Design and optimisation of a tailored nutrient-dense functional recipe to modulate severe acute malnutrition in children aged 6–59 months in Waliso, Ethiopia

Design and optimisation of a tailored nutrient-dense functional recipe to modulate severe acute malnutrition in children aged 6–59 months in Waliso, Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Design and optimisation of a tailored nutrient-dense functional recipe to modulate severe acute malnutrition in children aged 6–59 months in Waliso, Ethiopia Christine Murphy, Ihab Tewfik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8997306/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Introduction : Severe acute malnutrition (SAM) remains a critical public health crisis in Ethiopia, affecting 1.2 million children in 2023 alone. This study aimed to conceptualise a nutrient-dense, tailored-functional recipe (TFR) to modulate SAM in children 6 to 59 months in Waliso, Ethiopia. Methods: The study was conducted in two phases: a literature review and fieldwork for data collection and recipe development. A scoping review, based on the Campbell systematic review protocol, identified current approaches to SAM intervention. A market survey was conducted to assess local food security, including availability, pricing and seasonality of ingredients. Results: The literature review highlighted best practices in SAM treatment, including nutrient requirements, recovery indicators, and relapse prevention, such as maternal support and access to health services. Guided by this evidence, a nutrient-dense recipe prototype, iTEFF, was developed. Ingredient selection was based on nutritional value, availability, and affordability. The final recipe included mangoes (50 g), avocados (100 g), kale (40 g), red kidney beans (60 g), and teff (50 g), with a total of 300 g per serving, costing £0.53 per serving. Conclusion: The study identified key gaps in current SAM interventions, particularly the need for sustainable, locally sourced solutions to reduce dependence on foreign aid. The iTEFF recipe provides at least 50% of the recommended nutrient intakes (RNIs) for essential nutrients needed for recovery in children under five. It represents a culturally appropriate, cost-effective, and scalable option for SAM management. Future research should focus on testing iTEFF in community settings to evaluate efficacy and expanding the market surveys to support broader implementation. Severe acute malnutrition tailored-functional recipe (TFR) children 6 to 59 months Ethiopia nutrient Figures Figure 1 Figure 2 Introduction Ethiopia: Africa’s Oldest Country The Federal Democratic Republic of Ethiopia in East Africa is home to 126.5 million people, according to recent census data, with 14% of the population under 5 years of age (World Bank, 2023). Ethiopia has 12 regions, known as “regional states”, with 80% of Ethiopians living in rural areas and struggling to access essential healthcare services, food security, and clean water (WHO, 2023). The average annual income is ~$1000, with >20% of the population living on less than $2 USD per day, and nearly 20 million are food insecure (World Bank, 2024; United Nations, 2022). Among children under five, 25% live below the poverty line, with malnutrition disproportionately affecting those from poor and remote communities (UNICEF, 2023). Spanning >1,000,000 square kilometres, Ethiopia is the continent’s 10th-largest and 2nd-most populous country, with a rich agricultural history embedded in international trade (Embassy of Ethiopia, 2024; Asefa et al., 2020). The city of Waliso is in the southwest of the largest region, Oromia. Scale of the Problem Malnutrition, defined as “deficiencies, excesses or imbalances” in energy and nutrient intake, affects nearly 150 million children globally (WHO, 2024). Severe acute malnutrition (SAM), characterized by a “weight-for-height z-score below -3 standard deviation, bilateral pitting oedema, or a mid-upper arm circumference <115 mm”, affects over 18 million children and contributes to more than 300,000 child deaths annually (WHO, 2023). In Ethiopia, the economic burden of child undernutrition is significant, estimated at 16.5% of the national GDP (WFP 2022). Nationally, 39% of children under five are stunted, 21% underweight, and 7% wasted (UNICEF, 2023). Over 5 million of these children are affected by acute malnutrition, with the highest rates in the Southern Nations, Nationalities and Peoples’ (SNNP) and Somali regions, as shown in Figure 1 (Mihret et al., 2022; Seboka et al., 2021). Stunting has declined from 58% in 2000 to 38% in 2016, but little progress has been made since, with a prevalence of 37% in 2019 (GNR, 2023; EPHI, 2021). Meanwhile, the under-five mortality rate (U5MR) dropped from 123 per 1,000 live births to 59 in 2019, a 52% decrease largely due to improved healthcare access (Yemane, 2022). Still, the U5MR remains 46.5, nearly 1.3 times the global average (UNICEF, 2023). Impact of SAM on the Nutritional Status of Children Under Five SAM can have devastating effects on the immediate and lifelong health of children (Gebreegziabiher, et al., 2024). Acute effects of SAM impair the immune system, significantly increasing susceptibility to infections and illnesses, creating a double burden of disease (Gizaw et al., 2018). Children will also present with micronutrient deficiencies (MND), including vitamin A, iron, iodine and zinc, with one in every five Ethiopian children entering grade school with at least one MND (Vresk et al. , 2025; Gebeye et al., 2024). The long-term effects of SAM, including impaired cognitive development affecting academic and professional outcomes, can directly impact the economic potential of countries with high SAM prevalence (Mwene-Batu, et al. , 2020). Current Interventions and Gaps in Ethiopia’s Treatment of Severe Acute Malnutrition Over the last two decades, Ethiopia has addressed hunger and malnutrition with targeted programmes and policies to support interventions (Ministry of Health-Ethiopia, 2024). The majority of programmes are established by the national government and designed to support the Sustainable Development Goals 2030, including SDG 2, which aims to eliminate hunger worldwide (United Nations, 2025). Current interventions targeted at child malnutrition in the country are discussed below. The Seqota Declaration: Introduced in 2015, this policy aims to end child malnutrition in Ethiopia by 2030 through nutrition-focused, behaviour-driven programmes (The Seqota Declaration, 2015). A 2018 survey showed challenges in healthcare access and household technology (EPHI, 2018). By 2024, nearly 110,000 children, over 90,000 under five, avoided stunting (Johns Hopkins University, 2024). Continued progress depends on sufficient funding (FAO, 2021). Ethiopian Health Sector Transformation Plan (HSTP-II): The national health strategy was updated in 2021 and aims for universal healthcare, with a focus on child nutrition (FAO, 2024). Achievements include 88% of health facilities providing guideline-driven SAM treatment and 76% vitamin A coverage in under-fives (Croke, 2020). Challenges remain in rural access and funding (Assefa, et al., 2020). National Nutrition Programme (NNP): Since 2008, NNP has focused on food security in the first 1000 days of life and Community Management of Acute Malnutrition (CMAM) among its objectives (Ministry of Health-Ethiopia, 2024). Stunting dropped from 58% to 37% and underweight from 41% to 21% from 2000 to 2019 (EPHI, 2020). However, less than 15% of children under two meet the recommended nutritional intake, and over 20% of the population remains undernourished (Woldeyohannes et al., 2023). Despite ongoing efforts, SAM affects nearly 15% of Ethiopian children under five each year, contributing to around 45% of child deaths through direct or indirect links to undernutrition (Belay, et al., 2023; Anato, A., 2022). Evidence underscores the need for sustainable, effective interventions, yet current programmes often rely heavily on foreign aid and NGOs, raising concerns about long-term reliability (Gebresilassie et al., 2023). Moreover, there is limited research on using locally available foods in SAM treatment, an approach that could enhance both sustainability and food security (Belay, et al., 2022; Amadou and Lawaii, 2022). One promising solution is the use of tailored-functioned recipes (TFR), defined as organic, accessible, and economical foods, often consumed in concentrated forms with verified physiological therapeutic effects exceeding standard nutrition (Amlogu, et al., 2016). Given the potential of TFRs in addressing nutrition-related diseases, this study proposes the following aim and objectives: Aim: To formulate and optimize a nutrient-dense, tailored functional recipe (TFR) to modulate severe acute malnutrition (SAM) in children 6 to 59 months old in Waliso, Ethiopia Objectives: Evaluate current best practice on nutrition interventions of severe acute malnutrition (SAM) in children 6 to 59 months old in Africa. Utilize an evidence-based market survey of local, indigenous foods to identify ingredients that are sustainable and food secure for a cost-effective, tailored functional recipe [TFR]. Hypothesis: A nutrient-dense, tailored-functional recipe developed using local, indigenous food sources will provide a more effective and sustainable solution in improving the nutritional status of children 6 to 59 months with severe acute malnutrition compared to standard therapeutic foods. Significance of the Study Public health, “the science and art of preventing disease, prolonging life, and promoting health”, guides interventions like this study, which aligns with the Sustainable Development Goals (SDG), including SDG 2 (zero hunger) and SDG 3 (health and well-being for all) (Faculty of Public Health, 2024; UN, 2024). Developing culturally appropriate interventions supports improved health outcomes, policy development, and multi-sectoral engagement, which ultimately can aid in disease prevention and health longevity for millions of Ethiopian children at risk for SAM. Scope of the Study A robust, evidence-based literature review following the Campbell systematic review protocol identified current best practices for treating uncomplicated severe acute malnutrition in children aged 6 to 59 months. Infants under 6 months are recommended to be exclusively breastfed for optimal nutrition and protection against infections (WHO, 2025). Children with complicated SAM, with the addition of medical complications, require inpatient care due to their fragile condition (Lencha, et al., 2024). Thus, this study focused on children aged 6 to 59 months with uncomplicated SAM to develop the tailored-functional recipe (TFR) prototype. Nutrient requirements, including macronutrients and condition-specific micronutrients, were established from the scoping review, with emphasis on non-animal food sources to ensure economic viability for the target population. Additionally, an evidence-based local market survey was conducted, informed by Save the Children’s Cost of Diet (CotD) framework, to identify indigenous foods that are seasonally and sustainably available in Waliso, Ethiopia (Save the Children, 2024). Methods Rationale for methodology The proposed study was implemented in two phases, including a literature review and fieldwork for data collection and recipe development. An evidence-based market survey was selected as the primary research tool and provided comprehensive data on local foods, including retailer prices, availability, and seasonality. The tool was chosen based on previous studies with successful objectives using this approach (Kapoor, 2016; Amlogu, et al., 2016; Azagba-nyako, 2017). The survey framework was guided by ‘The CotD’, a research software tool developed by Save the Children UK in 2013 to assess the cost and availability of indigenous foods among low-income populations (Save the Children, 2024). Phase 1: Literature Review and Analysis A scoping review of the current literature was conducted using the Campbell systematic review protocol to provide insight into contemporary approaches to SAM interventions for children aged 6 to 59 months. Attention was given to interventions in developing countries to fine-tune study design and include macronutrient and micronutrient recommendations for the target population. Research search engines included Web of Science and PubMed, with the inclusion criteria of articles published between 2020 and 2025, peer-reviewed literature, and evidence-based reports published by reputable organisations (e.g., the World Health Organisation, UNICEF). Keywords for the literature search were based on the PICO framework (Table 1), identifying the population, intervention, comparison, and outcome, using Boolean operators to enhance the quality of results. All articles that met the inclusion criteria were included in a PRISMA flow chart (Figure 2) to support the selection of articles for study development included in the scoping review summary (Table 2). Table 1: PICO Framework ( Adapted from: Health Science, 2009 ) Element Descriptives P opulation Children 6 to 59 months in Africa I ntervention/Exposure Severe acute malnutrition; nutrition interventions for child malnutrition C omparison Standard interventions (e.g. RUTF) versus locally sourced foods/diets O utcome Alleviated and/or resolved SAM symptoms in children 6 to 59 months Table 2: Scoping Review Summary Author (s) Title Year Objective Methods Major outcomes Author’s critical views and recommendations for improvement Tsegaye, et al. Predictors of time to recovery from uncomplicated severe acute malnutrition among 6-59 months children treated in outpatient treatment in health posts of Nagele Arsi district: a retrospective cohort study 2022 Identify factors in recovery time from SAM in 6 to 59 months old children in Nagele Arsi district (Ethiopia) Retrospective cohort study on 300+ children over two-year period. Statistical analysis of recovery time from SAM treatment Determinates of recovery time including vitamin A supplementation, deworming, antibiotics and co-morbidity. Recovery time with Sphere Standards Strength(s): Identified area with limited data on factors in SAM recovery (e.g. Nagele Arsi, South Ethiopia). Outcomes compared against SPHERE standards. Limitation(s): Only used MUAC score and oedema criteria to determine SAM (did not include anthropometric markers). Did not assess family demographics (as many studies have including maternal education as a significant factor in SAM recovery). Some records were incomplete with needed study variables and were removed from analysis. Way forward: Results attributed to specified area (e.g. Nagele Arsi district) and would need to be expanded to additional areas for translatability. Follow-up studies should include children unidentified/untreated without access or attendance at local health clinics. Incorporate family demographics into data collection/analysis as previous studies have identified these variables as impactful to SAM recovery. Wondie, et al. Time to recovery and its predictors among children aged 6-59 months with severe acute malnutrition admitted to outpatient therapeutic program in Southwest Ethiopia: retrospective cohort study 2022 Estimate recovery time from outpatient treatment for SAM and determining factors for children 6-59 months Retrospective cohort study on 588 children. Statistical analysis of recovery time from SAM Early detection of SAM and additional morbidities (malaria, diarrhoea) determined as significant factors in recovery time Strength(s): Identified gap in research on time to recovery from SAM in OTP centres. Significant sample size of 588 children. Limitation(s): Incomplete records were excluded due to retrospective study design. Unable to assess potential factors not collected in the data (e.g. caregiver education, exposure to breastfeeding, nutritional status of mother) Way forward: Improvement to CHW trainings in OTP centres to meet SPHERE standard recovery (>75% vs study outcome of 54.4%). Strengthen early detection and management of concurrent illnesses. Bizuneh, et.al. Time to recovery from severe acute malnutrition and its predictors among children aged 6-59 months at Asosa general hospital, Northwest Ethiopia. A retrospective follow-up study 2022 Determine time to recover from SAM and determining factors in children 6 to 59 months in Benishangul Gumuz, Ethiopia Retrospective study from 2015 to 2019 on 454 children. Statistical analysis to determine recovery time and factors. Factors impacting recovery time including routine follow-up, HIV status and type of malnutrition (marasmus vs marasmus-kwashiorkor) Strength(s): Identified gap in research on recovery time in children under 5 with SAM. Included data over 5-year period. Significant sample size of 454 children. Limitation(s): Missing data due to retrospective study required some participant records could not be used. Difficulty translating outcomes to rural areas due to study location in urban city hospital. Way forward: Monitoring nutritional status of children with HIV to improve health outcomes. Addition of prospective studies to limit incomplete records. Ongoing optimisation of SAM treatment centres to improve life expectancy. Gemechu, et al. Determinants of severe acute malnutrition among children aged 6-59 months in the pastoral community of Liban District, Guji Zone, Oromia Regional State, Southeastern Ethiopia: a case-control study 2021 Factors in severe acute malnutrition among children 6 to 59 months in pastoral area of Ethiopia Case-control study (88 cases; 117 control) using structured interviews and