Abstract

Ready-to-use therapeutic foods (RUTF) play a fundamental role in the management protocol for severe acute malnutrition in children aged 6 to 59 months. Their availability, , therefore, constitutes a major issue in the fight against infant morbidity and mortality in developing countries. In Côte d'Ivoire, frequent shortages of RUTF are observed in the majority of health structures with repercussions on the level of performance of nutritional programs. Faced with this situation, an Ivorian research team proposed formulating therapeutic foods based on local products. The study was carried out at the National Institute of Public Health and the Nangui Abrogoua University of Côte d'Ivoire. The objective was to develop a formula meeting the recommended nutritional and microbiological requirements in order to use it as a substitute for reference products. It made it possible to develop a ready-to-use therapeutic food using the linear programming technique, then produced using traditional methods. The nutritional and microbiological qualities were determined and confirm that the formula based on corn and beans meets the recommended nutritional and microbiological needs for severely acutely malnourished children without complications. It will be subject to current clinical trial processes in order to use it with complete peace of mind.

1. Introduction

Acute malnutrition among children aged 0 to 5 years is a real public health problem in developing countries and Ivory Coast is not spared. It is the result of an insufficient quantity and/or quality of food provided according to the needs of the individual ¹. This condition can occur in the event of food shortage, recent acute illness, inappropriate diet or a combination of some of these factors ¹. Acute malnutrition can be moderate, severe without complications or severe with complications ^{2, 3}.

In its management, ready-to-use therapeutic foods (RUTF) are effective means ⁴. They are in the form of spreads, cookies or bars (BP-100) or drinks, composed of ingredients such as cereals, vegetable oil, sugar and vitamin complexes ⁵.

In Ivory Coast, their unavailability is becoming very frequent and constitutes a major problem in the management of malnutrition. Faced with this challenge, a research team set out to develop ready-to-use therapeutic foods (RUTF) based on local ingredients.

The objective of this work is to formulate one of these nutritional complexes based on corn and beans, meeting nutritional and microbiological recommendations, with a view to use it as substitutes for reference products.

2. Material and Methods

This is an experimental study over a period of 6 months at the Nutritional Rehabilitation Department of the National Institute of Public Health (NIPH) and the Nutrition Laboratory of the University of Nangui Abrogoua (UNA).

The major ingredient is the corn. As protein foods, soy, beans, eggs, and milk were used. Sugar was used for its contribution to the final taste of the product. The refined palm oil was, also, used for energy density and texture formation. Spirulina and baobab leaves were selected to cover the mineral salt and vitamin components.

Linear programming was used to carry out the formulation. The model allowed us to have the variables which are the quantities of ingredients to incorporate, the energy values and the nutrient contents which correspond to the quantities to use. The obtained food formula are composed of; corn and bean flour, palm oil and olive oil; dried egg white powder and spirulina. The quantities are as follows; corn (21 g/100 g), bean (27 g/100 g), egg white powder (4 g/100 g), palm oil (20 g/100 g), olive oil (10 g/100 g), and sugar (11 g/100 g). A premix composed of spirulina (4 g) and baobab leaves powder (2 g), vitamin C (50 mg/100 g) and emulsifier (950 mg/100 g) was added. The particle size of the retained powdered ingredients was ≤ 300 µm ⁶.

The RUTF formula based on local ingredients was prepared by combining the ingredients. The formulated recipe was standardized as follows:

- Palm oil was first mixed with soy lecithin powder in a multi-function mixer (SOKANY^®, KF-103S) and then heated to a temperature between 50 and 56 ° C using a SEVERIN^® brand dryer, HT0104 for 15 min. The temperature control was carried out via the infrared thermometer. The sugar glaze (Very finely powdered sugar) was then added to the previous mixture of corn flour previously roasted over a low heat for 2 to 5 minutes until a homogeneous paste was obtained constituting mixture 1.

- To mixture 1, bean flour previously roasted, egg white powder, olive oil were added, then heated at 50°C for 5 min to obtain mixture 2.

- To this mixture 2, premix was added then homogenized at different speeds (2 to 8) for 3 min/speed degree in order to simulate the silo conditions in the reference RUTF production plants.

- The final mixture is the ready-to-use local food called MAHA. It was stored between 45 and 50°C in 100 ml polypropylene plastic containers.

Microbiological analysis of total mesophilic aerobic germs (TMAG), Yeasts and Molds, Total and faecal coliforms, Escherichia coli and Staphylococci was performed according to standard procedures for the preparation of culture media and the enumeration of germs ¹¹. The dosage of each microorganism, 10g of each formula was aseptically removed and added to 90 ml of Buffered Peptone Water (BPE) prepared according to the manufacturer's recommendations (SCHARLAB S. L®, Spain).

The collected data were processed with Graph Pad Prism software version 7.00. The experimental results are expressed as arithmetic means and accompanied by the standard error (m ± SEM). The nutritional composition was compared to that of the reference product. Thus an analysis of variance (ANOVA) followed by a Newman-Keuls test at the 5% threshold was then carried out.

3. Result

The nutritional composition of MAHA is presented in Table 1 and Table 2. The energy value of the formula is 530.82 kcal per 100g of matter. The lipid content is 32.59 ± 0.18 g/100g. The protein composition of the formula is 13.70 ± 0.75 g/100g. The carbohydrate content is 43.58 ± 0.56 g per 100 g. The moisture content is 2.57 ± 0.1g per 100 g of matter. The MAHA formula has a dry matter content of 98.3 ± 0.1g. The fiber content is 2.77 ± 0.15 g/100g. The mineral composition of the food is made of Potassium (1213mg), Calcium (414mg), Sodium (215), Phosphorus (390), Magnesium (122), Zinc (13.4) and Copper (1.4). The comparison of means is carried out by the Newman-Keuls test at the 5% threshold. The means on the same raw, assigned different letters in superscript are not significantly different between the local formula and Plumpy’Nut® (p < 0.05) according to the parameter studied.

