Improved Therapeutic Foods Improve Cognition in Malnourished Children – Washington University School of Medicine in St. Louis

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DHA, an omega-3 fatty acid, may improve language, social and motor skills

Reginald Lee / University of Washington

A nutritional supplement popular in the United States and added to certain types of yogurt, milk and infant formula can dramatically improve cognition in severely malnourished children, according to a study by researchers at the Washington University School of Medicine in St. Louis.

Researchers found that when the omega-3 fatty acid known as docosahexaenoic acid (DHA) was added to a nutrient-dense and internationally prescribed ready-to-use therapeutic food (RUTF), similar to butter peanut, children’s overall cognition improved. Children who ate DHA fortified food outperformed those who did not in gross and fine motor skills, language skills and social skills – all related to brain health.

Additionally, reducing the amount of linoleic acid – an omega-6 polyunsaturated fatty acid – in food also helped children’s neurological abilities. This is because the chemical composition of omega-6 fatty acid counteracts the production of brain-stimulating DHA, the latter being essential for brain development during pregnancy and infancy and is also associated with improved vision, heart health and immune system function. .

“This is the first evidence of the cognitive effects of ready-to-use therapeutic foods showing that DHA and a reduction in omega-6s are needed to increase brain power in children with severe acute malnutrition,” said the ” lead author of the study, Mark J. Manary, MD, Professor Helene B. Roberson of Pediatrics. “We believe the therapeutic food should be reformulated and standardized to include reduced DHA and omega-6s. All children deserve our best efforts to reach their neurocognitive potential.

The results were published online Nov. 2 in The American Journal of Clinical Nutrition.

Globally, more than 16 million children under 5 suffer from severe acute malnutrition. The disease is a form of starvation that mainly affects children in poor parts of Africa and Asia and causes excessive thinness or swelling of the body while compromising organ systems including the brain.

Severe acute malnutrition kills around 1 million children each year.

Nearly two decades ago, Manary launched an effort in Africa to tackle severe malnutrition by using a peanut butter therapeutic food fortified with micronutrients known to restore body and muscle mass. Foods that are high in energy and low in moisture are composed of peanuts, milk, vegetable oils and sugar and, like peanut butter, they do not require any cooking and do not spoil under ambient conditions. . Such characteristics make the food ideal for people living in extreme poverty or in areas hit by natural disaster, political unrest or other situations causing food shortage.

Outpatient feeding programs serving this ready-to-use therapeutic food have saved the lives of hundreds of thousands of malnourished children. Previous data has shown that severely acutely malnourished children who were treated with the food recovered at rates of 85-90%. But Manary and others caring for malnourished children have struggled to effectively deal with cognitive issues associated with severe malnutrition, such as difficulty speaking, mobility issues, and behavioral issues.

The malnourished brain needs additional special nutrients to restore normal function, namely the omega-3 polyunsaturated fatty acids most commonly found in fish and breast milk, Manary said. DHA makes up 10% of brain matter and is the most important nutrient for the brain.

“Adding it to the therapeutic food while reducing omega-6s, which are omega-3 antagonists, boosted cognition in starving children,” Manary said.

The clinical feeding trial was conducted from October 2017 to December 2020 at 28 clinics in rural Malawi in sub-Saharan Africa. It involved 2,565 children aged 6 months to 5 years with severe uncomplicated malnutrition, meaning they were diagnosed as severely malnourished but still had a good appetite, were not hospitalized and showed no signs of severe infection.

The children were randomly assigned to receive one of three ready-to-use therapeutic foods: the original standard version with higher levels of omega-6; a version with reduced amounts of omega-6 and an increase in omega-3; and a version that included DHA with reduced omega-6s. Trial investigators, families, and researchers analyzing the data did not know which groups the children were assigned to.

The treatments lasted for about eight weeks. Six months after the end of treatment, the researchers compared cognition in malnourished children. They measured cognition using the Malawi Developmental Assessment Tool, a battery of standardized and scientifically validated exercises that test language skills, social interaction, and gross and fine motor skills.

“Cognition was superior in the children who received the therapeutic food with additional omega-3s and DHA compared to the other two groups,” Manary said. “Their scores were higher overall. We noted a 22% greater improvement than those who received the standard ready-to-use therapeutic food.

“For half of the children, cognition is completely restored, but without low omega-6 plus DHA, severely malnourished children would have 10 IQ points below average,” he added.

The researchers also measured the levels of DHA in the children’s blood immediately after completing the ready-to-use therapeutic food therapy. After four weeks, DHA levels dropped by 25% in children given the standard food, most likely due to the high amount of omega-6 fatty acids. (Manary noted that these DHA levels would decrease significantly more if the children were not given any ready-to-use therapeutic food). Meanwhile, after four weeks, DHA levels increased by 49% in the children who received the food fortified with DHA.

“This suggests that the lack of DHA limited cognitive improvement,” Manary said. “This is fantastic news in that the DHA fortified therapeutic food could restore malnourished brains better than before, and these benefits can last anywhere from six months to a year or more.”

On November 8 and 9, the researchers will present their findings to the World Health Organization, which sets international guidelines for the treatment of malnutrition and other diseases. In addition, in early December, they will share their research to advocate for improvements in the formulation of ready-to-use therapeutic foods distributed around the world, at a meeting of the Codex Alimentarius, an international food safety organization. which sets standards followed by most nations. Manary and his colleagues plan to request that all ready-to-use therapeutic foods be prepared with reduced amounts of omega-6 fatty acids and fortified with DHA.

“Our goal is to change global politics,” Manary said. “These kids deserve nothing less.

Kevin Stephenson, MD of the University of Washington, Fellow in the Department of Medicine, and Meghan Callaghan-Gillespie, Masters of Public Health and Clinical Research Implementation Coordinator in the Department of Pediatrics, are the co-first authors of the study.

Stephenson K, Callaghan-Gillespie M, Maleta K, Nkhoma M, George M, Park HG, Lee R, Humpheries-Cuff I, Lacombe RJS, Wegner DR, Canfield RL, Brenna JT, Manary MJ. Low Linoleic Acid Foods With Added DHA Given To Malawian Children With Severe Acute Malnutrition Improve Cognition: A Controlled, Randomized, Triple-Blind Clinical Trial. The American Journal of Clinical Nutrition. Posted online November 2, 2021.

Disclosure: Manary is Associate Editor of AJCN.

The research is supported by funding from Unorthodox Philanthropy and Open Philanthropy. Wiley Companies supported the work with an ingredient donation for one of the foods in the study. Donors played no role in the design, implementation, analysis or interpretation of the study.

The 1,700 physicians on the Washington University School of Medicine faculty are also on the medical staff of Barnes-Jew and Saint-Louis children’s school hospitals. The School of Medicine is a leader in medical research, education, and patient care, consistently ranking among the nation’s top medical schools by US News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s Hospitals, the School of Medicine is linked to BJC Healthcare.


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