The inspiration for our recent research was a simple thought: “I wouldn’t feed that to my own kid.” One of us (SBR) does research primarily on obesity, but had been asked to design a randomized trial to test a conventional ready-to-use supplementary food for improving health in children in a Guinea-Bissau, a low-income country in West Africa. Enrolling participants was underway when we broke open a few sachets to try them out. It was a revelation: although ready-to-use supplementary foods unquestionably reduce the risk of death in children with severe-acute malnutrition, we were shocked at the sky-high sugar and calorie density— so similar to candy—and couldn’t help worrying that they could entrain unhealthy food preferences, leading to negative effects on long-term health.
Ready-to-use supplementary foods have developed the aura of being a magic bullet against malnutrition, but a close look at their formulation revealed that there are bigger concerns than a theoretical influence on the brain’s food reward system. Many modern principles of healthy nutrition are seemingly deprioritised in favour of using low-cost (and nutrient-weak) ingredients fortified with an incomplete list of vitamin and mineral powders. Knowing that many studies had tried—and failed—to improve cognition in undernourished children with this type of supplement led to the further thought that maybe a radically different type of supplement, providing more complete nutrition including protective antioxidant and anti-inflammatory ingredients, could do better.
It is rare to be able to take advantage of lightbulb moments in science, but in this case the stars were aligned. The emerging recognition that nutrition is far more than the sum of calories, protein and essential micronutrients was channeled into concrete plans for a new food supplement that might in theory support regenerative improvements in the brain. Our research partners in Africa were interested in testing the new food, especially since several of the ingredients could be purchased locally with added benefit to the local economy, and Boston philanthropists provided support through gifts to Tufts University.
One of the critical hurdles we had to overcome was how to detect changes in brain health. It is difficult to measure cognition in children living in communities with low levels of literacy that have no familiarity with western games and toys, but Tufts research psychologist Paul Muentener created an effective adaptation of a standard test of executive function. We also wanted to include a more direct measures of brain health, recognizing that any trial challenging conventional nutrition wisdom would be held to a high standard. MAF has been developing non-invasive methods to measure cerebral blood flow and oxygen metabolism using hand-held near-infrared spectroscopy devices, and was convinced enough about the potential of this project that she not only agreed to collaborate, but to fund her own travel to bring the specialized equipment and a colleague to Guinea-Bissau.
The strength of the effect we saw was remarkable: with just 23 weeks of supplementation, there was a substantial improvement in executive function, and more than doubling of brain blood flow in a region that is especially vulnerable to malnutrition. Publication of these strong results opens up many new directions. Replication of findings is fundamental to science, and the villagers who participated in the trial are eager to get the supplement back for extended implementation combined with educational enrichment to boost learning, and also want to try it in pregnant mothers. We also hope to do more research to optimize the formulation, and test other groups at risk of unhealthy nutrition and impaired cognition in Africa and high-income countries, including older adults.
Beyond the science, we hope that these results will encourage difficult—but nevertheless important—discussions about the goals of supplementary nutrition programs, including government food assistance for low-income families in affluent countries. Should they continue to focus on preventing death in the maximum number of children with the least expensive products, or based on these results start to move towards a system that balances consideration of cost with long-term brain and bodily health? And shouldn’t our articulated nutrition goals be the same for all children, irrespective of whether they live in Africa, affluent Boston, or low-income inner cities? If not, why not?
Susan B. Roberts is a professor of nutrition at Tufts University, and adjunct professor of psychiatry and scientific staff member in Pediatrics at Tufts Medical School, Boston MA.
Maria Angela Franceschini is a professor in radiology, Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston MA
Augusto Braima de Sa is executive director of International Partnership for Human Development in Guinea-Bissau.
Competing interests: Tufts University has filed a patent application claiming subject matter covered by this paper, and MAF has a financial interest in a company developing technology for assessing and monitoring cerebral blood flow. The research was conducted in accordance with institute conflict of interest policies; SBR was blinded to randomization and had no role in outcome testing or data analysis, and MAF was blinded to subject randomization during oversight of outcomes testing.