-height z-score, weight-for-age z-score and time to recovery, but have little or no effect on MUAC gain. One study on a multicomponent intervention (SFFs, antibiotics and counselling provided to high-risk MAM) compared to counselling only was reported narratively. The intervention may increase weight gain after 24 weeks but may have little or no effect on weight gain after 12 weeks and on non-response and mortality after 12 and 24 weeks of enrollment. The effect of this intervention on recovery was uncertain. In conclusion, SFFs may be beneficial for children with moderate wasting in humanitarian contexts. Programmatic recommendations should consider context and cost-effectiveness.

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Currently, no World Health Organization guidelines exist for the management of approximately 31.8 million moderately wasted children globally. The objective of this review was to synthesise evidence on the optimal type, quantity, and duration of dietary treatment for moderate wasting. Ten electronic databases were searched until the 23rd of August 2021. Experimental studies comparing interventions for the dietary management of moderate wasting were included. Meta-analyses were conducted and results were presented as risk ratios or mean differences with 95% confidence intervals. Seventeen studies comparing specially formulated foods were included involving 23,005 participants. Findings suggest little or no difference in recovery between Fortified Blended Foods (FBFs) with improved micronutrient and/or milk content (enhanced FBFs) and lipid-based nutrient supplements (LNS), whereas children treated with non-enhanced FBFs (locally produced FBFs or standard corn-soy blend) may have lower recovery rates than those treated with LNS. There was no difference in recovery when ready-to-use therapeutic and ready-to-use supplementary food were compared. Other outcomes mostly aligned with results for recovery. In conclusion, LNSs improve recovery compared to non-enhanced FBFs, but are comparable to enhanced FBFs. Programmatic choice of supplement should consider factors such as cost, cost-effectiveness, and acceptability. Further research is required to determine optimal dosing and duration of supplementation.

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Fortified blended foods (FBFs), a staple of food aid around the world, must maintain desirable characteristics for long periods of storage. This study estimated the shelf life of FBFs, including a traditional FBF (nonextruded corn soy blend plus [CSB+]) and 13 novel extrusion cooked FBFs. All products were stored under accelerated and real-time environments (real time = 30 °C and 65% relative humidity [RH], accelerated = 50 °C and 70% RH based on a Q10 factor of 2). Products were made into porridges and evaluated by a descriptive sensory panel for five times in each shelf life condition. Rancid and painty sensory characteristics were key determining factors for shelf life. Real-time (RT) and accelerated shelf life (ASL) testing agreed that most novel extrusion cooked FBFs had shelf lives of at least 2 years, which is comparable to current CSB+. However, ASL testing failed to predict RT shelf life of two novel FBFs, which were estimated by RT testing to have a 2+ year shelf life. The results indicated that novel extrusion cooked FBFs have high potential for use as alternative complementary food and maintain quality for long storage periods. It is essential to conduct RT testing parallel with ASLT testing, especially for new products, to obtain a more precise estimation of products' shelf life. PRACTICAL APPLICATION: These findings show that extrusion cooked novel fortified blended foods made with extrusion generally can last up to or exceeding 24 months at ambient conditions as measured either real-time or under accelerated conditions. This is plenty of time for storage, shipping, distribution, and home storage of such products by recipients. Thus, there should be no concerns about shelf life of these products for international distribution.

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Despite the wide use of traditional non-extruded fortified blended foods (FBFs), such as corn soy blend plus (CSB+), in supplementary feeding programs, there is limited evidence of its effectiveness on improving nutritional outcomes and little information on actual sensory properties. Fifteen novel extruded FBFs were developed with variations in processing and ingredients in order to improve the quality of food aid products based on the Food Aid Quality Review (FAQR) recommendations. Descriptive sensory analysis was performed to determine the effects of the processing parameters and ingredients on the sensory properties of traditional and novel FBFs. The extrusion process affected the aroma and flavor of the tested products. Novel FBFs from the extrusion process had more pronounced toasted characteristics, probably because of the high temperature used during extrusion. The ingredient composition of the FBFs also had a significant impact on the sensory properties of the products. The addition of sugar to novel FBFs leads to a significant increase in sweetness, which could improve acceptance. The level of lipids in binary blends appeared to be mainly responsible for the bitterness of the product. In addition, legumes, which were a primary ingredient, contributed to the beany characteristics of the products. The higher amounts of legume used in the formulations led to beany characteristics that could be perceived from the products and could be a negative trait depending on consumers' prior use of legume-based products.