anthropometric measurements Factors determining SAM diagnosis included maternal education, underweight, family size and inappropriate infant feeding practices Strength(s): Study focused on pastoral communities that are known to have high prevalence of SAM with lack of treatment due to location and limited healthcare services and minimal research completed. High participation rate of >95%. Limitation(s): Results were dependent on participant self-report which can include recall bias and socially favourable responding. Way forward: Collect multiple different qualitative data from different stakeholders to support overarching themes. Request community members as surveyors to support improved participant responses and comfortability. Teshale, et. al Relapse of severe acute malnutrition among children discharged from outpatient therapeutic program in western Ethiopia 2023 Determine prevalence of recurrent SAM post-discharge in children 6 to 59 months in Western Ethiopia Cross-sectional study on 208 children 6 to 59 months discharged from outpatient clinic deemed as “cured” of SAM 10.1% relapse; factors involved including inadequate supplementary food post-discharge, mothers with limited education on Infant and Young Child Feeding (IYCF) and premature discharge Strength(s): Identified gap in research on post-discharge relapse of SAM. Use of cross-sectional study design to determine prevalence of relapse to support future programme and policy development. Mixed-method approach for comprehensive analysis of the situation. Limitation(s): Unable to determine causal relationship with cross-sectional approach. Risk of recall bias from caregivers with questionnaire tool. Study conducted in specific area/location creating limits with generalizing to other populations/communities. Way forward: Importance of using anthropometric and oedema criteria to determine discharge protocol. Incorporation of nutrition education provided to caregiver in reducing SAM relapse. Bune, et al. Recovery time and predictors of severe acute malnutrition in children aged 6-59 months via an outpatient therapeutic program in Borena zone: A prospective cohort study 2025 Determine recovery times and factors in children 6 to 59 months with SAM in Southern Ethiopia Prospective study on 322 children treated at outpatient clinics. Structured questionnaires with statistical analysis Primary factors impacting recovery time included earlier treatment with Amoxicillin with vomiting, diarrhoea and oedema delaying recovery time Strength(s): Use of primary data with mixed-method approach. Prospective approach tracking participants in real-time. Identified need for research in OTP outcomes for SAM children, specifically in rural areas. Limitation(s): Inconsistency in literature on defining SAM recovery creating challenges in translating outcomes and verifying results. Monitoring only completed for one-month. Way forward: Develop strategies that combine nutrition therapy and infection intervention for improved outcomes. Develop programmes that are specific to location/region addressing the challenges and barriers in the area to enhance recovery. Feleke, et al. Time to recovery and its predictors among children aged 6-59 months having uncomplicated severe acute malnutrition attending an outpatient therapeutic program in Northeast Ethiopia: prospective cohort study 2024 Determine factors in recovery time from SAM in outpatient clinics in Northeastern Ethiopia for children 6 to 59 months Semi-structured questionnaires and anthropometric measurements from February to July 2021 on 356 children Primary factors influencing recovery time including utilisation of health promotion services by mothers including nutrition counselling and overall maternal education including literacy Strength(s): Identified the gap in research on factors influencing recovery time from SAM. Significant sample size of 356 children. Semi-structure questionnaire delivered weekly for 5 months. Longitudinal prospective study design allowed for causal relationships to be determined between study variables. Limitation(s): Potential impact of seasonal influences on OTP admissions and RUTF use (study conducted during low/no harvest season). Although followed weekly, study was only 5 months in duration. No ongoing follow-up to determine potential relapse or health outcomes post-discharge. Way forward: Develop programmes that support maternal education and nutrition counselling for prospective mothers (incl. Growth Monitoring Programmes-GMP). Conduct over a full agricultural year to determine impact of seasonal variations. Lencha, et al. Severe Acute Malnutrition among Children in Bale Zone Southeast Ethiopia: Treatment Outcome and its Determinant Factors 2024 Determine outcomes of SAM treatment on children 6 to 59 months in Southeast Ethiopia Retrospective cross-sectional study in multiple institutions in the Bale Zone; statistical analysis completed on data to identify factors in SAM outcomes Primary factors influencing positive treatment outcomes included: maternal education, anaemia, child’s age and use of NG tube in treatment protocol Strength(s): Recovery from SAM was 93.2% (higher than the international standard). Study methods were comprehensive using multivariate analysis. Limitation(s): Unexplained discrepancy in recovery time in differing parts of Ethiopia. Differing outcomes in recovery across multiple studies related to maternal awareness of malnutrition in children and role of deworming. Way forward: Incorporate qualitative data collection (e.g. biomarkers, medical history, etc.) to strengthen comprehensive understanding of factors in SAM recovery. Banda, et al. Report of a Pilot Program Using a Milk-Free Ready-to-Use Therapeutic Food Made from Soya, Maize, and Sorghum to Treat Severe Acute Malnutrition 2021 Assess effectiveness of non-milk RUTF on SAM treatment in CMAM program in Malawi Non-milk RUTF tested on 742 children 6 to 59 months old. Assess recovery time within Sphere Standards as an alternative to standard RUTF Non-milk RUTF alternative met Sphere Standards for recovery time and is an effective alternative to standard RUTF due to cost and local availability of ingredients Strength(s) : Adhered to SPHERE standards. Development of a plant-based RUTF using foods commonly found in sub-Saharan Africa without common allergens (e.g. peanut, milk) Limitation(s ): Study completed in area with all elements of CMAM integrated into the community including supplementary feeding programs (SFP) for follow-up after discharge from OTP. Unable to determine if therapeutic food translates to populations/communities without well-established CMAM programs. Way forward: Develop additional RUTF recipes using local foods from additional countries and communities to determine translatability. Test plant-based RUTF in communities without well-established CMAM (e.g. without SFP follow-up post-OTP discharge) to determine if outcomes are similar for children/participants. Yitayew, et al. Acute malnutrition relapse and associated factors among 6-59 months old children treated in the community-based management of acute malnutrition in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia 2024 A cross-sectional study to determine factors in SAM relapse of children 6 to 59 months enrolled in CMAM program in Northeast Ethiopia Data collected on 318 children from April to May 2021. Statistical analysis assessed relapse in relation to several factors including child age, MUAC at discharge, diarrhoea at discharge and family wealth status Over one-third of participants experience SAM or MAM relapse. Determined importance of health education and counselling services to improve maternal support for mothers with children diagnosed with SAM Strength(s): Identified gap in research on factors in SAM relapse in children. Use of WHO Anthro 3.2.2.2 software for analysis of z-scores. Participants followed across three different towns for broader understanding of CMAM programming in the areas. Limitation(s): Unable to determine causal relationship with cross-sectional study design. Only identified relapse rate between 1 to 12 months and unable to translate to relapse at various points in the 12-month period. Mothers self-reported immunization status and presence of diarrhoea with potential for recall bias. Way forward: Research on MUAC discharge criteria to determine any changes/improvements to minimize risk of relapse. Develop programmes that include health and nutrition education for mothers/caregivers with children post-SAM and at-risk for SAM. Girma, et al. Nutrition status and morbidity of Ethiopian children after recovery from severe acute malnutrition: Prospective matched cohort study 2022 Determine factors in malnutrition relapse in children 6 to 59 months discharged from CMAM programs in Ethiopia Prospective cohort study on 215 post-SAM and 215-non wasted children from September 2013 to September 2015. Statistical analysis on data to identify factors Relapse in post-SAM cases was 14 times higher compared to non-wasted children. Unable to identify factors impacting relapse but recommended further research on post-discharge interventions supporting catch-up growth and management of comorbidities Strength(s): Identified need for research on post-SAM recovery long-term health implications. Results recognized need for post-discharge interventions to improve long-term quality of life and minimise risk of early death post-SAM recovery. Followed participants monthly for 12 months. Limitation(s): Conflicting studies show post-SAM follow-up only need for 3-month period. Cost of implementing long-term follow-up programmes following OTP (e.g. Growth Monitoring and Promotion programmes-GMP) in economically constrained communities. Way forward: Additional longitudinal studies to support outcomes in lesser understood research area. Advocating for funding for comprehensive CMAM programmes to address benefits of long-term follow-up in post-SAM children. Teshale, et al. Evaluation of the outpatient therapeutic program for severe acute malnourished children aged 6-59 months implementation in Dehana District, Northern Ethiopia: a mixed-methods evaluation 2022 Evaluate the effectiveness of outpatient therapeutic programs (OTP) in SAM treatment in rural Ethiopia on children 6 to 59 months Cross-sectional, mixed-method study evaluating 39 indicators with 422 mothers and 384 children enrolled (with acute malnutrition). Statistical analysis on records and interviewer-guided questionnaires with maternal participants for thematic evaluation OTP judged on availability, compliance and accessibility. Judgement was deemed “fair” with need for improvements. Primary concerns with vitamin A, folic acid and antibiotics provided below recommended standards Strength(s): Mixed-method study design providing comprehensive understanding of research aim. OTP implementation as 78% with trained health care providers, ORS and RUTF available at all health sites. Limitation(s): The evaluation focused on a limited area of OTP implementation likely impacting outcomes. Study also noted concerns with the Hawthorne effect during patient appointments/engagement with providers (initial 3 observations were removed from each post were not used in data analysis to limit this effect). Way forward: Develop and analyse a comprehensive framework for assessing OTP implementation. Use anonymous or confidential assessment tools for patient-provider interactions to reduce bias. Monitor follow-up to determine long-term impacts and outcomes of OTP intervention. Phase 2 : Local Market Survey Development and Implementation The market survey identified indigenous foods based on four evaluation areas: accessibility, affordability, availability, and sustainability. Seasonality of local foods was identified to highlight any barriers to agriculture throughout the year. Due to travel warnings issued by the U.K.’s Foreign, Commonwealth and Development Office (FCDO) in 2025, there were active travel restrictions at the time of the study proposal. Although Ethiopia consists of 12 regions with notable similarities and differences in diet, it was deemed best to survey three local markets surrounding the city centre in the Waliso District due to limited safety risks and previous connections with the University of Westminster (Jateno, et al. , 2023). The data collection method included physical observation of available food items, including costing, photographs, and availability within the local market area. A legend was developed, as shown in Table 3, to assist in determining the level of market availability. Ingredients observed as available in at least two market areas, or more, were included in recipe consideration to ensure accessibility for the target population. A cost-benefit analysis was conducted [see Discussion section: Economic Value of iTEFF], assessing the retailer price of items based on the price per kilogram of the food items to support the economic benefit of the recipe prototype. Table 3: Identification of Market Availability Identifying Marker Availability Level + Available in 1 market area or < ++ Available in 2 market areas or < +++ Available in all 3 market areas Foods included in the survey were selected based on widely consumed regional staples (EHNRI, 1998), using a checklist informed by CoTD-validated tools (CoTD, 2024). The checklist was completed through visual observation and real-time conversations with vendors in Waliso’s market areas, supported by the local guide who provided language translation and navigation. Prior to market days, the researcher identified likely food sources through street-level observation and cross-referenced them with the checklist. During market visits, vendors were consulted with their consent on food cost, seasonal availability, community consumption, and permission for photographs. In total, the researcher spoke to 21 vendors over the three market days attended. To remain discreet, the checklist was not carried openly during observations, and instead, notes and photos were securely recorded on a password-protected mobile device and later transferred to the electronic market survey. Data analysis and recipe prototype development were completed post-fieldwork in London. Nutrient composition of selected food items was analysed using Nutritics © software and a country-specific nutrient composition table to determine macronutrient and micronutrient content (EHNRI, 1998). Analysis was tailored to identify nutrient-dense foods that met the nutritional requirements of the target population in the SAM treatment, with the results guiding recipe formulation (WHO, 2013). Ethical Considerations, Health and Safety The study did not involve any human participants or highly sensitive data. An Ethical application ‘Part-A’ was completed as required for ethical clearance. All data was secured on password-protected equipment in a secure location. Prior to travel, the University of Westminster Field/Overseas Trip Risk Assessment form (e.g., Appendix G) was completed, with safety and risk mitigation measures addressed for travelling in the country. Below are the commitments agreed to: Respect and adherence to current local norms related to cultural customs, including respect for the local, indigenous community through actions and speech Adhering to travel warnings and recommendations while in the country, including avoiding areas of high volatility or danger. Results Phase 1: Literature Review: Nutritional Recommendations for Children 6 to 59 months with SAM The literature review identified nutrient requirements for children under five with SAM, as shown in Table 4, in line with the World Health Organisation Guidelines for the Management of Severe Acute Malnutrition in Infants and Children (WHO, 2013). The findings emphasised critical macro- and micronutrient needs essential for improving recovery from SAM, including vitamin A, key amino acids, and folic acid, in alignment with Sphere Standards (Tsegaye, et al ., 2022; Teshale, et al . 2022). These recommendations responded to the significantly increased nutritional demands of children with SAM in vulnerable contexts where food insecurity and limited access to clean water are prevalent challenges impacting health outcomes (Lencha, et al., 2024; Gemechu, et al., 2021). Recovery of healthy body composition and minimising SAM relapse were identified as crucial factors in SAM intervention (Bune, et al ., 2025; Yitayew, et al ., 2024; Teshale, et al . 