4. Discussion
wasting, stunting, tuberculosis, weight gain, Weight gain
WASTING, TUBERCULOSIS
To our knowledge, this study is the first large trial in Indonesia comparing the acceptability and effectiveness of RUTFs based on locally available ingredients compared with a standard RUTF. This study showed that RUTF products made from locally available ingredients were comparable to the standard peanut-based RUTF in terms of weight gain. Weight gain was between 1.3–1.6 g/kg BW/day, which is in line with findings of effectiveness trials in Cambodia and Vietnam [More than 60% of the children in this study were less than 2 years old, indicating that severe wasting is a serious public health problem during early childhood in Indonesia. Recent evidence from Africa and South-East Asia shows that children who experience a period of wasting are at an increased risk of stunting and mortality in the period thereafter. Hence, given that the majority of severe wasting occurs within the window of opportunity to reduce stunting, early detection and treatment of severe wasting will contribute significantly to the efforts of the Government of Indonesia to reduce stunting. The importance of counselling, both on IYCF and continued severe wasting treatment, cannot be underestimated, with most dropouts in the <2 years age group and >40% of children in the control group not finishing treatment.Most products seem to be acceptable, in particular, local products and especially the MUN2 and PEA products were well received by the younger children (6–11 months old); the PEA RUTF was crushed by the caregivers before presentation to their children when the child was below 11 months of age. The MUN2 product, which had lower viscosity than the other pastes, was less well received by older children (24–59 months). The relatively lower acceptability of CON RUTF is in line with findings in other South-East Asian countries [Based on the findings of this study, the successful implementation of an IMAM program in Indonesia will depend on the production and distribution of local RUTF products, because the almost 40% drop-out within the first weeks of SAM treatment observed with the current gold standard (peanut–milk paste RUTF) is untenable. Therefore, local development and production of RUTF should be strongly encouraged. Further revision of the products in this study is recommended to further increase the nutrient density and acceptability of the local products. The availability of a larger choice of products can increase the success of a larger national program as it enables catering to personal and local preferences in terms of ingredients, taste and form, and can be adapted to the age of the child.The lack of impact for 4 of the 5 RUTFs is in line with studies from Africa and Asia, which showed little or no improvement in haemoglobin concentrations in children receiving SAM treatment with standard RUTF [It is important to note that close monitoring and intensive counselling are essential for the success of SAM treatment at home. Not only should the importance of the treatment be stressed, but counselling should include infant and young child feeding, given the high proportion of children under 2 years who have SAM. Therefore, government programs should consider incorporating Social and Behavioural Change Communication (SBCC) and a ‘buddy’ system similar to that used in tuberculosis programs to motivate the parents and ensure optimal compliance.Overall, the results of the present study confirm that the development of RUTFs adapted to the local availability of ingredients and local organoleptic preferences contribute to higher acceptance of the products and thereby can contribute to more efficient IMAM programs.