Ready-to-use foods restored moderate malnutrition equally well, Ethiopia trial finds

For children with moderate acute malnutrition in Ethiopia, a single daily sachet of ready-to-use therapeutic food worked about as well as the standard supplementary food, and doubling the dose added only a marginal gain at a large cost in product, a randomised trial has found [s1]. The results, from the MODAM-MAM trial, were published in PLOS Medicine on 11 August [s1].

Moderate acute malnutrition affects over 30 million children globally and substantially increases the risk of illness and death [s1]. Globally in 2022, an estimated 45 million children under 5 were wasted — too thin for height — and nearly half of deaths among children under 5 are linked to undernutrition, most of them in low- and middle-income countries, the World Health Organization says [s2]. In 2023, WHO recommended lipid-based nutrient supplements for children needing supplementation for moderate malnutrition, either ready-to-use supplementary food (RUSF) or ready-to-use therapeutic food (RUTF) — but left open which product, and what dose, works best [s1].

What the trial tested

MODAM-MAM was a three-arm, parallel, individually randomised controlled trial [s1]. It enrolled children aged 6 to 59 months with moderate acute malnutrition, defined as a mid-upper arm circumference of 11.5 to 12.4 cm or a weight-for-height z-score between minus 3 and minus 2, without oedema [s1].

The children were randomised to one of three regimens: one 540-kilocalorie sachet of RUSF per day, the de facto standard of care; one 500-kilocalorie sachet of RUTF per day; or two sachets of RUTF per day [s1]. Both RUTF arms were tested for non-inferiority to the standard RUSF arm, using a prespecified margin of 6 percentage points [s1]. The primary outcome was anthropometric recovery, defined as reaching both a mid-upper arm circumference of at least 12.5 cm and a weight-for-height z-score of at least minus 2 across two consecutive visits within 16 weeks [s1].

The results

A total of 2,414 children were analysed in the intention-to-treat analysis [s1]. Recovery proportions were 84.8% (679 of 801) for the standard one-sachet RUSF arm, 85.0% (674 of 793) for one sachet of RUTF, and 88.1% (721 of 818) for two sachets of RUTF [s1].

Measured against the standard of care, the risk difference for recovery was plus 0.2 percentage points for the single RUTF sachet (95% confidence interval minus 3.3 to 3.7; p = 0.944) and plus 3.4 percentage points for the double RUTF dose (95% CI 0.0 to 6.7; p = 0.050) [s1]. Both intervention arms met the non-inferiority criteria [s1]. In plain terms, one sachet of therapeutic food matched the supplementary food almost exactly, and two sachets edged ahead by a small margin that only just reached statistical significance.

Anthropometric gains and the median length of stay, 56 days, were similar across the arms [s1]. The cost side, though, was not. Ration use was comparable for the single-sachet RUSF and RUTF arms, but the two-sachet RUTF regimen required 1.6-fold more product [s1].

Why the dose question matters

The finding lands on an operational choice that programmes make constantly. RUTF and RUSF are both lipid-based supplements, but supply, cost and the logistics of getting boxes of sachets to clinics in low-resource settings all hinge on how much product each child needs. If one daily sachet of therapeutic food recovers children as well as the standard supplementary food, programmes gain flexibility to use whichever product they can source, without trading away results. And the modest extra recovery from doubling the dose has to be weighed against needing 1.6 times as much of a supply-constrained commodity — a trade that, at scale, decides how many children a fixed budget can reach.

What to hold in mind

The trial evaluated a single RUSF formulation, so its result speaks to that product rather than to every supplementary food on the market, the authors note [s1]. They also flag that case-finding happened earlier than is typical, because of intensive screening built into the study — which can make recovery look easier than it does in routine practice, where children often present later and sicker [s1]. The trial was conducted in one country, and malnutrition's drivers and comorbidities vary across settings.

There is also a definitional point the trial quietly sharpens. RUTF and RUSF sit either side of a line that programmes draw between treating severe and moderate malnutrition, but both are lipid-based nutrient supplements, and WHO's 2023 recommendation already allows either product for children needing supplementation for moderate acute malnutrition [s1]. Evidence that a single therapeutic-food sachet recovers moderately wasted children as well as the supplementary ration blurs that line usefully: a clinic that runs short of one product, or can source the other more cheaply, has a defensible basis for substituting it. With 45 million children under 5 wasted worldwide in 2022, and nearly half of all under-five deaths linked to undernutrition, that flexibility is not a small administrative gain [s2].

What MODAM-MAM adds is a direct, head-to-head answer to a question WHO's 2023 guidance left open: for moderate acute malnutrition, one daily sachet of therapeutic food is not inferior to the standard supplementary ration, and paying for a second sachet buys very little.

Sources

• Comparative effectiveness of lipid-nutrient spread supplementation regimens for moderate acute malnutrition in Ethiopia: The MODAM-MAM individually randomized controlled trial — PLOS Medicine, 11 August 2026
• Malnutrition (fact sheet) — World Health Organization