The obtained value for total aerobic mesophilic germs of local formula is lower than the standard (51 CFU/g). Yeasts were observed but in quantities lower than the pre-established standards. On the other hand, total and faecal coliforms, molds, salmonella, Escherichia coli and staphylococci were not detected in this formula. Thus, the fungal and bacteriological loads detected in the MAHA formula correspond to the microbiological criteria applicable to ready-to-use therapeutic foods intended for children under five years of age with severe acute malnutrition without complications ¹². The microbiological analyses are presented in Table 3.

4. Discussion

The objective of this study is to formulate a ready-to-use therapeutic food based on local nutritional products for the management of severe cases of uncomplicated acute malnutrition. The ingredients were selected based on the recommendations of Collins (2006) ¹³. These are corn, bean, egg white, palm oil, olive oil and cane sugar. Spirulina, baobab leaves powder and vitamin C were used as micronutrient supplements. Soy lecithin was used as an emulsifier.

The quantity per food ingredient was defined by linear programming. A formulation work made it possible to obtain a ready-to-use therapeutic food called "MAHA".

Its nutritional composition was studied and compared to international standards. In terms of macronutrients, the energy density of MAHA is 530.29 ± 1.73 Kcal per 100g of material. This is an important quality of RUTF intended for the rehabilitation of severely malnourished children without complications due to their high energy requirement. This result is the same as that of the Amegovu et al. study in 2014 ¹⁴.

According to international experts, malnourished children need a diet rich in fat ^{15, 16}. The local MAHA formula has a statistically adequate lipid level (32.59 ± 0.18 /100g) because its value remains within the limits set from 28 to 36g / 100g ^{17, 18}. These lipids are necessary for the absorption of vitamins A and E according to FAO/IFAD/UNICEF/WFP/WHO ¹⁸. These vitamins are also important for rapid recovery and reduction of the incidences associated with acute malnutrition. In addition, the protein content of the Formula (14.17 ± 0.27 g/100g) is superimposable to the recommended standards ¹¹, ^{19, 20}. These proteins are essential for the rehabilitation of lean mass in malnourished people.

Indeed, they are involved in many biological functions such as muscle tissue formation, enzyme and hormone production, and growth ²¹. Concerning carbohydrates, the carbohydrate content of MAHA is adequate according to the work of Amegovu et al (2014) ¹⁴.

These carbohydrates contribute to protein synthesis and are involved in thermoregulation in malnourished people ²².

The mineral profile of MAHA has also been studied. It is satisfactory according to the work of Adjou., et al. (2012) ²³. These minerals play an important role in the restoration of intracellular and extracellular fluids. They are involved in many biological functions including enzymatic activities as well as the electrolytic balance of the blood flow where certain minerals (Na, K, and Mg) must have a perfect adequacy for the proper functioning of the body ¹⁸.

Sodium and potassium are minerals necessary for maintaining the osmotic balance of body fluids as well as body pH by regulating nervous and muscular irritability ^{24, 25}. They also help control glucose absorption and improve normal protein retention during growth ²⁶. The Na/K ratio of the body is of great interest in the prevention of cardiovascular disorders. A Na/K ratio of less than 1 is therefore recommended ^{21, 22}, ^{27, 28}. The Na/K ratio of the formula obtained is less than 1. The results of the “MAHA” mineral profile have values that globally represent 80% of the recommended minimum requirements ⁸. At the end of this analysis, it appears that the nutritional composition of MAHA is superimposable to that suggested by experts for the management of children with severe acute malnutrition without complications ¹⁸. The study of the microbiological quality of the local formula indicates that the load of total mesophilic aerobic germs is lower than the microbiological criteria (< 104 CFU/g) indicated by the different organizations involved in the management of acute malnutrition ¹², ^{29, 30}. The moisture content of the formula is statistically included in the levels set in ready-to-use foods according to the work of Santini., et al. (2013) ³¹. This moisture content is due to the different cooking, drying and roasting treatments applied to the different inputs including beans, corn and eggs. The cooking/drying and drying/roasting couplings have allowed a significant reduction in the load of mesophilic aerobic germs. This low moisture content of the local formula is beneficial for better and long-term conservation ²⁶.

Other authors such as Tarhouni et al. (2015) ²⁰, also showed that precooking and drying flours reduce total mesophilic aerobic germs. The absence of hygiene control germs (faecal coliforms) and pathogenic germs (S. aureus, Salmonella) in the local formula proves the effectiveness of the cooking conditions (temperature/time). These results could also reflect the compliance with good hygiene practices (GHP) and manufacturing practices (GMP) during the production of local RUTF.

5. Conclusion

The fight against malnutrition in children under five years of age is one of the major areas of public health intervention in the world. The availability of ready-to-use therapeutic foods plays an important role in this process. In Côte d'Ivoire, the frequent shortage of these therapeutic foods motivated the conduct of this study in order to formulate a RUTF based on local ingredients. The work demonstrated its nutritional and microbiological qualities which are superimposable to international standards. The "MAHA" could therefore be used for the management of cases of severe acute malnutrition without complications. It will follow the ongoing clinical trial process in order to be safely prescribed to children.

References