Research report Malawian mothers’ attitudes towards the use of two supplementary foods for moderately malnourished children Valerie L. Flax a,b, *, Chrissie Thakwalakwa b , John Phuka b , Ulla Ashorn a,b , Yin Bun Cheung c , Kenneth Maleta d , Per Ashorn b,e a School of Public Health, 33014 University of Tampere, Finland b Department of International Health, University of Tampere Medical School, 33014 University of Tampere, Finland c Singapore Clinical Research Institute, Nanos #02-01, 31 Biopolis Way, Singapore 138669, Singapore d Department of Community Health, College of Medicine, University of Malawi, Private Bag 360, Blantyre 3, Malawi e Department of Paediatrics, Tampere University Hospital, 33014 University of Tampere, Finland Introduction Moderate malnutrition affects a large number of children younger than five years in low-income countries (United Nations Children’s Fund, 2008), and contributes to child mortality and disease burden (Black et al., 2008). It is also associated with increased morbidity (Mata, Kromal, Urrutia, & Garcia, 1977; Scrimshaw & SanGiovanni, 1997), and if left untreated may progress to severe acute malnutrition. Supplementary feeding programs to treat moderately malnourished children have existed for decades, and have typically used micronutrient-fortified corn– soy blend (CSB) (Dijkhuizen, 2000; Hoppe et al., 2008). Similar types of fortified cereal or cereal/legume mixtures tested in Africa and Asia have had inconsistent effects on child growth (Bhandari et al., 2001; Dewey & Adu-Afarwuah, 2008; Lartey, Manu, Brown, Peerson, & Dewey, 1999; Oelofse et al., 2003; Owino et al., 2007). Lipid-based nutrient supplements (LNS) are ready-to-use foods that are attractive food supplements for malnourished children because they can supply adequate nutrients in a hygienic form that requires no cooking (Briend, 2002). LNS are effective for treating severe acute malnutrition in children at home (Manary, Ndekha, Ashorn, Maleta, & Briend, 2004; World Health Organization/World Food Programme/United Nations System Standing Committee on Nutrition/The United Nations Children’s Fund, 2007), and some evidence that LNS improves the growth of moderately malnour- ished children is now available (Adu-Afarwuah et al., 2007; Matilsky, Maleta, Castleman, & Manary, 2009; Phuka et al., 2008). There is strong interest in the international community in the possibility of using LNS for the prevention and treatment of moderate malnutrition in children (The PLoS Medicine Editors, 2008). Large trials comparing different versions of LNS to CSB or other supplements in this target group are underway, but information about similarities or differences in maternal attitudes towards the two foods is lacking. Appetite 53 (2009) 195–202 ARTICLE INFO Article history: Received 13 February 2009 Received in revised form 12 June 2009 Accepted 14 June 2009 Keywords: Maternal attitudes Acceptability Supplementary food Lipid-based nutrient supplements Corn–soy blend Underweight Children Africa ABSTRACT The efficacy of lipid-based nutrient supplements (LNS) versus corn–soy blend (CSB) in promoting the growth of moderately malnourished children is currently being tested, but information about maternal attitudes towards the two supplements is lacking. This research studied 504 Malawian mothers’ attitudes about LNS and CSB through exit interviews completed at the end of three 12-week clinical trials and compared differences between the groups. Exploratory analyses of factors associated with withholding of supplements during fever, diarrhea, and cough were performed using logistic regression. Mothers generally had similar, positive attitudes towards LNS and CSB. Both supplements were said to be highly acceptable, children learned to eat them within two weeks, and mothers were willing to use them again. Mothers in the LNS group were reportedly more likely to withhold supplements from their children during cough, due to its sweetness, and were willing to pay more for a one-week supply of supplement than mothers in the CSB group. Maternal literacy was negatively and child’s weight-for- height z-score was positively associated with withholding of supplements during illness. Our results indicate that the sweetness in LNS should be reduced, and programs using supplements in Malawi could include advice on appropriate feeding of supplements during illness. ß 2009 Elsevier Ltd. All rights reserved. * Corresponding author at: Department of International Health, University of Tampere Medical School, Finn-Medi 3 Building, FIN-33014 University of Tampere, Finland. E-mail address: valerie.flax@uta.fi (V.L. Flax). Contents lists available at ScienceDirect Appetite journal homepage: www.elsevier.com/locate/appet 0195-6663/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2009.06.008