# Community-Based Management of Acute Malnutrition

This is an interim intervention report. We have spent limited time to form an initial view of this program and, at this point, our views are preliminary. We plan to consider undertaking additional work on this program in the future.

## Summary

• What is the program? Community-based management of acute malnutrition (CMAM) is a strategy for identifying and treating uncomplicated cases of severe acute malnutrition (SAM) without requiring hospitalization, potentially increasing coverage and decreasing cost relative to treating SAM in a hospital setting.
• What is its evidence of effectiveness? Randomized controlled trials (RCTs) suggest that CMAM increases the chances of recovery from severe acute malnutrition, but its effects on mortality remain uncertain. However, the mechanism through which CMAM would reduce mortality is plausible and straightforward. Our current best guess is that CMAM is effective for reducing mortality from SAM, but we would need to do additional work to investigate this preliminary conclusion and determine the magnitude of the effect.
• How cost-effective is it? Our initial cost-effectiveness estimate suggests that CMAM may be in the range of cost-effectiveness of our current top charities. Several outstanding questions limit our confidence in this estimate.
• Does it have room for more funding? We have not yet completed a full analysis of this question, but our understanding from speaking with charities working on this program is that there is substantial room for more funding.
• Bottom line: This intervention appears promising, but we would need to conduct additional research to better understand its evidence of effectiveness and cost-effectiveness.

Published: May 2018

• 2016 report on severe acute malnutrition (SAM)

## What is the problem?

Severe acute malnutrition (SAM) is a life-threatening condition "defined by a very low weight-for-height…, by visible severe wasting, or by the presence of nutritional oedema," a swelling of the legs and feet.1 The WHO estimates that in 2016, approximately 17 million children under five years old suffered from SAM, with the largest numbers in Asia, followed by Africa.2

Estimates of the fatality rate of untreated SAM vary widely, but the only estimate we found that pooled mortality data from multiple sources reports an annual fatality rate of approximately 21 percent in untreated children.3 We have not engaged deeply with this estimate, and we believe it may overestimate the true mortality rate because it is based on data from the 1980s and 1990s, when baseline mortality risk in children may have been higher. We have not yet found information on the outcomes of children who survive untreated SAM.

The World Health Organization (WHO) states that SAM is caused by inadequate food quantity and/or quality, often in combination with infectious disease.4

## What is the program?

Until recently, SAM was treated in a hospital setting. This approach is expensive and offers limited coverage in regions where hospitals are scarce.5 The development of ready-to-use therapeutic food (RUTF), a nonperishable, calorie- and micronutrient-dense food designed for treating malnutrition, now allows most cases of SAM to be treated at home for lower cost and greater coverage.6

Community-based management of acute malnutrition (CMAM) is a strategy for identifying and treating uncomplicated SAM without requiring hospitalization. According to the WHO, it involves:

• Identifying SAM in the community, often by screening children using colored plastic strips to measure mid-upper-arm circumference.7
• Assessment of screened children by a skilled health worker, who determines whether the child should be treated at home or in a hospital.
• Providing RUTF for six to eight weeks and a short course of oral medication to treat possible infections.8

## Does the program have strong evidence of effectiveness?

We reviewed two types of evidence for this program:

• RCTs focused on the question of whether RUTF leads to better results than standard care (supplying nutritious non-RUTF foods and medical care). These trials suggest that RUTF increases the likelihood of recovery from SAM, but they do not report clear impacts on mortality.
• Observational studies of CMAM programs that reported mortality outcomes. These studies generally find low rates of mortality in children with SAM treated with CMAM.

Although evidence that CMAM reduces mortality is limited, CMAM has a plausible and straightforward mechanism of action: improving the nutritional status of malnourished children. This mechanism is supported by the ability of CMAM to increase growth and recovery from SAM in RCTs. Our best guess is that CMAM is effective for reducing mortality in children with SAM, but we would need to do additional work to investigate this preliminary conclusion.

### Randomized controlled trials

We found limited RCT evidence supporting the effectiveness of CMAM. We rely primarily on a Cochrane review published in 2013 as well as two additional small trials published after 2013.9 All trials compare RUTF to standard care including provision of enriched foods, and collectively find increased likelihood of recovery from SAM but do not report clear impacts on mortality. Since SAM seems to be caused in large part by inadequate quantity and/or quality of nutrition,10 providing a control group with nutritious food should attenuate the difference between intervention and control groups

A 2013 Cochrane meta-analysis of quasi-randomized controlled trials reported:

• Relative to providing supplemental enriched flour, RUTF increases the likelihood of recovering from SAM by 32 percent (relative risk of 1.32; 95 percent confidence interval of 1.16 to 1.50 ).
• Relative to providing supplemental enriched flour, there is insufficient evidence to determine whether RUTF improves mortality, relapse, or weight gain.11

