First phase diet in severe malnutrition
Phase 1 of nutritional rehabilitation Andre M.N Renzaho 03.05.2000
First phase diet in severe malnutrition Mark Manary 04.05.2000
First phase diet in severe malnutrition Liana Steenkamp 17.05.2000
Zn Bioavailablity with Phytate Mark Manary 19.05.2000

Date: Wed, 03 May 2000 19:57:41 +0100

From: "Andre M.N Renzaho" <>

Subject: Phase 1 of nutritional rehabilitation


Dear Colleagues,

I had a discussion with somebody working in India a month ago about nutrition of severely malnourrished admitted in TFC in the first phase of nutritional treatment initiation. This person seems to be confused. He said that there is somewhere where soya-based porridges are being used to treat severely malnourrished admitted in the nutritional treatment initiation phase. As fas as I know, severely malnourrished children must be treated exclusively with therapeutic milk for the first 5-7 days at a dose of 100 Kcal/Kg body weight/day and no more than 3 g prot/kg/day and porridges could only be introduced in phase two and/or after a week when the child shows sign of appetite, change of attitude etc. I reiterated that soya-based porridges as a replacement for therapeutic milk during the first phase of nutritional treatment initiation could lead to cardiac failure given the protein and energy content of this particular diet (osmotic values) and the altered metabolism mechanisms of severely malnourished children. Ignorant and unaware of the UNHCRWFP and MSF nutrition guideline, this man did not beleive me and seemed confident with his argument.

Is there any study at all which has used soya-based porridges in the first phase of nutritional treatment initiation as a replacement of therapeutic milk or is there any NGO using such a practice? if so, what is the success of this particular practice? i.e recovery rate, mortality within the feeding centre, length of stay an so on. Could you share this discussion with me please, may be my argument was wrong. (see other discussion on "Soya-based products to treat severe malnutrition")



Andre M.N Renzaho


Note added:

Dear Andre. For very ill children even the standard therapeutic milk can be problematic because it has quite a high osmolality and renal solute load, a higher protein than one would wish for this phase of treatment and certainly a higher sodium. For these reasons there is a special diet to use in the initial phase (called F75 in the WHO manual). There are many places where therapeutic milk is not available and provided that the correct nutritional principles are followed I am sure that there are a number of diets that can be used successfully.

Soya based porridges are, however, probably a very poor choice of starting material (see other discussion on "Soya-based products to treat severe malnutrition"). They are high in phytate and protein and low in potassium, magnesium and zinc. These are all important factors. The high phytate is a problem because in this situation it induces zinc deficiency - even with diets using soya-based infant formula diets we got very poor results in Jamaica and wrote this up in AJCN (Golden BE Golden MH 34:892-899;1981 and 34:900-908;1981).

However, the recent data analysed from ACF-TFCs shows that the type of diet is much less important than the inappropriate use "rehydration" fluid and mis-management of electrolyte balance in causing death in the severely malnourished.

Date: Thu, 04 May 2000 15:23:53 +0100

From: Mark Manary,

Subject: First phase diet in severe malnutrition


I have used egg and egg white with additional oil and sugar in phase 1 feeding with kwashiorkor, and found it to be just as successful (or unsuccessful) as milk. My recipe provided 70 kcal/kg/d and 1.2 g protein/kgd.

Michael mentions phytate as an inhibitor of zinc absorption. Phytate seems to be a potent inhibitor in animal studies and volunteers from the first world. I have spent much time doing zinc stable isotope studies measuring zinc homeostasis in Malawian children who habitually consume a high phytate diet (Phy:Zn =30:1) without consuming animal products. Interesting we found that about 25% of dietary zinc is absorbed (greater than many people would predict), and this did not improve with phytate reduction. We studied this in village children and well children waiting at the hospital.

However, among children recovering from tb (with increased zinc requirements), phytate reduction was associated with increased fractional and absolute zinc aborption (41%). I am not sure if the zinc requirement is increased in phase 1 treatment of PEM (it doesn't seem like it would be), but it might be in the rapid catch up growth phase.

Mark Manary

Date: Wed, 17 May 2000 14:03:24 +0100

From: "Liana Steenkamp" <>

Subject: First phase diet in severe malnutrition


I have three questions relating to this discussion:

  1. A report in 1989 in the American Journal of Clinical Nutrition indicated that when inorganic Zn is added to Soy based diets, the body would utilize this source of Zn. Would this still be an issue (impact of phytate on Zn bioavailability) in soy/maize supplements with added inorganic ZN?
  2. What about the phytate content of maize which is very much similar to a high quality soy protein isolate. Would that not have a similar effect on Zn bioavailibility?
  3. Are there any recent bioavailability studies available - it seems that most of the studies were done more that 20 years ago when the quality of soy protein isolates used in products were poor and the phytate content higher than in products currently available?


Liana Steenkamp, M Sc Dietetics

South Africa



Note added:

Inorganic zinc added to the diets can indeed make sufficient zinc available: but this means that the diet has to be fortified with the correct amount - and not used directly.

You are correct there is also a major problem with maize in the treatment of severe malnutrition. It should never be used in the first phase. The problems with maize for the later management of severe malnutrition is not entirely explicable on the basis of zinc chelation alone (other cereals give better results) - but the reasons are unclear.

Modern soy protein isolates are mainly used as ingredients in formulations prepared for use in rich countries.

Date: Fri, 19 May 2000 18:33:29 +0100


Subject: Zn Bioavailablity with Phytate



Working in conjunction with a group in Colorado and New Zealand, we have studied zinc bioavailability in maize and maize/ soy diets in Malawi with stable isotopes. This work is in the process of publication, so you won't find any references now, but certainly you can in a few months. First we studied 2 groups of children in hospital who received a maize/ soy porridge for 10-14 d, nothing else other than a few groundnuts and fruit. One group was well children awaiting elective surgery, children with frozen arms from previous fractures, congential deformities, ect. We thought these would be similar to normal children. Children were aged 5-12 y. The phytate: Zn molar ratio was about 27:1, clearly in the range where we would expect inhibition of zinc absorption. They absorbed 24% of their dietary zinc, had adequate homeostasis, and no biochemical signs of zinc deficiency.

Reducing the phytate:Zn molar ratio to 6:1 (for 10-14 d) had no effect on absorption or homeostasis. In contrast children recovering from tb with rapid growth absorbed 24% of dietary Zn on the high phytate diet, but 40% of Zn on the reduced phytate diet, and retained more zinc on the reduced phytate diet. We concluded that even though the diet was very high in phytate, normal children adapted and maintained adequate zinc homeostasis, but in situations where the zinc requirement was increased, phytate reduction was helpful in improving zinc bioavailability. Perhaps during periods of rapid growth like infancy, pregnancy and adolescence phytate compromises zinc homeostasis?

The second study we did was in free living, well village children aged 2.5-5 y. Their diet was mostly maize, with red beans and groundnuts. They took almost no animal products in their diet. They first had zinc homeostasis studied on a high phytate diet (Phytate: Zn = 23:1), and then continued the same diet except phytate was reduced to 5:1 molar ratio by soaking maize flour and adding phytase. Again these children absorbed 24% of dietary zinc and maintained adequate homeostasis on the high phytate diet, and incurred no change in zinc status on the reduced phytate diet.

However, their iron status improved on the reduced phytate diet.

We studied indigenous maize/ soy grown in Malawi, and this probably is not the 'newer, lower phytate' foods you alluded to. If I can be of further help, let me know.

Mark Manary