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BACKGROUND: Sorghum-Soy Blend (SSB) and Sorghum-Cowpea Blend (SCB) fortified blended food aid porridge products were developed as alternatives to Corn-Soy Blend Plus (CSB+) and Super Cereal Plus (SC+), the most widely used fortified blended food aid products. However, the cost and nutrient cost-effectiveness of these products procured from different geographical areas have not been determined. OBJECTIVE: The objective of this study is to determine the nutrient cost-effectiveness of SSB and SCB compared to existing fortified blended foods. METHODS: Nutritional data as well as ingredient, processing, and transportation cost for SSB, SCB, and existing fortified blended foods were compiled. Using the omega value, the ratio of the fortified blended food's Nutrient Value Score to the total cost of the fortified blended food divided by an identical ratio of a different fortified blended food or the same fortified blended food produced in a different country and the nutrient cost-effectiveness of each of the fortified blended foods procured in the United States and several African countries were determined. RESULTS: Both CSB+ and SC+ are less expensive than SSB and SCB, but they also have lower Nutrient Value Scores of 7.7 and 8.6, respectively. However, the omega values of CSB+ and SC+ are all above 1 when compared to SSB and SCB, suggesting that the existing fortified blended foods are more nutrient cost-effective. CONCLUSIONS: Comparing the nutrient cost-effectiveness of various food aid products could provide valuable information to food aid agencies prior to making procurement decisions.

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BACKGROUND: Corn- and soybean-based fortified blended foods (FBFs) have been the primary food aid product provided by the United States. Sorghum and cowpea have been suggested as alternative FBF commodities because they are drought-tolerant, grown in food aid-receiving areas, and not genetically modified. Extrusion processing has also been suggested to improve the quality of these FBFs. OBJECTIVES: The aim of this study was to determine the protein quality and iron and vitamin A bioavailability of novel FBFs in broiler chickens. METHODS: Whey protein concentrate (WPC)-containing FBFs corn-soy blend 14, sorghum-soy, and sorghum-cowpea (SC); a soy protein isolate (SPI)-containing SC FBF (SC+SPI); 2 reformulated, overprocessed SC FBFs (O-SC+WPC, O-SC+SPI); and a nonextruded WPC-containing SC FBF were developed. Nonextruded corn-soy blend plus (CSB+), a currently used FBF, and a gamebird starter/grower diet were used as comparison diets. In the prepared FBF study, 9 groups of 8-d-old broiler chicks (n = 10) consumed prepared FBFs for 21 d. In the dry study, 8 groups of 4-d-old broiler chicks (n = 24; control: n = 23) consumed dry FBFs for 14 d. Results were analyzed by 1-factor ANOVA with least-significant-difference test. RESULTS: In the prepared study, novel formulated FBFs significantly increased caloric and protein efficiency and nonsignificantly increased body weight gain, despite similar food intake compared with CSB+. In the dry study, novel formulated FBFs, except for O-SC+SPI, significantly increased food intake, caloric efficiency, and protein efficiency and nonsignificantly increased body-weight gain compared with CSB+. Novel formulated FBFs nonsignificantly and significantly increased hepatic iron concentrations compared with all FBFs in the prepared and dry studies, respectively. CONCLUSION: Novel formulated FBFs, apart from O-SC+SPI, resulted in improved protein efficiencies and hepatic iron concentrations compared with CSB+, suggesting that they are of higher nutritional quality.

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The preference of porridge made from extruded fortified blended foods (FBFs) compared to a current nonextruded product (corn soy blend plus [CSB+]) among infants and young children was studied in Mwanza region, Tanzania. Five extruded, fortified blends were chosen as novel FBFs in this study: (i) corn soy blend 14 (CSB14), (ii) white sorghumFontanelle 4525 soy blend (SSB), (iii) white sorghumFontanelle 4525 cowpea blend (WSC1), (iv) white sorghum738Y cowpea blend (WSC2), and (v) red sorghum217X Burgundy cowpea blend (RSC). Paired preference testing between CSB+ and each novel FBF was conducted using approximately 600 children for each pair. Results showed that infants and young children prefer CSB14 and SSB over CSB+. Children did not show a preference between CSB+ and any of the 3 sorghum cowpea blends (WSC1, WSC2, and RSC) probably because of a distinct beany flavor from cowpea that they were not familiar with. This study indicated that novel FBFs have potential to be used successfully as supplementary food with higher or comparable preference compared to FBFs currently used in food aid programs. PRACTICAL APPLICATION: Successful novel fortified blended foods (FBFs) can be developed with appropriate nutrition and sensory appeal from indigenous and alternative food sources. Development of such foods requires an understanding not only of the nutritional composition, but also how ingredients impact sensory properties and how they can influence preferences. From this research, novel FBFs from sorghum and cowpea were shown to be equally or preferentially preferred and should be successful. Such information is important for creating new standards and alternative formulations for FBFs.

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Adding amylase to fortified blended foods can improve energy density, and increase child's energy and nutrient intake. The efficacy of this strategy is unknown for the World Food Programme's Super Cereal Plus (SC+) and Super Cereal (SC) blends. The primary goal of this study was to investigate the increased energy intake from amylase-containing SC+ and SC compared to control porridges in Burkinabe children. Secondly, energy intake from amylase-containing porridges compared to CERELAC® , Vitazom, and eeZeeBAR™ was studied. Thirdly, caregivers' (n = 100) porridge acceptability was investigated. The design was a randomized double-blind controlled cross-over trial studying the effect of amylase addition to SC+ and SC flours on porridge energy and nutrient intake in healthy Burkinabe children aged 12-23 (n = 80) and 24-35 months (n = 40). Amylase added to porridges increased energy density from 0.68 to 1.16 kcal/g for SC+ and from 0.66 to 1.03 kcal/g for SC porridges. Among children aged 12-23 months, mean energy intake from all porridges with amylase (135-164 kcal/meal) was significantly higher compared to control SC+ porridges (84-98 kcal/meal; model-based average). Among children aged 24-35 months, mean energy intakes were also significantly higher from all porridges with amylase added (245-288 kcal/meal) compared to control SC porridges (175-183 kcal/meal). Acceptability of the porridges among caregivers was rated neutral to good, both for amylase-added and non-amylase-containing porridges. These findings suggest that, among 12-35-month-old, adding amylase to fortified blended foods significantly increased energy and consequently nutrient intake per meal by 67% for SC+ and 47% for SC. Moreover, amylase-containing porridges were well accepted by the caregivers.

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Corn and soyabean micronutrient-fortified-blended foods (FBF) are commonly used for food aid. Sorghum and cowpeas have been suggested as alternative commodities because they are drought tolerant, can be grown in many localities, and are not genetically modified. Change in formulation of blends may improve protein quality, vitamin A and Fe availability of FBF. The primary objective of this study was to compare protein efficiency, Fe and vitamin A availability of newly formulated extruded sorghum-, cowpea-, soya- and corn-based FBF, along with a current, non-extruded United States Agency for International Development (USAID) corn and soya blend FBF (CSB+). A second objective was to compare protein efficiency of whey protein concentrate (WPC) and soya protein isolate (SPI) containing FBF to determine whether WPC inclusion improved outcomes. Eight groups of growing rats (n 10) consumed two white and one red sorghum-cowpea (WSC1 + WPC, WSC2 + WPC, RSC + WPC), white sorghum-soya (WSS + WPC) and corn-soya (CSB14 + WPC) extruded WPC-containing FBF, an extruded white sorghum-cowpea with SPI (WSC1 + SPI), non-extruded CSB+, and American Institute of Nutrition (AIN)-93G, a weanling rat diet, for 4 weeks. There were no significant differences in protein efficiency, Fe or vitamin A outcomes between WPC FBF groups. The CSB+ group consumed significantly less food, gained significantly less weight, and had significantly lower energy efficiency, protein efficiency and length, compared with all other groups. Compared with WSC1 + WPC, the WSC1 + SPI FBF group had significantly lower energy efficiency, protein efficiency and weight gain. These results suggest that a variety of commodities can be used in the formulation of FBF, and that newly formulated extruded FBF are of better nutritional quality than non-extruded CSB+.

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Products that will be prepared by consumers must be tolerant to various cooking procedures that those consumers may use. Fortified blended foods (FBFs) are used as a source of nutrition for disaster or famine relief in developing countries. Many FBFs are served as porridge and may have a wide of solids content, cooking times and variations in added ingredients. Sorghum is being examined as a potential alternative to wheat and corn based FBF products. This study was intended to evaluate the tolerance to preparation variations for porridge made as a FBF intended for food aid. Whole Sorghum Soy Blend (WSSB), a fortified, extruded, ground cooked cereal was selected as the FBF for this study. Descriptive sensory analysis and Bostwick flow rate measurements were performed to evaluate the tolerance of porridge products made from variations in ingredients and cooking procedures. The results showed that most sensory properties were only marginally affected although some expected large differences in a few sensory properties were found when solids content varied (that is, thickness, adhesiveness) or fruit (banana flavor) was added. Moreover, Bostwick flow rate was a reasonable indicator of thickness characteristics of porridges in some cases, but not in others. Tolerance testing showed that the sensory properties of WSSB had high tolerance to variations in cooking procedures, which means that the product can be modified during preparation by consumers without having a major impact on most sensory properties other than ones they intended to change such as thickness, sweetness, or fruit flavor.

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BACKGROUND: Dairy is recommended in specially formulated supplementary foods to treat children with moderate acute malnutrition (MAM) but with limited evidence and added cost. OBJECTIVE: Review studies of ready-to-use foods (RUFs) versus fortified blended foods (FBFs) to determine whether inclusion of dairy modifies the comparative effectiveness and cost. METHODS: We reviewed literature comparing FBF and RUF in treatment of MAM among children younger than 5 years in developing countries. Outcomes of recovery from MAM, weight, and length gain were compared among treatment categories: FBF with dairy (FBF+), FBF without dairy (FBF-), RUF with dairy (RUF+), and RUF without dairy (RUF-). Supplement cost was compared per 500 kcal. RESULTS: Eight studies were included. Rations were heterogeneous in energy and type of dairy. Overall, RUF+, RUF-, and FBF+ performed similarly, with higher recovery and weight gain compared with FBF-. RUF+ had higher recovery (in 5 of 6 comparisons), weight gain (4 of 4), and length gain (1 of 4) versus FBF-. The RUF+ had higher recovery (1 of 2) versus FBF+, with no other differences. The RUF- versus FBF+ had no differences (0 of 2). The RUF- had higher recovery (1 of 2), weight gain (2 of 2) versus FBF-. Four studies reported supplement costs, which averaged US$0.15 (FBF-), US$0.18 (FBF+), US$0.18 (RUF-), and US$0.37 (RUF+) per 500 kcal. CONCLUSIONS: There is a consistent benefit of FBF that include dairy in treatment of children with MAM. Benefits of dairy in RUF require further investigation. Evidence from rigorous quantitative analysis of existing data, cost-effectiveness, and prospective trials will be essential in determining policy on treatment for children with MAM.

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