An important caveat is that control groups in these trials received substantial nutrition and care, including flour enriched with protein and micronutrients.12 To supplement the Cochrane meta-analysis, we performed a medium-depth literature search for RCTs published after its search date of April 2013. This search identified two additional relevant trials:

• Shewade et al. 2013 randomized 26 Indian children with uncomplicated SAM to receive counseling, supplementary nutrition, and monitoring (control group), or counseling, supplementary nutrition, monitoring, and RUTF (intervention group). Children in the intervention group met the prespecified weight gain threshold more often than those in the control group.13
• Bhandari et al. 2016 randomized 906 Indian children with uncomplicated SAM to receive 1) centrally-produced RUTF, 2) locally-prepared RUTF, or 3) micronutrient-enriched energy-dense home-prepared foods (the control group). Both RUTF formulations led to greater recovery rates than the control group, but the finding for the centrally-produced RUTF was not statistically significant.14

### Observational studies

We identified two review papers that pooled estimates representing a maximum of 21 programs and 23,511 children treated for SAM. These papers suggest that mortality rates are relatively low in CMAM programs (0.7 to 4.1 percent), although the underlying studies have variable and often short follow-up periods.15

These review papers do not report mortality rates in the absence of CMAM, so it’s difficult to know how much the intervention reduced mortality. We have not reviewed the primary studies underlying these review papers to assess potential limitations (such as high dropout rates and short follow-up periods) that may bias results. Finally, because of the interim nature of this report, we may have missed other review papers that would provide additional data.

## How cost-effective is the program?

The International Rescue Committee (IRC), an organization that implements CMAM, reports a cost of between $100 and$500 per child treated, excluding the cost of RUTF, which is donated by the UN Children’s Fund.16 We created a rough cost-effectiveness estimate (see our model here) for this program that suggests CMAM may be in the range of cost-effectiveness of our top charities. Academic studies we found have similar (though slightly more optimistic) estimates for the cost-effectiveness of this program. Two such studies, cited in the Disease Control Priorities 3 report, estimate that CMAM has a cost per life saved of $869 and$1,760.17

Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

Major uncertainties in our model include:

• Cost per person. IRC's cost figures do not include RUTF or shared costs borne by local medical systems and individuals. Costs may vary by program and location.
• Reduction in mortality attributable to CMAM in RCTs. RCT data are based on limited evidence that is not statistically significant, making our assumptions about the mortality reduction benefit uncertain. These trials provided substantial nutrition to control groups, likely narrowing the between-group difference and making it difficult to estimate the effectiveness of CMAM relative to no treatment.
• Reduction in mortality attributable to CMAM in observational studies. The observational data we identified do not permit a direct comparison with an untreated group, making it difficult to estimate how much the treatment reduced SAM mortality. We estimated the reduction in mortality in observational studies by assuming a mortality rate of 21 percent in the absence of treatment, but this estimate is for all SAM cases, whereas CMAM is only used for lower-risk "uncomplicated SAM". Therefore, our calculation may overestimate the program's true cost-effectiveness. We have no information about the longer-term outcomes of children treated with CMAM; it remains possible that they have higher mortality and/or lower quality of life in the years after treatment than children who haven't experienced SAM .
• Increase in consumption resulting from increased early-life growth. Our model assumes that increases in child growth will cause increases in adult consumption/income. The data that underlie this assumption are from studies of birth weight differences between identical twins and are highly uncertain in this context.
• SAM outcomes in the absence of treatment. We assume a baseline mortality rate of 21 percent for untreated SAM, but this figure derives from older observational studies and is uncertain. We have not yet encountered information on the outcomes of untreated children who don’t die of SAM; we do not know to what degree they recover in height and weight.

## Organizations and room for more funding

We have not conducted a comprehensive search for charities implementing CMAM programs, but we have identified and spoken with two charities that have such programs: IRC and Helen Keller International (HKI). Both IRC and HKI told us that they have funding gaps for this program, and we expect that other charities may have funding gaps to implement CMAM as well.

## Focus of further investigation

Questions we would ask as part of further investigation include:

• Is there a more reliable estimate of the mortality rate of children with untreated SAM than what we used in our cost-effectiveness analysis?
• Is there more informative observational evidence on the effectiveness of CMAM than what we used in our cost-effectiveness analysis?
• What are the limitations of the observational evidence on CMAM?
• What access to nutritional services would children have in the absence of a CMAM program?
• What are the longer-term outcomes of children who are treated with CMAM?
• What are the outcomes of children who survive untreated SAM?
• What is the cost-effectiveness of CMAM as implemented by IRC and HKI?
• How much room for more funding does HKI’s CMAM program have?