2022). Table 4. Nutrient Requirements for Children 6 to 59 months with SAM (Guideline: updates on the management of severe acute malnutrition in infants and children, WHO, 2013; UNICEF, 2024) Nutrient RNI for SAM Recovery (per 100 g RUTF) Energy (kcal) 100-135 kcal/kg/d (rehabilitation phase) Carbohydrate 50-60% total energy intake Protein 10-15% total energy intake Fat 30-40% total energy intake Iron (mg) 10 mg/d Folate (µg) 150 µg/d Zinc (mg) 4.1 mg/d Vitamin A (µg) 400 µg/d RAE Vitamin C (mg) 30 mg/d The primary indicators of successful SAM intervention included maternal support, appropriate Infant and Young Child Feeding (IYCF) practices, access to health services, and recommended nutrition supplementation, as discussed in the following section. Key Indicators in Severe Acute Malnutrition Recovery and Relapse Maternal partnership in intervention and treatment : The role of mothers in the caring and support of children with SAM was undeniable. Several studies highlighted that children with 1) mothers in the home and 2) mothers able to understand and implement SAM intervention were more likely to recover from SAM and had decreased risk of relapse (Gemechu, et al. , 2021; Teshale, et. al. , 2023; Tadesse, et al. , 2021; Lencha, et al. , 2024; Yitayew, et al. , 2024). Appropriate IYCF practices: In conjunction with maternal support, appropriate IYCF practices were found to be crucial not only in treating SAM but also in preventing malnutrition in children under five. Multiple studies highlighted the need for comprehensive IYCF education, specifically among women in developing countries to support appropriate feeding practices and noted the link with improved under-five mortality rates (U5MR) in areas with robust IYCF education (Gemechu, et al. , 2021; Teshale, et. al. , 2023; Lencha, et al. , 2024). Health promotion services, including nutrition-related programming : Studies highlighted the need and benefit of ample and consistent health promotion services, specifically in providing nutrition education for caregivers of children under five years (Tadesse et. al. , 2021; Yitayew et al. , 2024). This was primarily achieved by supporting maternal education through community-based nutrition counselling starting from the time of infant delivery (Feleke, et al. , 2024). Importance of essential nutrition supplementation : Focused intervention that included specific micronutrient supplementation (e. g. vitamin A, iron, folate) and Ready-to-Use Therapeutic Food (RUTF) that meet Sphere Standards significantly improved SAM recovery and minimised relapse (Girma, et al., 2022; Bune, et al. , 2025; Bizuneh, et al., 2022; Wondie, et al., 2022; Tsegaye, et. al., 2022). This was strengthened by the use of local, sustainable foods as an alternative RUTF in communities with established CMAM programmes as an economical solution, highlighting the ongoing need for expansion in the development of these options (Banda, et al., 2021). Phase 2: Recipe Conceptualisation Recipe Determination Development of the recipe prototype was guided by nutrient requirements for the target population identified in the scoping review on SAM intervention, as shown in Table 3. Food ingredients were selected based on their nutritional benefits, price, and availability in the local market area (Araro, et al., 2020; Asefa, et al., 2020). Formulation specifically addressed key nutritional deficiencies associated with SAM, including protein, zinc, iron, and vitamins A, C and K. Each component contributes essential macronutrients and micronutrients known to support immune function, tissue regeneration, and restore body composition needed in SAM recovery (Wondie, et al., 2022). Selection was supported by evidence-based guidelines from the World Health Organisation (WHO) for SAM management and informed by the availability and cultural attenuation of local, indigenous food sources (WHO, 2013; Amadou and Lawaii, 2022). Recipe Formulation The recipe prototype, with the proposed name iTEFF , was developed using the Nutrics © software to analyse the nutrient content of individual ingredients. Analysis included adherence to recommended nutrient intake for the target population and limiting the single serving size to 300 grams per serving, as shown in Table 5. Avocados, red kidney beans, kale, teff, and mangoes were selected for inclusion in the recipe. Recipe optimisation was supported by contemporary models of recipe design and considerations, with specific attention to the use of indigenous food sources, beneficial nutrients for the target population, and cost-effectiveness within a vulnerable community (Fereno et al., 2019; Ayoob et al., 2024; World Vision International, 2021). Recipe Costing Analysis A cost analysis was conducted for the food items selected for recipe inclusion including price per 100 g serving, weight, and market location, as shown in Table 5. Pricing was based on local market information gathered during survey collection and reflective of retail cost. The total cost of individual ingredients was calculated using the average prices across all market areas, reflecting typical local pricing. Pricing fluctuations across market areas were moderate (e.g., +/- 1-2 birr), suggesting that variations are unlikely to significantly affect affordability for the target population. Ingredient weight was provided by individual retailers and could not be weighed by the researcher for verification. All food sources were observed in their raw state, either wet or dry, based on the ingredient. Table 5. Nutrient Composition and Costing Analysis of Recipe Prototype, iTEFF (Nutritics, 2025, WHO, 2023) Food Item Quantity ( w = wet, d = dry) Cost (per 300 grams) (1 Ethiopian birr = £ 0.01 ) Mangoes 50 g w (~1 medium mango) £0.04 Avocadoes 100 g w (~1 large avocado) £0.005 Kale 40 g w (~ ½ bunch) £0.04 Red kidney beans 60 g d £0.27 Teff 50 g d £0.18 Total Cost (per 300 g serving) £0.53 ( May 2025 ) Nutrient Composition of iTEFF Nutrient per 300 g % RNI per WHO Guidelines provided for SAM recovery (per 100 g iTEFF) Energy 614 kcal 16-33% Protein 24 g 33-36% Fat 18 g 28-33% Carbohydrate 77 g 16% Iron 10.3 mg 33% Folate 382 µg 84% Zinc 2.6 mg 21% Vitamin A 207 µg 16% Vitamin C 59 mg 63% Recipe Preparation The recipe prototype, iTEFF, is a mixture of wet and dry ingredients. Proposed preparation steps are provided in Table 6. The prepared recipe would be served while warm, covered to keep out flies, and any leftovers would be discarded within 2 hours of preparation. Consistency and texture would be tailored to the child’s age and developmental stage to minimise the risk of aspiration and ensure safe ingestion. Table 6. iTEFF Recipe Preparation CATEGORY INGREDIENT Dry ingredients 50 g teff Wet ingredients 50 g mango 100 g avocado 40 g kale 60 g red kidney bean 600 ml water INSTRUCTIONS Rinse teff. Place in pot with 350 ml water. Cook on low for 15 to 20 mins. Rinse kidney beans. Boil for 10 mins. Simmer for 1 to 1.5 hours until soft/tender* Cut mango and kale into bite-size pieces. Place in separate pot with 250 ml water and cook over medium heat until smooth Mash avocados and cooked kidney beans into puree/paste Add kidney beans-avocado puree and mango-kale mixture to teff. Stir until combined and simmer for 7 to 10 minutes Serve while warm (may be soup or porridge depending on consistency) *Soak kidney beans overnight, preparing ahead to expedite recipe preparation Discussion The discussion section of the report will provide overall context for the results of the scoping review, the impact of the market survey on recipe formulation, and the notable limitations of the study. This includes an enhanced understanding of the nutritional and economic benefits of the iTEFF and its potential long-term implications on the Sustainable Development Goals (SDGs). Evidence-Based Drivers of Recovery in Severe Acute Malnutrition The literature review identified primary contributors to SAM recovery as caregiver-focused nutrition education, implementation of standardised therapeutic protocols (e.g. WHO guidelines, SPHERE Standards), and the adaptation of treatment strategies to local contexts, including the use of indigenous food sources (Teshale, et al., 2023; Bune, et al., 2025). Caregiver-focused nutrition and health education contributed to greater resilience throughout SAM recovery and improved adherence to treatment recommendations, including appropriate RUTF utilisation and follow-up participation in outpatient therapeutic programmes (OTP) (Feleke, et al., 2024; Yitayew, et al., 2024). ensuring therapeutic interventions, including RUTF, align with RNI standards set by organisations such as WHO and SPHERE, were strongly linked to accelerated recovery and a lower incidence of relapse in children (Wondie et al., 2022; Tsegaye et al., 2022). The scoping review consistently emphasised the importance of developing treatment and follow-up programmes tailored to specific communities. Several studies found that locally sourced RUTF formulations were not only viable alternatives to standard products but, in some cases, outperformed them in exceeding SPHERE Standards when delivered in well-established CMAM programmes (Banda et al., 2021; Gemechu et al., 2021; Lencha et al., 2024). Despite the strong association between these factors and SAM recovery, few interventions have intentionally integrated them into program design. The proposed recipe prototype, iTEFF, directly aligns with the key factors identified as critical to effective SAM recovery. iTEFF leverages local, indigenous food sources as an alternative approach to SAM treatment, offering communities access to ingredients that are both locally available and economically viable. Its recipe formulation follows WHO guidelines for SAM management, ensuring that each 300-gram serving provides at least 50% of the recommended nutrient intakes (RNI). If the piloted iTEFF recipe demonstrates improved SAM recovery outcomes, future implementation would include community-based workshops for caregivers, offering practical guidance on iTEFF use, alongside nutrition education for SAM management. To support boarder scale-up, it is recommended that future efforts explore wholesale pricing with vendors to reduce retail costs and enhance the economic feasibility of the recipe. Recognising and responding to these key drivers can support the design of effective interventions and guide future research in malnutrition management. The Therapeutic Potential of iTEFF in the Context of SAM Recovery in Ethiopia Given the widespread impact of SAM on overall bodily function, it is essential to identify both macronutrient and micronutrient needs to ensure interventions comprehensively support growth and development (Mwene-Batu, et al., 2020). iTEEF’s selected food sources are anticipated to contribute meaningfully to SAM recovery, providing a nutrient profile that meets at least 50% of the recommended RNIs, as recommended by the WHO guidelines (WHO, 2013). Mango : Mangoes, classified as stone fruits, are an excellent source of vitamins A and C, dietary fibre, and antioxidants that offer notable health benefits (Nutrics, 2025). Commonly cultivated in tropical regions due to their need for warm climates, mangoes are the second-most widely grown fruit in Ethiopia (Asefa et al., 2020). Their nutrient composition contributes significantly to the local diet and supports SAM recovery by restoring immune function, tissue repair, and gut health (Lencha et al., 2024). Avocado : Avocados, often mistakenly believed to be a vegetable, are tree-grown, high-fat fruit with several beneficial nutrients, including potassium, magnesium, vitamins E, K and C, favouring warm, humid climates, most notably in the southern regions of Ethiopia (Nutrics, 2025; Embassy of Ethiopia, 2024). Avocados have been recommended in food insecurity management among developing countries as a primary intervention for malnutrition treatment, providing a significant source of the monounsaturated fat, oleic acid (World Vision International, 2021). These nutrients can play a key role in restoring electrolyte imbalances, supporting immune recovery, and reducing systemic inflammation, all of which are necessary for SAM recovery (Fekele et al., 2024). Red Kidney Bean : Red kidney beans are part of the “common bean” family, which includes pinto, black, and haricot beans, and are one of the most prevalent crops in Ethiopia during the rainy season, best grown in wet, humid climates (Asefa et al., 2020). Incorporated into flour blends for its high protein content of 22.5 grams per 100-gram serving, red kidney beans are also an excellent source of iron, potassium, manganese, folate and vitamin B 1 (thiamine) (Nutrics, 2025). These nutrients are ideally suited for SAM management due to their positive impact on energy production, immune function and recovery from MND (Araro, et al., 2020). Kale : A cruciferous vegetable associated with kale is known for its abundant nutrient composition, providing an excellent source of vitamins K, C and A in addition to potassium, fibre and folate (Nutrics, 2025). Currently, Ethiopian kale is primarily grown in the Oromia region, the largest region crossing from the western to eastern edges of the country and has been known to be underutilised considering its significant nutritional value despite being grown by 4.5 million farmers in the country annually (Asefa, et al., 2020; Embassy of Ethiopia, 2024). Its nutritional profile can help restore physiological function, promote catch-up growth, and reduce the risk of complications during SAM rehabilitation (Teshale et al., 2023). Teff : Teff is a gluten-free grain native to Ethiopia and a staple of the country’s diet. It is an excellent source of protein, fibre, potassium, and iron, key nutrients for addressing common deficiencies in SAM, including anaemia and muscle wasting (Tsegaye et al., 2022). Recent studies indicate that whole-grain teff surpasses other common grains, such as maize and wheat, in micronutrient content, providing 2 to 3 times more iron, 5 times more calcium, and over twice the folate (Gebru and Kim, 2020). Teff is a highly desirable crop in Ethiopia due to its resilience during inclement weather, including drought and flooding, both of which are notable concerns in the country’s routine weather system. Economic Implications of iTEFF Severe acute malnutrition places a substantial economic burden on Ethiopia, as well-documented in this report. This study aimed to identify a cost-effective intervention that not only addresses the high prevalence of SAM but also contributes to broader poverty alleviation efforts. The use of underutilised, locally available food sources, such as those in iTEFF, can enhance agricultural sustainability, promote workforce development, and strengthen socio-economic resilience (Amadou and Lawaii, 2022). A key finding of this study is that iTEFF presents a viable, lower-cost alternative to standard therapeutic foods. According to WHO guidelines, RUTFs should provide 150-180 kcal/kg/d for SAM treatment (WHO, 2013). The widely used Plumpy’Nut delivers 520-550 kcal per sachet and costs approximately $2.50 USD per 500 grams (UNICEF Supply Catalogue, 2018). In comparison, iTEFF demonstrates a cost savings of $0.33 USD per 100 grams, underscoring its potential as an economic and sustainable solution for SAM interventions. iTEFF and the Sustainable Development Goals (SDGs) The primary objective of this intervention is to improve the nutritional status of the target population by using the proposed recipe, iTEFF. Key indicators of successful SAM recovery, including weight gain, restoration of lean muscle mass, and correction of micronutrient deficiencies, are potential outcomes of iTEFF implementation. This aligns with the 2030 Sustainable Development Goals (SDGs), particularly SDG 2 (zero hunger) and SDG 3 (health and well-being for all) (UN, 2025). The anticipated public health outcomes associated with iTEFF use are outlined in Table 7. Table 7: Predictive Benefits of iTEFF in Connection to SDGs Predictive Benefits of iTEFF Link with SDGs ( United Nations, 2025 ) Restoration of healthy nutritional status including weight regain lean muscle mass and alleviation of micronutrient deficiencies 2.2 End all forms of malnutrition, including achieving…. internationally agreed targets on stunting and wasting in children under 5 years of age Use of local, indigenous food sources for vulnerable populations 2.1 Ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round Use of local, indigenous food sources for recipe prototype 2.4 Ensure sustainable food production systems and implement resilient agricultural practices that increase productivity and production, that help maintain ecosystems Addressing U5MR in SAM intervention for target population 3.2 end preventable deaths of newborns and children under 5 years of age…. under-5 mortality to at least as low as 25 per 1,000 live births Provide economic option for SAM intervention with cost-effective TFR 1.1 Eradicate extreme poverty for all people everywhere, currently measured as people living on less than $1.25 a day Identified Limitations to Project Implementation Fieldwork for this project was conducted in a geographically limited area of a developing country, where notable challenges emerged. These limitations highlight important considerations for future implementation and scale-up. Identified constraints and their implications are discussed in the following section. Surveyable market area : Due to ongoing conflict, regional unrest and travel advisories, data collection was limited to the Waliso area. While valuable insights were obtained, a comprehensive assessment of the intervention’s potential would require expanding market surveys to additional regions. Lack of water and electricity during fieldwork : During the fieldwork week, Waliso experienced a significant power outage that severely limited access to water and electricity. This disruption affected local markets, disrupting the availability of food items and the ability of vendors to operate. For future scale-up, it would be advisable to extend fieldwork over 3 to 6 months, incorporating monthly market surveys to capture trends, fluctuations, and supply consistency under both stable and unforeseen conditions. Market vendor perceptions of the researcher : While vendors were generally willing to share information about food products, some expressed disappointment that the research did not include purchasing food items. For future scale-up, it is recommended that the research budget include funds for purchasing selected foods, both as a gesture of goodwill and to support data collection. Collaborating with local hospitals or community health workers could facilitate the appropriate distribution of these foods, ensuring ethical and community-focused engagement. Seasonal variability and availability : Fieldwork was conducted over 1 week during a visit to Waliso during the traditional rainy season. To ensure sustainability and broader applicability, additional market surveys should be carried out across different seasons to assess the impact of seasonal changes on food availability. This would help identify any significant fluctuations that may affect ingredient access. In addition, it may be necessary to develop multiple recipe variations tailored to seasonal food availability, enabling greater flexibility and comprehensive intervention strategies. Recipe conceptualisation : Although fieldwork data informed the recipe prototype, the recipe was formulated using virtual tools, including Nutritics. Due to time constraints, the recipe was not physically prepared or tested with a target population for acceptability and receptivity. For future scale-up, the proposed next steps include delivering community workshops for mothers of children under five, offering guidance on recipe preparation and home implementation. These sessions would also provide valuable opportunities to collect user feedback and assess practical feasibility. Conclusion and recommendations This study aimed to identify a nutrient-dense, locally sourced, and sustainable option for modulating severe acute malnutrition in children aged 6 to 59 months in Waliso, Ethiopia. The broader objective would be to utilise the recipe framework with similar populations across the country and globally. The conceptualisation of iTEFF included important aspects of nutrient optimisation in the SAM intervention, and its economic value provides a cost-effective alternative to traditional RUTF in economically constrained countries. Key findings of the study identified current gaps in SAM intervention and treatment, including sustainable options that decrease reliance on foreign aid. The literature review provided insight into the primary factors in successful SAM intervention, including the impact of maternal awareness of IYCF and health promotion services. iTEFF can help meet these identifiable markers of improvement and support alignment with the Sustainable Development Goals (SDGs) by improving the nutritional status and overall health of children under 5 years old. It is recommended that children with SAM be treated in community-based settings to minimise travel burdens on caregivers and reduce the risk of hospital-acquired infections, emphasising the need for alternative treatment protocols independent of inpatient admission. As in all research, opportunities for improvements and recommendations need to be addressed. The primary limitation of the study was the inability to test the recipe prototype within the target population. A recommendation for scalability is to test iTEFF in the community setting to determine beneficial outcomes. For future research-scale-up, it is proposed to conduct an intervention programme to pilot the recipe prototype. Based on findings, it is recommended to share the optimised recipe with mothers of children with SAM through community-based workshops. If feasible, the follow-up study would also expand market surveys to additional regions of the country to provide a more robust, comprehensive understanding of the food system, including accessibility and seasonality. Addressing each of these areas of improvement would provide exponential validation of the proposed recipe's efficacy. Ethiopia is among the fastest-growing economies in Africa and is expected to play an impactful role in the region’s development. With ongoing armed conflict and devastating food insecurity, the country vitally needs options for addressing severe acute malnutrition in the under-five population for the future development of the country. This dissertation provides a nutrient-dense, economical, and sustainable option to address a primary health concern of severe acute malnutrition in Ethiopia. Future scale-up and ongoing support for interventions like iTEFF could significantly reduce global under-five mortality rates associated with SAM and improve the health and livelihoods of future generations in developing countries. Abbreviations CMAM: Community Management of Acute Malnutrition EDHS: Ethiopian Demographic Health Survey FCDO: Foreign, Commonwealth and Development Office HSTP-II: Ethiopian Health Sector Transformation Plan II EPHI: Ethiopian Public Health Institute IYCF: Infant and Young Child Feeding LBW: Low Birth Weight MND: Micronutrient Deficiency NNP: National Nutrition Programme OTP: Outpatient Therapeutic Programme PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses PICO: Population, Intervention, Comparison, Outcome RUTF: Ready-to-Use Therapeutic Food SAM: Severe Acute Malnutrition SDG: Sustainable Development Goals TFR: Tailored-Functional Recipe U5MR: Under-Five Mortality Rate UNICEF: United Nations International Children’s Emergency Fund WHO: World Health Organization Declarations Acknowledgements Not applicable Author contributions C.M. and I.T. collaborated on scoping review, research protocol, literature search, data extraction, and synthesis of findings, with C.M. leading and I.T. guiding, drafting, revising, and approving the final manuscript. Funding The authors declare that they did not receive any funding for this study. Availability of data and material All the data generated during this study are included in this published article. Declarations Ethics approval and consent to participate Ethical approval was obtained from the University of Westminster, in accordance with the code of practice governing the ethical conduct of research and the institution's code of good research practice. Consent for publication Not applicable. Competing interests The authors state that they possess no competing interests. Author details 1 School of Life Sciences, University of Westminster, 115 New Cavendish Street, London W1W 6UW, UK. References Abdi, F.A., Gemede, H.F. and Olika Keyata, E. 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(2002) 'Dietary Reference Intakes: summary of applications in dietary assessment', Public Health Nutrition, 5(6a), pp. 843 Available at: https://doi.org/10.1079/phn2002389. Mwene-Batu, P., Bisimwa, G., Baguma, M., Chabwine, J., Bapolisi, A., Chimanuka, C., Molima, C., Dramaix, M., Kashama, N., Macq, J. and Donnen, P. (2020) 'Long-term effects of severe acute malnutrition during childhood on adult cognitive, academic and behavioural development in African fragile countries: The Lwiro cohort study in Democratic Republic of the Congo', PLOS ONE, 15(12) Available at: https://doi.org/10.1371/journal.pone.0244486. Nane, D., Hatløy, A., Tadesse, E. and Lindtjørn, B. (2019) 'Research protocol local ingredients-based supplementary food as an alternative to corn-soya blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: a randomized controlled non-inferiority trial in Wolaita', BMC Public Health, 19(1) Available at: https://doi.org/10.1186/s12889-019-8031-3. 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(2019) 'Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age', Cochrane Database of Systematic Reviews, 2019(5) Available at: https://doi.org/10.1002/14651858.cd009000.pub3. Shragai, T., Talley, L., Summers, A., Behringer, H., Wrabel, M., Stobaugh, H. and Leidman, E. (2022) 'Outcomes after Acute Malnutrition Program Adaptations to COVID-19, Uganda, Ethiopia, and Somalia', Emerging Infectious Diseases, 28(13) Available at: https://doi.org/10.3201/eid2813.212266. Stephen, A., Alles, M., De Graaf, C., Fleith, M., Hadjilucas, E., Isaacs, E., Maffeis, C., Zeinstra, G.G., Matthys, C. and Gil, A. (2012) 'The role and requirements of digestible dietary carbohydrates in infants and toddlers', European Journal of Clinical Nutrition, 66(7), pp. 765 Available at: https://doi.org/10.1038/ejcn.2012.27. Teshale, E.B., Nigatu, Y.D. and Delbiso, T.D. (2023) 'Relapse of severe acute malnutrition among children discharged from outpatient therapeutic program in western Ethiopia', BMC Pediatrics, 23(1) Available at: https://doi.org/10.1186/s12887-023-04269-7. Teshale, G., Debie, A., Dellie, E. and Gebremedhin, T. (2022) 'Evaluation of the outpatient therapeutic program for severe acute malnourished children aged 6–59 months implementation in Dehana District, Northern Ethiopia: a mixed-methods evaluation', BMC Pediatrics, 22(1) Available at: https://doi.org/10.1186/s12887-022-03417-9. Tsegaye, A., Lencha, B. and Kumsa, K. (2022) 'Predictors of time to recovery from uncomplicated severe acute malnutrition among 6–59 months children treated in outpatient treatment in health posts of Nagele Arsi district: a retrospective cohort study', BMC Pediatrics, 22(1) Available at: https://doi.org/10.1186/s12887-022-03767-4. UNICEF (2024) Ethiopia: Humanitarian Situation Report No. 8. Available at: https://www.unicef.org/media/164361/file/UNICEF%20Ethiopia%20Humanitarian%20Situation%20Report%20No.%208%20-%20August%20-%20September%202024.pdf.pdf (Accessed: 22 December 2024). UNICEF (2022) Ready-to-eat therapeutic innovation product specification sheet. Available at: https://www.unicef.org (Accessed: 1 May 2025). United Nations (2024) The Sustainable Development Goals. United Nations. Available at: https://sdgs.un.org/goals (Accessed: 23 December 2024). United Nations News (2024) UN food agency ramps up deliveries amid worsening food security in Ethiopia. Available at: https://news.un.org/en/story/2024/02/1146252#:~:text=The%20Government%20of%20Ethiopia%27s%20most,humanitarian%20relief%20to%20resilience%20programmes. (Accessed: 21 December 2024). USAID Advancing Nutrition (2023) Managment of Moderate Wasting Using Local Foods. USAID. Available at: https://www.advancingnutrition.org/sites/default/files/2023-11/mam_treatment_local_foods_report_execsumm_tagged.pdf (Accessed: December 25, 2024). USDA (2024) USDA Food Central Data Search. Available at: https://fdc.nal.usda.gov/ (Accessed: 22 June 2025). USDA (2019) USDA Food Central Data Search. Available at: https://fdc.nal.usda.gov/ (Accessed: 22 June 2025). WHO (2013) Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization. Available at:(Accessed: May 13 2025). Woldekidan, M.A., Arja, A., Worku, G., Walker, A., Kassebaum, N.J., Hailemariam, A., Naghavi, M., Hay, S. and Misganaw, A. (2024) 'The burden and trends of child and maternal malnutrition across the regions in Ethiopia, 1990–2019: The Global Burden of Disease Study 2019', PLOS Global Public Health, 4(7) Available at: https://doi.org/10.1371/journal.pgph.0002640. Woldeyohannes, M., Girma, M., Petros, A., Hussen, A., Samuel, A., Dinssa, D.A., Challa, F., Laillou, A., Chitekwe, S., Baye, K., Noor, R., Donze, A.S., Tollera, G., Dangiso, M.H., Tadesse, L., Zelalem, M. and Tessema, M. (2023) 'Ethiopia National Food and Nutrition Survey to inform the Ethiopian National Food and Nutrition Strategy: a study protocol', BMJ Open, 13(4) Available at: https://doi.org/10.1136/bmjopen-2022-067641. Wondie, S.G., Zinab, B., Gizaw, G. and Tamrat, M. (2022) 'Time to recovery and its predictors among children aged 6–59 months with severe acute malnutrition admitted to outpatient therapeutic program in Southwest Ethiopia: retrospective cohort study', BMC Pediatrics, 22(1) Available at: https://doi.org/10.1186/s12887-022-03205-5. World Bank (2024) Ethiopia. World Bank. Available at: https://www.worldbank.org/en/country/ethiopia/overview#:~:text=With%20about%20126.5%20million%20people,middle%2Dincome%20status%20by%202025. (Accessed: 22 December 2024). World Food Programme (2013) The Cost of Hunger in Ethiopia. Available at:(Accessed: 18 February 2025). World Food Programme, UNICEF and World Health Organization (2007) Community-Based Management of Severe Acute Malnutrition. Available at: https://iris.who.int/handle/10665/44295 (Accessed: 1 March 2025). World Health Organization (2024) Ethiopia. Available at: https://data.who.int/countries/231 (Accessed: 21 December 2024). World Health Organization (2013) Guideline: updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization. Available at: https://iris.who.int/handle/10665/95584 (Accessed: May 13 2025). World Vision International (2021) Addressing malnutrition through avocados in Peru. Available at: https://www.wvi.org/stories/hunger-crisis/more-than-a-meal/addressing-malnutrition-through-avocados-peru (Accessed: 6 June 2025). Yemane, G.D. (2022) 'The factors associated with under-five mortality in Ethiopia', Annals of Medicine & Surgery, 79 Available at: https://doi.org/10.1016/j.amsu.2022.104063. Yitayew, Y.A., Yalew, Z.M., Nebiyu, S. and Jember, D.A. (2024) 'Acute malnutrition relapse and associated factors among 6–59 months old children treated in the community-based management of acute malnutrition in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia', Frontiers in Public Health, 11 Available at: https://doi.org/10.3389/fpubh.2023.1273594. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8997306","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603360545,"identity":"b0a4487a-0682-4645-9f6a-dc98ae4258ca","order_by":0,"name":"Christine Murphy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABIElEQVRIie2RMUvDQBSAXwnE5WrXhEL8C1cODgepfyVH4Kagg4uCSCQQl+Kc4pC/EBCK48WDm664FhRECp0TAuIgYqKLQ2IdHe7bHo8PvscDMBj+IzuXV2/V+4E3+h6dHyvUoyAp3HnEiRs1g2gVe5vicH88jO5ZLr4U2K5gEeLJ/E4QsgpkXYX7R3tZrEo4nwLWokfR2K/0k0dXnDvFwjnByg5SUAHgZdSp0GKGi9TeEPoYUmgUltuINHUC8EN3GJVoEiNbstub47pslSwZ1QAfvyhNhjVMJMvHIbRhLFLIgkEiesMOtaUGqebEed5QZ9mGKU6AXQfI7TnfzV4SKE+bV87kujxbXLAslmsoX6ferva7y7rx+x9pMBgMhj/wCSqHabDddOd6AAAAAElFTkSuQmCC","orcid":"","institution":"University of Westminster","correspondingAuthor":true,"prefix":"","firstName":"Christine","middleName":"","lastName":"Murphy","suffix":""},{"id":603360546,"identity":"73fff67c-1f04-4111-8708-7ffbf53d236d","order_by":1,"name":"Ihab Tewfik","email":"","orcid":"","institution":"University of Westminster","correspondingAuthor":false,"prefix":"","firstName":"Ihab","middleName":"","lastName":"Tewfik","suffix":""}],"badges":[],"createdAt":"2026-02-28 18:09:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8997306/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8997306/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104582078,"identity":"2ff524bb-74b4-4c1c-bbca-4868adac2656","added_by":"auto","created_at":"2026-03-13 15:11:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":137781,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRates of acute and severe malnutrition among children aged 6–59 months in Ethiopia \u003c/strong\u003e\u003cem\u003e(EDHS, 2019)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8997306/v1/a1e62c3ea6054a0e7dcc87af.png"},{"id":104582327,"identity":"27e8073a-e7d7-4bfe-a78d-1e1deaf1b96a","added_by":"auto","created_at":"2026-03-13 15:12:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":83057,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flowchart, \u003c/strong\u003e\u003cem\u003e(Adapted from: Moher, et al.,2009)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8997306/v1/2cd44a27d7415b5a91692dcb.png"},{"id":104582536,"identity":"d3ba17af-7bff-4c8c-96c8-cc172ae0bb92","added_by":"auto","created_at":"2026-03-13 15:12:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1730777,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8997306/v1/f5461b88-23f8-4b1b-ab82-fa07eeb01327.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Design and optimisation of a tailored nutrient-dense functional recipe to modulate severe acute malnutrition in children aged 6–59 months in Waliso, Ethiopia","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cem\u003eEthiopia: Africa\u0026rsquo;s Oldest Country\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Federal Democratic Republic of Ethiopia in East Africa is home to 126.5 million people, according to recent census data, with 14% of the population under 5 years of age (World Bank, 2023). Ethiopia has 12 regions, known as \u0026ldquo;regional states\u0026rdquo;, with 80% of Ethiopians living in rural areas and struggling to access essential healthcare services, food security, and clean water (WHO, 2023). The average annual income is ~$1000, with \u0026gt;20% of the population living on less than $2 USD per day, and nearly 20 million are food insecure (World Bank, 2024; United Nations, 2022). Among children under five, 25% live below the poverty line, with malnutrition disproportionately affecting those from poor and remote communities (UNICEF, 2023). Spanning \u0026gt;1,000,000 square kilometres, Ethiopia is the continent\u0026rsquo;s 10th-largest and 2nd-most populous country, with a rich agricultural history embedded in international trade (Embassy of Ethiopia, 2024; Asefa \u003cem\u003eet al.,\u003c/em\u003e 2020). The city of Waliso is in the southwest of the largest region, Oromia. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eScale of the Problem\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMalnutrition, defined as \u0026ldquo;deficiencies, excesses or imbalances\u0026rdquo; in energy and nutrient intake, affects nearly 150 million children globally (WHO, 2024). Severe acute malnutrition (SAM), characterized by a \u0026ldquo;weight-for-height z-score below -3 standard deviation, bilateral pitting oedema, or a mid-upper arm circumference \u0026lt;115 mm\u0026rdquo;, affects over 18 million children and contributes to more than 300,000 child deaths annually (WHO, 2023). In Ethiopia, the economic burden of child undernutrition is significant, estimated at 16.5% of the national GDP (WFP 2022). Nationally, 39% of children under five are stunted, 21% underweight, and 7% wasted (UNICEF, 2023). Over 5 million of these children are affected by acute malnutrition, with the highest rates in the Southern Nations, Nationalities and Peoples\u0026rsquo; (SNNP) and Somali regions, as shown in Figure 1 (Mihret \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2022; Seboka \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2021). Stunting has declined from 58% in 2000 to 38% in 2016, but little progress has been made since, with a prevalence of 37% in 2019 (GNR, 2023; EPHI, 2021). Meanwhile, the under-five mortality rate (U5MR) dropped from 123 per 1,000 live births to 59 in 2019, a 52% decrease largely due to improved healthcare access (Yemane, 2022). Still, the U5MR remains 46.5, nearly 1.3 times the global average (UNICEF, 2023). \u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImpact of SAM on the Nutritional Status of Children Under Five\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSAM can have devastating effects on the immediate and lifelong health of children (Gebreegziabiher, \u003cem\u003eet al.,\u003c/em\u003e 2024). Acute effects of SAM impair the immune system, significantly increasing susceptibility to infections and illnesses, creating a double burden of disease (Gizaw \u003cem\u003eet al.,\u003c/em\u003e 2018). Children will also present with micronutrient deficiencies (MND), including vitamin A, iron, iodine and zinc, with one in every five Ethiopian children entering grade school with at least one MND (Vresk \u003cem\u003eet al.\u003c/em\u003e, 2025; Gebeye \u003cem\u003eet al.,\u003c/em\u003e 2024). The long-term effects of SAM, including impaired cognitive development affecting academic and professional outcomes, can directly impact the economic potential of countries with high SAM prevalence (Mwene-Batu, \u003cem\u003eet al.\u003c/em\u003e, 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCurrent Interventions and Gaps in Ethiopia\u0026rsquo;s Treatment of Severe Acute Malnutrition\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOver the last two decades, Ethiopia has addressed hunger and malnutrition with targeted programmes and policies to support interventions (Ministry of Health-Ethiopia, 2024). The majority of programmes are established by the national government and designed to support the Sustainable Development Goals 2030, including SDG 2, which aims to eliminate hunger worldwide (United Nations, 2025). Current interventions targeted at child malnutrition in the country are discussed below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Seqota Declaration:\u0026nbsp;\u003c/strong\u003eIntroduced in 2015, this policy aims to end child malnutrition in Ethiopia by 2030 through nutrition-focused, behaviour-driven programmes (The Seqota Declaration, 2015). A 2018 survey showed challenges in healthcare access and household technology (EPHI, 2018). By 2024, nearly 110,000 children, over 90,000 under five, avoided stunting (Johns Hopkins University, 2024). Continued progress depends on sufficient funding (FAO, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthiopian Health Sector Transformation Plan (HSTP-II):\u0026nbsp;\u003c/strong\u003eThe national health strategy was updated in 2021 and aims for universal healthcare, with a focus on child nutrition (FAO, 2024). Achievements include 88% of health facilities providing guideline-driven SAM treatment and 76% vitamin A coverage in under-fives (Croke, 2020). Challenges remain in rural access and funding (Assefa, \u003cem\u003eet al.,\u003c/em\u003e 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNational Nutrition Programme (NNP):\u0026nbsp;\u003c/strong\u003eSince 2008, NNP has focused on food security in the first 1000 days of life and Community Management of Acute Malnutrition (CMAM) among its objectives (Ministry of Health-Ethiopia, 2024). Stunting dropped from 58% to 37% and underweight from 41% to 21% from 2000 to 2019 (EPHI, 2020). However, less than 15% of children under two meet the recommended nutritional intake, and over 20% of the population remains undernourished (Woldeyohannes \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite ongoing efforts, SAM affects nearly 15% of Ethiopian children under five each year, contributing to around 45% of child deaths through direct or indirect links to undernutrition (Belay, \u003cem\u003eet al.,\u003c/em\u003e 2023; Anato, A., 2022). Evidence underscores the need for sustainable, effective interventions, yet current programmes often rely heavily on foreign aid and NGOs, raising concerns about long-term reliability (Gebresilassie \u003cem\u003eet al.,\u003c/em\u003e 2023). Moreover, there is limited research on using locally available foods in SAM treatment, an approach that could enhance both sustainability and food security (Belay, \u003cem\u003eet al.,\u003c/em\u003e 2022; Amadou and Lawaii, 2022). One promising solution is the use of tailored-functioned recipes (TFR), defined as organic, accessible, and economical foods, often consumed in concentrated forms with verified physiological therapeutic effects exceeding standard nutrition (Amlogu, \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2016). Given the potential of TFRs in addressing nutrition-related diseases, this study proposes the following aim and objectives:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAim:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo formulate and optimize a nutrient-dense, tailored functional recipe (TFR) to modulate severe acute malnutrition (SAM) in children 6 to 59 months old in Waliso, Ethiopia\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObjectives:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eEvaluate current best practice on nutrition interventions of severe acute malnutrition (SAM) in children 6 to 59 months old in Africa.\u003c/li\u003e\n \u003cli\u003eUtilize an evidence-based market survey of local, indigenous foods to identify ingredients that are sustainable and food secure for a cost-effective, tailored functional recipe [TFR].\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cem\u003eHypothesis:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA nutrient-dense, tailored-functional recipe developed using local, indigenous food sources will provide a more effective and sustainable solution in improving the nutritional status of children 6 to 59 months with severe acute malnutrition compared to standard therapeutic foods.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSignificance of the Study\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePublic health, \u0026ldquo;the science and art of preventing disease, prolonging life, and promoting health\u0026rdquo;, guides interventions like this study, which aligns with the Sustainable Development Goals (SDG), including SDG 2 (zero hunger) and SDG 3 (health and well-being for all) (Faculty of Public Health, 2024; UN, 2024). Developing culturally appropriate interventions supports improved health outcomes, policy development, and multi-sectoral engagement, which ultimately can aid in disease prevention and health longevity for millions of Ethiopian children at risk for SAM.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eScope of the Study\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA robust, evidence-based literature review following the Campbell systematic review protocol identified current best practices for treating uncomplicated severe acute malnutrition in children aged 6 to 59 months. Infants under 6 months are recommended to be exclusively breastfed for optimal nutrition and protection against infections (WHO, 2025). Children with complicated SAM, with the addition of medical complications, require inpatient care due to their fragile condition (Lencha, \u003cem\u003eet al.,\u003c/em\u003e 2024). Thus, this study focused on children aged 6 to 59 months with uncomplicated SAM to develop the tailored-functional recipe (TFR) prototype.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNutrient requirements, including macronutrients and condition-specific micronutrients, were established from the scoping review, with emphasis on non-animal food sources to ensure economic viability for the target population. Additionally, an evidence-based local market survey was conducted, informed by Save the Children\u0026rsquo;s Cost of Diet (CotD) framework, to identify indigenous foods that are seasonally and sustainably available in Waliso, Ethiopia (Save the Children, 2024).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eRationale for methodology\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe proposed study was implemented in two phases, including a literature review and fieldwork for data collection and recipe development. An evidence-based market survey was selected as the primary research tool and provided comprehensive data on local foods, including retailer prices, availability, and seasonality. The tool was chosen based on previous studies with successful objectives using this approach (Kapoor, 2016; Amlogu, \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2016; Azagba-nyako, 2017). The survey framework was guided by \u0026lsquo;The CotD\u0026rsquo;, a research software tool developed by Save the Children UK in 2013 to assess the cost and availability of indigenous foods among low-income populations (Save the Children, 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhase 1: Literature Review and Analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA scoping review of the current literature was conducted using the Campbell systematic review protocol to provide insight into contemporary approaches to SAM interventions for children aged 6 to 59 months. Attention was given to interventions in developing countries to fine-tune study design and include macronutrient and micronutrient recommendations for the target population. Research search engines included Web of Science and PubMed, with the inclusion criteria of articles published between 2020 and 2025, peer-reviewed literature, and evidence-based reports published by reputable organisations (e.g., the World Health Organisation, UNICEF). Keywords for the literature search were based on the PICO framework (Table 1), identifying the population, intervention, comparison, and outcome, using Boolean operators to enhance the quality of results. All articles that met the inclusion criteria were included in a PRISMA flow chart (Figure 2) to support the selection of articles for study development included in the scoping review summary (Table 2). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: PICO Framework\u0026nbsp;\u003c/strong\u003e(\u003cem\u003eAdapted from: Health Science, 2009\u003c/em\u003e)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescriptives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003eopulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eChildren 6 to 59 months in Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eI\u003c/strong\u003entervention/Exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eSevere acute malnutrition; nutrition interventions for child malnutrition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003eomparison\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eStandard interventions (e.g. RUTF) versus locally sourced foods/diets\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eO\u003c/strong\u003eutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eAlleviated and/or resolved SAM symptoms in children 6 to 59 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Scoping Review Summary\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"930\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor (s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTitle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMajor outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s critical views and recommendations for improvement\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eTsegaye, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003ePredictors of time to recovery from uncomplicated severe acute malnutrition among 6-59\u0026thinsp;months children treated in outpatient treatment in health posts of Nagele Arsi district: a retrospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eIdentify factors in recovery time from SAM in 6 to 59 months old children in Nagele Arsi district (Ethiopia)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eRetrospective cohort study on 300+ children over two-year period. Statistical analysis of recovery time from SAM treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eDeterminates of recovery time including vitamin A supplementation, deworming, antibiotics and co-morbidity. Recovery time with Sphere Standards\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIdentified area with limited data on factors in SAM recovery (e.g. Nagele Arsi, South Ethiopia). Outcomes compared against SPHERE standards.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Only used MUAC score and oedema criteria to determine SAM (did not include anthropometric markers). Did not assess family demographics (as many studies have including maternal education as a significant factor in SAM recovery). Some records were incomplete with needed study variables and were removed from analysis.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Results attributed to specified area (e.g. Nagele Arsi district) and would need to be expanded to additional areas for translatability. Follow-up studies should include children unidentified/untreated without access or attendance at local health clinics. Incorporate family demographics into data collection/analysis as previous studies have identified these variables as impactful to SAM recovery.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eWondie, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eTime to recovery and its predictors among children aged 6-59\u0026thinsp;months with severe acute malnutrition admitted to outpatient therapeutic program in Southwest Ethiopia: retrospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eEstimate recovery time from outpatient treatment for SAM and determining factors for children 6-59 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eRetrospective cohort study on 588 children. Statistical analysis of recovery time from SAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eEarly detection of SAM and additional morbidities (malaria, diarrhoea) determined as significant factors in recovery time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIdentified gap in research on time to recovery from SAM in OTP centres. Significant sample size of 588 children.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Incomplete records were excluded due to retrospective study design. Unable to assess potential factors not collected in the data (e.g. caregiver education, exposure to breastfeeding, nutritional status of mother)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Improvement to CHW trainings in OTP centres to meet SPHERE standard recovery (\u0026gt;75% vs study outcome of 54.4%). Strengthen early detection and management of concurrent illnesses.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eBizuneh, et.al.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eTime to recovery from severe acute malnutrition and its predictors among children aged 6-59 months at Asosa general hospital, Northwest Ethiopia. A retrospective follow-up study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eDetermine time to recover from SAM and determining factors in children 6 to 59 months in Benishangul Gumuz, Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eRetrospective study from 2015 to 2019 on 454 children. Statistical analysis to determine recovery time and factors.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eFactors impacting recovery time including routine follow-up, HIV status and type of malnutrition (marasmus vs marasmus-kwashiorkor)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIdentified gap in research on recovery time in children under 5 with SAM. Included data over 5-year period. Significant sample size of 454 children.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Missing data due to retrospective study required some participant records could not be used. Difficulty translating outcomes to rural areas due to study location in urban city hospital.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Monitoring nutritional status of children with HIV to improve health outcomes. Addition of prospective studies to limit incomplete records. Ongoing optimisation of SAM treatment centres to improve life expectancy. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eGemechu, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eDeterminants of severe acute malnutrition among children aged 6-59 months in the pastoral community of Liban District, Guji Zone, Oromia Regional State, Southeastern Ethiopia: a case-control study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eFactors in severe acute malnutrition among children 6 to 59 months in pastoral area of Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eCase-control study (88 cases; 117 control) using structured interviews and anthropometric measurements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eFactors determining SAM diagnosis included maternal education, underweight, family size and inappropriate infant feeding practices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eStudy focused on pastoral communities that are known to have high prevalence of SAM with lack of treatment due to location and limited healthcare services and minimal research completed. High participation rate of \u0026gt;95%.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Results were dependent on participant self-report which can include recall bias and socially favourable responding.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Collect multiple different qualitative data from different stakeholders to support overarching themes. Request community members as surveyors to support improved participant responses and comfortability.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eTeshale, et. al\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eRelapse of severe acute malnutrition among children discharged from outpatient therapeutic program in western Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eDetermine prevalence of recurrent SAM post-discharge in children 6 to 59 months in Western Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eCross-sectional study on 208 children 6 to 59 months discharged from outpatient clinic deemed as \u0026ldquo;cured\u0026rdquo; of SAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e10.1% relapse; factors involved including inadequate supplementary food post-discharge, mothers with limited education on Infant and Young Child Feeding (IYCF) and premature discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIdentified gap in research on post-discharge relapse of SAM. Use of cross-sectional study design to determine prevalence of relapse to support future programme and policy development. Mixed-method approach for comprehensive analysis of the situation.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e\u0026nbsp; Unable to determine causal relationship with cross-sectional approach. Risk of recall bias from caregivers with questionnaire tool. Study conducted in specific area/location creating limits with generalizing to other populations/communities.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Importance of using anthropometric and oedema criteria to determine discharge protocol. Incorporation of nutrition education provided to caregiver in reducing SAM relapse.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"930\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eBune, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eRecovery time and predictors of severe acute malnutrition in children aged 6-59 months via an outpatient therapeutic program in Borena zone: A prospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eDetermine recovery times and factors in children 6 to 59 months with SAM in Southern Ethiopia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eProspective study on 322 children treated at outpatient clinics. Structured questionnaires with statistical analysis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePrimary factors impacting recovery time included earlier treatment with Amoxicillin with vomiting, diarrhoea and oedema delaying recovery time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eUse of primary data with mixed-method approach. Prospective approach tracking participants in real-time. Identified need for research in OTP outcomes for SAM children, specifically in rural areas.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Inconsistency in literature on defining SAM recovery creating challenges in translating outcomes and verifying results. Monitoring only completed for one-month.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Develop strategies that combine nutrition therapy and infection intervention for improved outcomes. Develop programmes that are specific to location/region addressing the challenges and barriers in the area to enhance recovery.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eFeleke, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eTime to recovery and its predictors among children aged 6-59 months having uncomplicated severe acute malnutrition attending an outpatient \u0026nbsp;therapeutic program in Northeast Ethiopia: prospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eDetermine factors in recovery time from SAM in outpatient clinics in Northeastern Ethiopia for children 6 to 59 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eSemi-structured questionnaires and anthropometric measurements from February to July 2021 on 356 children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePrimary factors influencing recovery time including utilisation of health promotion services by mothers including nutrition counselling and overall maternal education including literacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIdentified the gap in research on factors influencing recovery time from SAM. Significant sample size of 356 children. Semi-structure questionnaire delivered weekly for 5 months. Longitudinal prospective study design allowed for causal relationships to be determined between study variables.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Potential impact of seasonal influences on OTP admissions and RUTF use (study conducted during low/no harvest season). Although followed weekly, study was only 5 months in duration. No ongoing follow-up to determine potential relapse or health outcomes post-discharge.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Develop programmes that support maternal education and nutrition counselling for prospective mothers (incl. Growth Monitoring Programmes-GMP). Conduct over a full agricultural year to determine impact of seasonal variations.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eLencha, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eSevere Acute Malnutrition among Children in Bale Zone Southeast Ethiopia: Treatment Outcome and its Determinant Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eDetermine outcomes of SAM treatment on children 6 to 59 months in Southeast Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRetrospective cross-sectional study in multiple institutions in the Bale Zone; statistical analysis completed on data to identify factors in SAM outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePrimary factors influencing positive treatment outcomes included: maternal education, anaemia, child\u0026rsquo;s age and use of NG tube in treatment protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eRecovery from SAM was 93.2% (higher than the international standard). Study methods were comprehensive using multivariate analysis.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Unexplained discrepancy in recovery time in differing parts of Ethiopia. Differing outcomes in recovery across multiple studies related to maternal awareness of malnutrition in children and role of deworming.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Incorporate qualitative data collection (e.g. biomarkers, medical history, etc.) to strengthen comprehensive understanding of factors in SAM recovery.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eBanda, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eReport of a Pilot Program Using a Milk-Free Ready-to-Use Therapeutic Food Made from Soya, Maize, and Sorghum to Treat Severe Acute Malnutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eAssess effectiveness of non-milk RUTF on SAM treatment in CMAM program in Malawi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNon-milk RUTF tested on 742 children 6 to 59 months old. Assess recovery time within Sphere Standards as an alternative to standard RUTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eNon-milk RUTF alternative met Sphere Standards for recovery time and is an effective alternative to standard RUTF due to cost and local availability of ingredients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s)\u003c/em\u003e\u003c/strong\u003e: \u0026nbsp;Adhered to SPHERE standards. Development of a plant-based RUTF using foods commonly found in sub-Saharan Africa without common allergens (e.g. peanut, milk)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s\u003c/em\u003e\u003c/strong\u003e): Study completed in area with all elements of CMAM integrated into the community including supplementary feeding programs (SFP) for follow-up after discharge from OTP. Unable to determine if therapeutic food translates to populations/communities without well-established CMAM programs.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Develop additional RUTF recipes using local foods from additional countries and communities to determine translatability. Test plant-based RUTF in communities without well-established CMAM (e.g. without SFP follow-up post-OTP discharge) to determine if outcomes are similar for children/participants.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eYitayew, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAcute malnutrition relapse and associated factors among 6-59\u0026thinsp;months old children treated in the community-based management of acute malnutrition in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eA cross-sectional study to determine factors in SAM relapse of children 6 to 59 months enrolled in CMAM program in Northeast Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eData collected on 318 children from April to May 2021. Statistical analysis assessed relapse in relation to several factors including child age, MUAC at discharge, diarrhoea at discharge and family wealth status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eOver one-third of participants experience SAM or MAM relapse. Determined importance of health education and counselling services to improve maternal support for mothers with children diagnosed with SAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIdentified gap in research on factors in SAM relapse in children. Use of WHO Anthro 3.2.2.2 software for analysis of z-scores. Participants followed across three different towns for broader understanding of CMAM programming in the areas.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Unable to determine causal relationship with cross-sectional study design. Only identified relapse rate between 1 to 12 months and unable to translate to relapse at various points in the 12-month period. Mothers self-reported immunization status and presence of diarrhoea with potential for recall bias.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Research on MUAC discharge criteria to determine any changes/improvements to minimize risk of relapse. Develop programmes that include health and nutrition education for mothers/caregivers with children post-SAM and at-risk for SAM.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eGirma, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eNutrition status and morbidity of Ethiopian children after recovery from severe acute malnutrition: Prospective matched cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eDetermine factors in malnutrition relapse in children 6 to 59 months discharged from CMAM programs in Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eProspective cohort study on 215 post-SAM and 215-non wasted children from September 2013 to September 2015. Statistical analysis on data to identify factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eRelapse in post-SAM cases was 14 times higher compared to non-wasted children. Unable to identify factors impacting relapse but recommended further research on post-discharge interventions supporting catch-up growth and management of comorbidities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIdentified need for research on post-SAM recovery long-term health implications. Results recognized need for post-discharge interventions to improve long-term quality of life and minimise risk of early death post-SAM recovery. Followed participants monthly for 12 months.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e Conflicting studies show post-SAM follow-up only need for 3-month period. Cost of implementing long-term follow-up programmes following OTP (e.g. Growth Monitoring and Promotion programmes-GMP) in economically constrained communities.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Additional longitudinal studies to support outcomes in lesser understood research area. Advocating for funding for comprehensive CMAM programmes to address benefits of long-term follow-up in post-SAM children.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eTeshale, et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eEvaluation of the outpatient therapeutic program for severe acute malnourished children aged 6-59\u0026nbsp;months implementation in Dehana District, Northern Ethiopia: a mixed-methods evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eEvaluate the effectiveness of outpatient therapeutic programs (OTP) in SAM treatment in rural Ethiopia on children 6 to 59 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eCross-sectional, mixed-method study evaluating 39 indicators with 422 mothers and 384 children enrolled (with acute malnutrition). Statistical analysis on records and interviewer-guided questionnaires with maternal participants for thematic evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eOTP judged on availability, compliance and accessibility. Judgement was deemed \u0026ldquo;fair\u0026rdquo; with need for improvements. Primary concerns with vitamin A, folic acid and antibiotics provided below recommended standards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrength(s):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eMixed-method study design providing comprehensive understanding of research aim. OTP implementation as 78% with trained health care providers, ORS and RUTF available at all health sites.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitation(s):\u003c/em\u003e\u003c/strong\u003e The evaluation focused on a limited area of OTP implementation likely impacting outcomes. Study also noted concerns with the Hawthorne effect during patient appointments/engagement with providers (initial 3 observations were removed from each post were not used in data analysis to limit this effect).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWay forward:\u003c/em\u003e\u003c/strong\u003e Develop and analyse a comprehensive framework for assessing OTP implementation. Use anonymous or confidential assessment tools for patient-provider interactions to reduce bias. Monitor follow-up to determine long-term impacts and outcomes of OTP intervention.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003ePhase 2\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eLocal Market Survey Development and Implementation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe market survey identified indigenous foods based on four evaluation areas: accessibility, affordability, availability, and sustainability. Seasonality of local foods was identified to highlight any barriers to agriculture throughout the year. Due to travel warnings issued by the U.K.\u0026rsquo;s Foreign, Commonwealth and Development Office (FCDO) in 2025, there were active travel restrictions at the time of the study proposal. Although Ethiopia consists of 12 regions with notable similarities and differences in diet, it was deemed best to survey three local markets surrounding the city centre in the Waliso District due to limited safety risks and previous connections with the University of Westminster (Jateno, \u003cem\u003eet al.\u003c/em\u003e, 2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data collection method included physical observation of available food items, including costing, photographs, and availability within the local market area. A legend was developed, as shown in Table 3, to assist in determining the level of market availability. \u0026nbsp;Ingredients observed as available in at least two market areas, or more, were included in recipe consideration to ensure accessibility for the target population. A cost-benefit analysis was conducted [see Discussion section: Economic Value of iTEFF], assessing the retailer price of items based on the price per kilogram of the food items to support the economic benefit of the recipe prototype. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Identification of Market Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdentifying Marker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 409px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 409px;\"\u003e\n \u003cp\u003eAvailable in 1 market area or \u0026lt;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e++\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 409px;\"\u003e\n \u003cp\u003eAvailable in 2 market areas or \u0026lt;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e+++\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 409px;\"\u003e\n \u003cp\u003eAvailable in all 3 market areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFoods included in the survey were selected based on widely consumed regional staples (EHNRI, 1998), using a checklist informed by CoTD-validated tools (CoTD, 2024). The checklist was completed through visual observation and real-time conversations with vendors in Waliso\u0026rsquo;s market areas, supported by the local guide who provided language translation and navigation. Prior to market days, the researcher identified likely food sources through street-level observation and cross-referenced them with the checklist. During market visits, vendors were consulted with their consent on food cost, seasonal availability, community consumption, and permission for photographs. In total, the researcher spoke to 21 vendors over the three market days attended. To remain discreet, the checklist was not carried openly during observations, and instead, notes and photos were securely recorded on a password-protected mobile device and later transferred to the electronic market survey. Data analysis and recipe prototype development were completed post-fieldwork in London. Nutrient composition of selected food items was analysed using Nutritics\u003csup\u003e\u0026copy;\u0026nbsp;\u003c/sup\u003esoftware and a country-specific nutrient composition table to determine macronutrient and micronutrient content (EHNRI, 1998). Analysis was tailored to identify nutrient-dense foods that met the nutritional requirements of the target population in the SAM treatment, with the results guiding recipe formulation (WHO, 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical Considerations, Health and Safety\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study did not involve any human participants or highly sensitive data. An Ethical application \u0026lsquo;Part-A\u0026rsquo; was completed as required for ethical clearance. All data was secured on password-protected equipment in a secure location.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrior to travel, the University of Westminster Field/Overseas Trip Risk Assessment form (e.g., Appendix G) was completed, with safety and risk mitigation measures addressed for travelling in the country. Below are the commitments agreed to:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eRespect and adherence to current local norms related to cultural customs, including respect for the local, indigenous community through actions and speech\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAdhering to travel warnings and recommendations while in the country, including avoiding areas of high volatility or danger.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003ePhase 1: Literature Review: Nutritional Recommendations for Children 6 to 59 months with SAM\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe literature review identified nutrient requirements for children under five with SAM, as shown in Table 4, in line with the World Health Organisation Guidelines for the Management of Severe Acute Malnutrition in Infants and Children (WHO, 2013). \u0026nbsp;The findings emphasised critical macro- and micronutrient needs essential for improving recovery from SAM, including vitamin A, key amino acids, and folic acid, in alignment with Sphere Standards (Tsegaye, \u003cem\u003eet al\u003c/em\u003e., 2022; Teshale, \u003cem\u003eet al\u003c/em\u003e. 2022). These recommendations responded to the significantly increased nutritional demands of children with SAM in vulnerable contexts where food insecurity and limited access to clean water are prevalent challenges impacting health outcomes (Lencha, \u003cem\u003eet al.,\u003c/em\u003e 2024; Gemechu, \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2021). Recovery of healthy body composition and minimising SAM relapse were identified as crucial factors in SAM intervention (Bune, \u003cem\u003eet al\u003c/em\u003e., 2025; Yitayew, \u003cem\u003eet al\u003c/em\u003e., 2024; Teshale, \u003cem\u003eet al\u003c/em\u003e. 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Nutrient Requirements for Children 6 to 59 months with SAM\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(Guideline: updates on the management of severe acute malnutrition in infants and children, WHO, 2013; UNICEF, 2024)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNutrient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRNI for SAM Recovery (per 100 g RUTF)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eEnergy (kcal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e100-135 kcal/kg/d (rehabilitation phase)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eCarbohydrate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e50-60% total energy intake\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eProtein\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e10-15% total energy intake\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eFat\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e30-40% total energy intake\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eIron (mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e10 mg/d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eFolate (\u0026micro;g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e150 \u0026micro;g/d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eZinc (mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e4.1 mg/d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eVitamin A (\u0026micro;g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e400 \u0026micro;g/d RAE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eVitamin C (mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e30 mg/d\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe primary indicators of successful SAM intervention included maternal support, appropriate Infant and Young Child Feeding (IYCF) practices, access to health services, and recommended nutrition supplementation, as discussed in the following section.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eKey Indicators in Severe Acute Malnutrition Recovery and Relapse\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal partnership in intervention and treatment\u003c/strong\u003e: The role of mothers in the caring and support of children with SAM was undeniable. Several studies highlighted that children with 1) mothers in the home and 2) mothers able to understand and implement SAM intervention were more likely to recover from SAM and had decreased risk of relapse (Gemechu, \u003cem\u003eet al.\u003c/em\u003e, 2021; Teshale, \u003cem\u003eet. al.\u003c/em\u003e, 2023; Tadesse, \u003cem\u003eet al.\u003c/em\u003e, 2021; Lencha, \u003cem\u003eet al.\u003c/em\u003e, 2024; Yitayew, \u003cem\u003eet al.\u003c/em\u003e, 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAppropriate IYCF practices:\u0026nbsp;\u003c/strong\u003eIn conjunction with maternal support, appropriate IYCF practices were found to be crucial not only in treating SAM but also in preventing malnutrition in children under five. Multiple studies highlighted the need for comprehensive IYCF education, specifically among women in developing countries to support appropriate feeding practices and noted the link with improved under-five mortality rates (U5MR) in areas with robust IYCF education (Gemechu, \u003cem\u003eet al.\u003c/em\u003e, 2021; Teshale, \u003cem\u003eet. al.\u003c/em\u003e, 2023; Lencha, \u003cem\u003eet al.\u003c/em\u003e, 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth promotion services, including nutrition-related programming\u003c/strong\u003e: Studies highlighted the need and benefit of ample and consistent health promotion services, specifically in providing nutrition education for caregivers of children under five years (Tadesse \u003cem\u003eet. al.\u003c/em\u003e, 2021; Yitayew \u003cem\u003eet al.\u003c/em\u003e, 2024). This was primarily achieved by supporting maternal education through community-based nutrition counselling starting from the time of infant delivery (Feleke, \u003cem\u003eet al.\u003c/em\u003e, 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImportance of essential nutrition supplementation\u003c/strong\u003e: Focused intervention that included specific micronutrient supplementation (e. g. vitamin A, iron, folate) and Ready-to-Use Therapeutic Food (RUTF) that meet Sphere Standards significantly improved SAM recovery and minimised relapse (Girma, \u003cem\u003eet al.,\u003c/em\u003e 2022; Bune, \u003cem\u003eet al.\u003c/em\u003e, 2025; Bizuneh, \u003cem\u003eet al.,\u003c/em\u003e 2022; Wondie, et al., 2022; Tsegaye, \u003cem\u003eet. al.,\u003c/em\u003e 2022). This was strengthened by the use of local, sustainable foods as an alternative RUTF in communities with established CMAM programmes as an economical solution, highlighting the ongoing need for expansion in the development of these options (Banda, \u003cem\u003eet al.,\u003c/em\u003e 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhase 2:\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003eRecipe Conceptualisation\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecipe Determination\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDevelopment of the recipe prototype was guided by nutrient requirements for the target population identified in the scoping review on SAM intervention, as shown in Table 3. Food ingredients were selected based on their nutritional benefits, price, and availability in the local market area (Araro, \u003cem\u003eet al.,\u003c/em\u003e2020; Asefa, \u003cem\u003eet al.,\u003c/em\u003e 2020). Formulation specifically addressed key nutritional deficiencies associated with SAM, including protein, zinc, iron, and vitamins A, C and K. Each component contributes essential macronutrients and micronutrients known to support immune function, tissue regeneration, and restore body composition needed in SAM recovery (Wondie, \u003cem\u003eet al.,\u003c/em\u003e2022). Selection was supported by evidence-based guidelines from the World Health Organisation (WHO) for SAM management and informed by the availability and cultural attenuation of local, indigenous food sources (WHO, 2013; Amadou and Lawaii, 2022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecipe Formulation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe recipe prototype, with the proposed name \u003cem\u003eiTEFF\u003c/em\u003e, was developed using the Nutrics\u003csup\u003e\u0026copy;\u003c/sup\u003e software to analyse the nutrient content of individual ingredients. Analysis included adherence to recommended nutrient intake for the target population and limiting the single serving size to 300 grams per serving, as shown in Table 5. Avocados, red kidney beans, kale, teff, and mangoes were selected for inclusion in the recipe. Recipe optimisation was supported by contemporary models of recipe design and considerations, with specific attention to the use of indigenous food sources, beneficial nutrients for the target population, and cost-effectiveness within a vulnerable community (Fereno \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2019; Ayoob \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2024; World Vision International, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecipe Costing Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA cost analysis was conducted for the food items selected for recipe inclusion including price per 100 g serving, weight, and market location, as shown in Table 5. Pricing was based on local market information gathered during survey collection and reflective of retail cost. The total cost of individual ingredients was calculated using the average prices across all market areas, reflecting typical local pricing. Pricing fluctuations across market areas were moderate (e.g., +/- 1-2 birr), suggesting that variations are unlikely to significantly affect affordability for the target population. Ingredient weight was provided by individual retailers and could not be weighed by the researcher for verification. All food sources were observed in their raw state, either wet or dry, based on the ingredient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Nutrient Composition and Costing Analysis of Recipe Prototype, iTEFF\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(Nutritics, 2025, WHO, 2023)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood Item\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuantity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003ew\u003c/em\u003e= wet, \u003cem\u003ed\u003c/em\u003e= dry)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCost (per 300 grams)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(1 \u003cem\u003eEthiopian birr =\u0026nbsp;\u003c/em\u003e\u0026pound;\u003cem\u003e0.01\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMangoes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e50 g\u003csup\u003ew\u003c/sup\u003e (~1 medium mango)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u0026pound;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAvocadoes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e100 g\u003csup\u003ew\u003c/sup\u003e (~1 large avocado)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u0026pound;0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eKale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e40 g\u003csup\u003ew\u003c/sup\u003e (~ \u0026frac12; bunch)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u0026pound;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eRed kidney beans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e60 g\u003cem\u003e\u003csup\u003ed\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u0026pound;0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eTeff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e50 g\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u0026pound;0.18\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Cost\u0026nbsp;\u003c/strong\u003e(per 300 g serving)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u0026pound;0.53 (\u003cem\u003eMay 2025\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 636px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNutrient Composition of iTEFF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNutrient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eper 300 g\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% RNI per WHO Guidelines\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eprovided for SAM recovery (per 100 g iTEFF)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eEnergy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e614 kcal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e16-33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eProtein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e24 g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e33-36%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e18 g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e28-33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eCarbohydrate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e77 g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e16%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eIron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e10.3 mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFolate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e382 \u0026micro;g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e84%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e2.6 mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eVitamin A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e207 \u0026micro;g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e16%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003eVitamin C\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e59 mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eRecipe Preparation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe recipe prototype, iTEFF, is a mixture of wet and dry ingredients. Proposed preparation steps are provided in Table 6. The prepared recipe would be served while warm, covered to keep out flies, and any leftovers would be discarded within 2 hours of preparation. Consistency and texture would be tailored to the child\u0026rsquo;s age and developmental stage to minimise the risk of aspiration and ensure safe ingestion. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. iTEFF Recipe Preparation\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCATEGORY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eINGREDIENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eDry ingredients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e50 g teff\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eWet ingredients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e50 g mango\u003c/li\u003e\n \u003cli\u003e100 g avocado\u003c/li\u003e\n \u003cli\u003e40 g kale\u003c/li\u003e\n \u003cli\u003e60 g red kidney bean\u003c/li\u003e\n \u003cli\u003e600 ml water\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eINSTRUCTIONS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003col\u003e\n \u003cli\u003eRinse teff. Place in pot with 350 ml water. Cook on low for 15 to 20 mins.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRinse kidney beans. Boil for 10 mins. Simmer for 1 to 1.5 hours until soft/tender*\u003c/li\u003e\n \u003cli\u003eCut mango and kale into bite-size pieces. Place in separate pot with 250 ml water and cook over medium heat until smooth\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMash avocados and cooked kidney beans into puree/paste\u003c/li\u003e\n \u003cli\u003eAdd kidney beans-avocado puree and mango-kale mixture to teff. Stir until combined and simmer for 7 to 10 minutes\u003c/li\u003e\n \u003cli\u003eServe while warm (may be soup or porridge depending on consistency)\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*Soak kidney beans overnight, preparing ahead to expedite recipe preparation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe discussion section of the report will provide overall context for the results of the scoping review, the impact of the market survey on recipe formulation, and the notable limitations of the study. This includes an enhanced understanding of the nutritional and economic benefits of the iTEFF and its potential long-term implications on the Sustainable Development Goals (SDGs).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence-Based Drivers of Recovery in Severe Acute Malnutrition\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe literature review identified primary contributors to SAM recovery as caregiver-focused nutrition education, implementation of standardised therapeutic protocols (e.g. WHO guidelines, SPHERE Standards), and the adaptation of treatment strategies to local contexts, including the use of indigenous food sources (Teshale, \u003cem\u003eet al.,\u003c/em\u003e 2023; Bune, \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2025). Caregiver-focused nutrition and health education contributed to greater resilience throughout SAM recovery and improved adherence to treatment recommendations, including appropriate RUTF utilisation and follow-up participation in outpatient therapeutic programmes (OTP) (Feleke, \u003cem\u003eet al.,\u003c/em\u003e 2024; Yitayew, \u003cem\u003eet al.,\u003c/em\u003e 2024). ensuring therapeutic interventions, including RUTF, align with RNI standards set by organisations such as WHO and SPHERE, were strongly linked to accelerated recovery and a lower incidence of relapse in children (Wondie \u003cem\u003eet al.,\u003c/em\u003e 2022; Tsegaye \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2022). The scoping review consistently emphasised the importance of developing treatment and follow-up programmes tailored to specific communities. Several studies found that locally sourced RUTF formulations were not only viable alternatives to standard products but, in some cases, outperformed them in exceeding SPHERE Standards when delivered in well-established CMAM programmes (Banda \u003cem\u003eet al.,\u003c/em\u003e 2021; Gemechu \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2021; Lencha \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the strong association between these factors and SAM recovery, few interventions have intentionally integrated them into program design. The proposed recipe prototype, iTEFF, directly aligns with the key factors identified as critical to effective SAM recovery. iTEFF leverages local, indigenous food sources as an alternative approach to SAM treatment, offering communities access to ingredients that are both locally available and economically viable. Its recipe formulation follows WHO guidelines for SAM management, ensuring that each 300-gram serving provides at least 50% of the recommended nutrient intakes (RNI). If the piloted iTEFF recipe demonstrates improved SAM recovery outcomes, future implementation would include community-based workshops for caregivers, offering practical guidance on iTEFF use, alongside nutrition education for SAM management. To support boarder scale-up, it is recommended that future efforts explore wholesale pricing with vendors to reduce retail costs and enhance the economic feasibility of the recipe. Recognising and responding to these key drivers can support the design of effective interventions and guide future research in malnutrition management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe Therapeutic Potential of iTEFF in the Context of SAM Recovery in Ethiopia\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGiven the widespread impact of SAM on overall bodily function, it is essential to identify both macronutrient and micronutrient needs to ensure interventions comprehensively support growth and development (Mwene-Batu, \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2020). iTEEF\u0026rsquo;s selected food sources are anticipated to contribute meaningfully to SAM recovery, providing a nutrient profile that meets at least 50% of the recommended RNIs, as recommended by the WHO guidelines (WHO, 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMango\u003c/em\u003e: Mangoes, classified as stone fruits, are an excellent source of vitamins A and C, dietary fibre, and antioxidants that offer notable health benefits (Nutrics, 2025). Commonly cultivated in tropical regions due to their need for warm climates, mangoes are the second-most widely grown fruit in Ethiopia (Asefa \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2020). Their nutrient composition contributes significantly to the local diet and supports SAM recovery by restoring immune function, tissue repair, and gut health (Lencha \u003cem\u003eet al.,\u003c/em\u003e 2024).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvocado\u003c/em\u003e: Avocados, often mistakenly believed to be a vegetable, are tree-grown, high-fat fruit with several beneficial nutrients, including potassium, magnesium, vitamins E, K and C, favouring warm, humid climates, most notably in the southern regions of Ethiopia (Nutrics, 2025; Embassy of Ethiopia, 2024). Avocados have been recommended in food insecurity management among developing countries as a primary intervention for malnutrition treatment, providing a significant source of the monounsaturated fat, oleic acid (World Vision International, 2021). These nutrients can play a key role in restoring electrolyte imbalances, supporting immune recovery, and reducing systemic inflammation, all of which are necessary for SAM recovery (Fekele \u003cem\u003eet al.,\u003c/em\u003e 2024).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRed Kidney Bean\u003c/em\u003e: Red kidney beans are part of the \u0026ldquo;common bean\u0026rdquo; family, which includes pinto, black, and haricot beans, and are one of the most prevalent crops in Ethiopia during the rainy season, best grown in wet, humid climates (Asefa \u003cem\u003eet al.,\u003c/em\u003e 2020). Incorporated into flour blends for its high protein content of 22.5 grams per 100-gram serving, red kidney beans are also an excellent source of iron, potassium, manganese, folate and vitamin B\u003csub\u003e1\u003c/sub\u003e (thiamine) (Nutrics, 2025). These nutrients are ideally suited for SAM management due to their positive impact on energy production, immune function and recovery from MND (Araro, \u003cem\u003eet al.,\u003c/em\u003e 2020).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eKale\u003c/em\u003e: A cruciferous vegetable associated with kale is known for its abundant nutrient composition, providing an excellent source of vitamins K, C and A in addition to potassium, fibre and folate (Nutrics, 2025). Currently, Ethiopian kale is primarily grown in the Oromia region, the largest region crossing from the western to eastern edges of the country and has been known to be underutilised considering its significant nutritional value despite being grown by 4.5 million farmers in the country annually (Asefa, \u003cem\u003eet al.,\u003c/em\u003e 2020; Embassy of Ethiopia, 2024). Its nutritional profile can help restore physiological function, promote catch-up growth, and reduce the risk of complications during SAM rehabilitation (Teshale \u003cem\u003eet al.,\u003c/em\u003e 2023).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTeff\u003c/em\u003e: Teff is a gluten-free grain native to Ethiopia and a staple of the country\u0026rsquo;s diet. It is an excellent source of protein, fibre, potassium, and iron, key nutrients for addressing common deficiencies in SAM, including anaemia and muscle wasting (Tsegaye \u003cem\u003eet al.,\u0026nbsp;\u003c/em\u003e2022). Recent studies indicate that whole-grain teff surpasses other common grains, such as maize and wheat, in micronutrient content, providing 2 to 3 times more iron, 5 times more calcium, and over twice the folate (Gebru and Kim, 2020). Teff is a highly desirable crop in Ethiopia due to its resilience during inclement weather, including drought and flooding, both of which are notable concerns in the country\u0026rsquo;s routine weather system.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEconomic Implications of iTEFF\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSevere acute malnutrition places a substantial economic burden on Ethiopia, as well-documented in this report. This study aimed to identify a cost-effective intervention that not only addresses the high prevalence of SAM but also contributes to broader poverty alleviation efforts. The use of underutilised, locally available food sources, such as those in iTEFF, can enhance agricultural sustainability, promote workforce development, and strengthen socio-economic resilience (Amadou and Lawaii, 2022). A key finding of this study is that iTEFF presents a viable, lower-cost alternative to standard therapeutic foods. According to WHO guidelines, RUTFs should provide 150-180 kcal/kg/d for SAM treatment (WHO, 2013). The widely used Plumpy\u0026rsquo;Nut delivers 520-550 kcal per sachet and costs approximately $2.50 USD per 500 grams (UNICEF Supply Catalogue, 2018). In comparison, iTEFF demonstrates a cost savings of $0.33 USD per 100 grams, underscoring its potential as an economic and sustainable solution for SAM interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eiTEFF and the Sustainable Development Goals (SDGs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary objective of this intervention is to improve the nutritional status of the target population by using the proposed recipe, iTEFF. Key indicators of successful SAM recovery, including weight gain, restoration of lean muscle mass, and correction of micronutrient deficiencies, are potential outcomes of iTEFF implementation. This aligns with the 2030 Sustainable Development Goals (SDGs), particularly SDG 2 (zero hunger) and SDG 3 (health and well-being for all) (UN, 2025). The anticipated public health outcomes associated with iTEFF use are outlined in Table 7.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7: Predictive Benefits of iTEFF in Connection to SDGs\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictive Benefits of iTEFF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLink with SDGs\u0026nbsp;\u003c/strong\u003e(\u003cem\u003eUnited Nations, 2025\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eRestoration of healthy nutritional status including weight regain lean muscle mass and alleviation of micronutrient deficiencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e2.2 End all forms of malnutrition, including achieving\u0026hellip;. internationally agreed targets on stunting and wasting in children under 5 years of age\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eUse of local, indigenous food sources for vulnerable populations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e2.1 Ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eUse of local, indigenous food sources for recipe prototype\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e2.4 Ensure sustainable food production systems and implement resilient agricultural practices that increase productivity and production, that help maintain ecosystems\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eAddressing U5MR in SAM intervention for target population\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e3.2 end preventable deaths of newborns and children under 5 years of age\u0026hellip;. under-5 mortality to at least as low as 25 per 1,000 live births\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eProvide economic option for SAM intervention with cost-effective TFR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e1.1 Eradicate extreme poverty for all people everywhere, currently measured as people living on less than $1.25 a day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eIdentified Limitations to Project Implementation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFieldwork for this project was conducted in a geographically limited area of a developing country, where notable challenges emerged. These limitations highlight important considerations for future implementation and scale-up. Identified constraints and their implications are discussed in the following section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurveyable market area\u003c/strong\u003e: Due to ongoing conflict, regional unrest and travel advisories, data collection was limited to the Waliso area. While valuable insights were obtained, a comprehensive assessment of the intervention\u0026rsquo;s potential would require expanding market surveys to additional regions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of water and electricity during fieldwork\u003c/strong\u003e: During the fieldwork week, Waliso experienced a significant power outage that severely limited access to water and electricity. This disruption affected local markets, disrupting the availability of food items and the ability of vendors to operate. For future scale-up, it would be advisable to extend fieldwork over 3 to 6 months, incorporating monthly market surveys to capture trends, fluctuations, and supply consistency under both stable and unforeseen conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarket vendor perceptions of the researcher\u003c/strong\u003e: While vendors were generally willing to share information about food products, some expressed disappointment that the research did not include purchasing food items. For future scale-up, it is recommended that the research budget include funds for purchasing selected foods, both as a gesture of goodwill and to support data collection. Collaborating with local hospitals or community health workers could facilitate the appropriate distribution of these foods, ensuring ethical and community-focused engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSeasonal variability and availability\u003c/strong\u003e: Fieldwork was conducted over 1 week during a visit to Waliso during the traditional rainy season. To ensure sustainability and broader applicability, additional market surveys should be carried out across different seasons to assess the impact of seasonal changes on food availability. This would help identify any significant fluctuations that may affect ingredient access. In addition, it may be necessary to develop multiple recipe variations tailored to seasonal food availability, enabling greater flexibility and comprehensive intervention strategies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecipe conceptualisation\u003c/strong\u003e: Although fieldwork data informed the recipe prototype, the recipe was formulated using virtual tools, including Nutritics. Due to time constraints, the recipe was not physically prepared or tested with a target population for acceptability and receptivity. For future scale-up, the proposed next steps include delivering community workshops for mothers of children under five, offering guidance on recipe preparation and home implementation. These sessions would also provide valuable opportunities to collect user feedback and assess practical feasibility.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion and recommendations ","content":"\u003cp\u003eThis study aimed to identify a nutrient-dense, locally sourced, and sustainable option for modulating severe acute malnutrition in children aged 6 to 59 months in Waliso, Ethiopia. The broader objective would be to utilise the recipe framework with similar populations across the country and globally. The conceptualisation of iTEFF included important aspects of nutrient optimisation in the SAM intervention, and its economic value provides a cost-effective alternative to traditional RUTF in economically constrained countries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKey findings of the study identified current gaps in SAM intervention and treatment, including sustainable options that decrease reliance on foreign aid. The literature review provided insight into the primary factors in successful SAM intervention, including the impact of maternal awareness of IYCF and health promotion services. iTEFF can help meet these identifiable markers of improvement and support alignment with the Sustainable Development Goals (SDGs) by improving the nutritional status and overall health of children under 5 years old. It is recommended that children with SAM be treated in community-based settings to minimise travel burdens on caregivers and reduce the risk of hospital-acquired infections, emphasising the need for alternative treatment protocols independent of inpatient admission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs in all research, opportunities for improvements and recommendations need to be addressed. The primary limitation of the study was the inability to test the recipe prototype within the target population. A recommendation for scalability is to test iTEFF in the community setting to determine beneficial outcomes. For future research-scale-up, it is proposed to conduct an intervention programme to pilot the recipe prototype. Based on findings, it is recommended to share the optimised recipe with mothers of children with SAM through community-based workshops.\u0026nbsp;If feasible, the follow-up study would also expand market surveys to additional regions of the country to provide a more robust, comprehensive understanding of the food system, including accessibility and seasonality. Addressing each of these areas of improvement would provide exponential validation of the proposed recipe\u0026apos;s efficacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthiopia is among the fastest-growing economies in Africa and is expected to play an impactful role in the region\u0026rsquo;s development. With ongoing armed conflict and devastating food insecurity, the country vitally needs options for addressing severe acute malnutrition in the under-five population for the future development of the country. This dissertation provides a nutrient-dense, economical, and sustainable option to address a primary health concern of severe acute malnutrition in Ethiopia. