Development and acceptability testing of ready-to-use supplementary food made from locally available food ingredients in Bangladesh

Bangladesh has one of the highest childhood malnutrition rates in the world. The prevalence of underweight (<-2 z score weight-for-age) among children less than five years old is 36 percent and stunting (<-2 z score height-for-age), which denotes chronic malnutrition, is 41 percent [1]. Bangladesh has an estimated 600,000 children with severe acute malnutrition (SAM) and 1.8 million with moderate acute malnutrition (MAM). As a result, currently there are 2.4 million children under five years of age in the country suffering from acute malnutrition (<-2 z score weight-for-height) [1]. Malnutrition is nearly always accompanied by deficiencies of essential micronutrients, raising the importance of evaluating the impact of micronutrient content of food products in reducing micronutrient deficiencies during 6–12 months of life [2]. Although breast feeding rates have increased considerably in Bangladesh (90 percent of under-two children breast fed and 64 percent exclusively breast fed during the first 6 months of life), only 24 percent of young children are fed as per appropriate infant and young child feeding (IYCF) practices [1]. Research done in rural Bangladesh showed that complementary foods are grossly deficient in essential micronutrients [3]. In a recent study we assessed the adequacy of intake of 11 micronutrients among 24–48 months children in rural Bangladesh [4]. The overall mean prevalence of adequacy of micronutrient intakes for children was only 43 percent. The prevalence of adequacy was less than 50 percent for iron, calcium, riboflavin, folate, and vitamin B12. In the same population we observed that children consumed sub-optimal amounts of fat and in most children, only one to four percent of the total energy came from essential fatty acids [5]. These observations reflect food insecurity which affects about 20–30 percent of the population of the country, as well as low dietary diversity and low feeding frequency of young children among a larger part of the population. Although effective counseling to improve the quality of complementary feeding works in food secure communities, supplementation with nutritious food may be imperative for children, especially those who cannot afford an adequately diverse diet [6, 7].

To reduce growth faltering among young children in resource constrained countries several food supplements have been developed and tested with contrasting results [8‐10]. However, considering the country context, a new supplementary food made of locally available food ingredients needs to be developed in Bangladesh. This new supplementary food was designed similar to the Pushti packet (a mixture of roasted rice and lentil flour, with molasses and oil), the food supplement used in the erstwhile National Nutrition Program of Bangladesh. This food supplement is referred in this paper as ‘Ready-to-use supplementary food’ (RUSF) made of locally available food ingredients and designed to have the required amount of micronutrients and vitamins essential for growth and development of children 6–24 months of age. RUSF does not require cooking and can be consumed without adding water either on its own or by mixing with other food such as rice porridge. It has minimal water content and thus, the risk of contamination or bacterial growth is greatly reduced. These characteristics make provision of RUSF a safe nutrition for young children in Bangladesh. This paper aims to describe the formulation of newly developed RUSF recipes and to assess whether these RUSF are acceptable compared with the existing Pushti packet among children aged 6–18 months in a clinical trial design.

Our results suggest that rice-lentil and chickpea-based RUSF were more acceptable than Pushti packet, which was the least acceptable of the three foods studied. The assessment of the acceptability of the three food supplements was a bit challenging because we had to depend partially on the opinion of mothers whose tastes and food preferences, as adults, are different from those of the children. Although our primary objective was to measure the mean proportion of offered food consumed by the children but we also measured the mean Hedonic Scale score. Our rationale was that with no forced feeding, the amount of the offered food consumed by children would depend largely on the extent to which they liked the food, given that none of the children were fed for at least 2 hours prior to the feeding session. Children consumed an average of 47.1-56.7 percent of the RUSF offered and 34.4 percent of Pushti packet offered. Mean Hedonic Scale score for Pushti packet was also significantly lower compared to the two RUSF. We can, therefore, say with reasonable certainty that children accepted rice-lentil and chickpea based RUSF more compared to Pushti packet. The Hedonic Scale responses from the mothers suggested a high level of acceptability, but as observed in a similar study in Mexico and Ghana [8, 13], such Hedonic Scale responses may not be conclusive because respondents could be reluctant to give any negative comment [14]. Our mean Hedonic Scale across all three foods was high suggesting this may have also occurred in our study. On the other hand, total consumption of the offered food is an option to assess the acceptability of food supplements [8, 10]. Thus, combining the results from Hedonic Scale testing and total consumption is probably the best way to judge the acceptability of the RUSF.

The concerns raised by few caregivers about the taste of RUSF being similar to a medicine warrants discussion. Our general observation was that caregivers considered the supplement as food, and therefore, they seem to expect it to taste much the same way as a typical food might taste. The relatively high mineral concentration makes any attempt to get the supplement to taste like a typical food a challenge, from a food technology perspective [3]. There may be a way to deal with the medicinal taste issue: it should be explained to caregivers that the RUSF, although it looks like food, has a high nutrient concentration and therefore may not taste like a normal food to few caregivers. Indeed it would be a point for counseling when the product will be launched at larger scale in a nutrition program.

Pushti packet was found less acceptable among children and caregivers. This supplement had one major characteristic that contributed to its lesser acceptance by the children or caregivers, which is: adding water to Pushti packet increases the volume of food and in turn it reduces the sweetness. Moreover, the fat content is less than RUSF. This study has provided useful insights for the efficacy trial of RUSF which is now being conducted in Gaibandah, in the northern part of Bangladesh, in collaboration with John Hopkins University and the World Food Programme. In this efficacy trial, approximately 5000 children, 6–18 months old, have been randomly assigned to the two locally produced RUSF, Supercereal Plus (also known as wheat soya blend plus plus or WSB++) and a commercially available, imported food supplement called Pumpy’Doz™. The trial will not only evaluate the effects of RUSF on the nutritional status of children, but will also provide extensive information on the long term acceptability of these products and add to what we have learned from this acceptability study.