## Our process

We searched for Cochrane meta-analyses on the effectiveness of CMAM for SAM, conducted medium-depth primary literature searches for CMAM trials published after the Cochrane meta-analysis and cost-effectiveness studies, conducted a shallow literature search for review papers of observational studies on CMAM, constructed a cost-effectiveness analysis, and spoke with representatives of IRC and HKI.

## Sources

Document Source
Bhandari et al. 2016 Source
Ciliberto et al. 2000 Source
Collins et al. 2006 Source
Gera 2010 Source
International Rescue Committee, Cost Efficiency Analysis: Treating Severe Acute Malnutrition Source
Lenters et al. 2013 Source
Manary et al. 2004 Source
Puett et al. 2013 Source
Schoonees et al. 2013 Source
The World Bank, Disease Control Priorities 3, volume 2 Source
WHO and UNICEF, Levels and trends in child malnutrition Source
WHO, Community-based management of severe acute malnutrition Source
WHO, Severe acute malnutrition Source
WHO, WHO issues new guidance for treating children with severe acute malnutrition, 2013 Source
• 1.

WHO, Severe acute malnutrition

• 2.
• Severe wasting is part of the definition of severe acute malnutrition: "In 2016, nearly 52 million children under 5 were wasted and 17 million were severely wasted." Pg. 2.
• "In 2016, more than two thirds of all wasted children under 5 lived in Asia and more than one quarter lived in Africa." Pg. 3.
• 3.

"A value appropriate for the median admission MUAC (106.7 mm) was calculated using linear interpolation and published data with cohorts of patients the same age as those in this programme, and located in countries with limited access to health services, including Bangladesh (Briend and Zimicki 1986; Briend et al. 1987), Malawi (Pelletier et al. 1994) and Uganda (Vella et al. 1994). Taking into account a baseline mortality risk of 1/10 000/day, the expected mortality rate was estimated as 207 deaths per 1000 cases per year. That is, 20.7% of the cohort of SAM cases would be expected to have died within a mean of 6 months of admission, or onset of a SAM episode. (See Supplementary Materials for further detail regarding the mortality estimate used in this analysis and discussion of methodological issues surrounding estimation of mortality attributable to untreated SAM.)" Puett et al. 2013, Pg. 389.

• 4.

"[SAM] occurs when infants and children do not have adequate energy, protein and micronutrients in their diet, combined with other health problems such as recurrent infections." WHO, WHO issues new guidance for treating children with severe acute malnutrition, 2013

• 5.

"Severe acute malnutrition remains a major killer of children under five years of age. Until recently, treatment has been restricted to facility-based approaches, greatly limiting its coverage and impact." WHO, Community-based management of severe acute malnutrition, Pg. 2.

• 6.

"Evidence shows that about 80 per cent of children with severe acute malnutrition who have been identified through active case finding, or through sensitizing and mobilizing communities to access decentralized services themselves, can be treated at home. The treatment is to feed children a ready-to-use therapeutic food (RUTF) until they have gained adequate weight." WHO, Community-based management of severe acute malnutrition, Pg. 3.

• 7.

"Community health workers or volunteers can easily identify the children affected by severe acute malnutrition using simple coloured plastic strips that are designed to measure mid-upper arm circumference (MUAC). In children aged 6–59 months, a MUAC less than 110 mm indicates severe acute malnutrition, which requires urgent treatment. Community health workers can also be trained to recognize nutritional oedema of the feet, another sign of this condition." WHO, Community-based management of severe acute malnutrition, Pgs. 2-3.

• 8.

"The treatment is to feed children a ready-to-use therapeutic food (RUTF) until they have gained adequate weight. In some settings it may be possible to construct an appropriate therapeutic diet using locally available nutrient-dense foods with added micronutrient supplements. However, this approach requires very careful monitoring because nutrient adequacy is hard to achieve. In addition to the provision of RUTF, children need to receive a short course of basic oral medication to treat infections. Follow-up, including the provision of the next supply of RUTF, should be done weekly or every two weeks by a skilled health worker in a nearby clinic or in the community." WHO, Community-based management of severe acute malnutrition, Pg. 3.

• 9.

We also found one additional, non-Cochrane meta-analysis that was published in the same year and reported similar findings: "There were no significant differences in mortality (figure 2). Children who received RUTF were 1.51 times more likely to recover (defined as attaining WHZ ≥ -2) than those receiving standard therapy (RR: 1.51, 95% 1.04 to 2.20) (figure 3)." Lenters et al. 2013, Pg. 3-4.

• 10.

"[SAM] occurs when infants and children do not have adequate energy, protein and micronutrients in their diet, combined with other health problems such as recurrent infections." WHO, WHO issues new guidance for treating children with severe acute malnutrition, 2013

• 11.

"When comparing RUTF with standard diet (flour porridge), we found three quasi-randomised cluster trials (n = 599). RUTF may improve recovery slightly (risk ratio (RR) 1.32; 95% confidence interval (CI) 1.16 to 1.50; low quality evidence), but we do not know whether RUTF improves relapse, mortality or weight gain (very low quality evidence)." Schoonees et al. 2013, abstract.

• 12.
• "Children who received standard inpatient therapy were fed F-100. On discharge from the hospital, the malnourished children received a generous supply of a supplemental 80% maize/ 20% soy blended flour (50 kg) that was to be consumed 7 times/d. The blended flour was supplemented with vitamins and minerals according to standard specifications of the World Food Programme. The staple, traditional foodstuff in Malawi is maize flour, with or without legumes, which is usually consumed as a soft solid dough more than once per day. Because the maize-soy blend that was given with the standard therapy was familiar to mothers as an everyday food, they were expected to prepare it for their children as they would their staple food." Ciliberto et al. 2000, Pg. 866.
• "The third group was given enough maize/soy flour to feed the entire nuclear family, including the affected child, who received a quantity sufficient for full catch-up growth, and a separate multivitamin/mineral supplement. All dietary groups received sufficient quantities of vitamins and micronutrients for recovery." Manary et al. 2004, Pg. 558.
• 13.

"Primary outcome, 115% of baseline weight, was attained in 6 of 13 (46.2%) and 1 of 13 (7.7%) children among study and control group, respectively [odds ratio: 10.28, 95% confidence interval (CI): 1.02–103.95]. Compared with control group, addition of RUTF in study group resulted in average additional increase in weight by 13 g/kg of baseline weight/week/child (95% CI: 2–23). Indigenous RUTF was effective in community-based management of uncomplicated SAM." Shewade et al. 2013, abstract.

• 14.

"Recovery rates with RUTF-L, RUTF-C and A-HPF were 56.9%, 47.5% and 42.8%, respectively. The adjusted OR was 1.71 (95% CI 1.20 to 2.43; p=0.003) for RUTF-L and 1.28 (95% CI 0.90 to 1.82; p=0.164) for RUTF-C compared with A-HPF. Weight gain in the RUTF-L group was higher than in the A-HPF group (adjusted difference 0.90 g/kg/day, 95% CI 0.30 to 1.50; p=0.003). Time to recovery was shorter in both RUTF groups." Bhandari et al. 2016, abstract.

• 15.
• "Twenty-one (21) community-based therapeutic care programs were implemented in Malawi, Ethiopia, and North and South Sudan between 2000 and 2005. These programs, which treated 23,511 cases of severe acute malnutrition, achieved recovery rates of 79.4% and mortality rates of 4.1%. Coverage rates were approximately 73%. Of the severely malnourished children who presented, 76% were treated solely as outpatients." Collins et al. 2006, abstract.
• "Data from observational studies showed the energy intake with RUTF to be comparable to F-100. The pooled recovery rate, mortality and default in treatment with RUTF was 88.3%, 0.7% and 3.6%, respectively with a mean weight gain of 3.2 g/kg/day." Gera 2010, abstract.
• 16.
• "The IRC’s SAM programs cost between $100 and$500 dollars per child treated. The average cost per child treated was $235, excluding the shared costs of country office management, and$300 when said costs were included." Pg. 1.
• "The ready-to-use therapeutic food (RUTF) these programs distribute is, in almost all cases, donated for free by the U.N. Children’s Fund (UNICEF), meaning the cost estimates do not include RUTF costs." Pg. 2.
• 17.

"Several studies have examined the costs and cost-effectiveness of CMAM programs. Puett and others (2012) compare the cost-effectiveness of a CMAM program delivered by CHWs in Bangladesh with standard inpatient treatment. The authors find that the CMAM program cost US$26 per DALY averted and US$869 per life saved. The costs of SAM treatment in the control group were US$1,344 per DALY averted and US$45,688 per life saved, respectively. A study in Ethiopia that retrospectively examined the costs of CMAM versus treatment in a therapeutic feeding center (TFC) finds that costs were substantially lower in the CMAM program, with a cost per recovered child for the CMAM and TFC of US$145.50 and US$320.00, respectively (Tekeste and others 2012). Studies in Malawi (Wilford, Golden, and Walker 2012) and Zambia (Bachmann 2009) examining the costs of CMAM compared with hypothetical simulations of no care both find CMAM to be cost-effective and on par with other child health interventions, including universal salt iodization, iron fortification, immunization, and micronutrient fortification. The study in Zambia also finds CMAM to be cost-effective according to the WHO standards, given that the cost per DALY averted was less than the national per capita gross domestic product (GDP). The study in Malawi finds CMAM to cost US$42 per DALY averted; the study in Zambia finds CMAM to cost US$53 per DALY averted. The authors estimated the cost per child to be US$203 and per life saved to be US$1,760 (Wilford, Golden, and Walker 2012)." The World Bank, Disease Control Priorities 3, volume 2, Pg. 217.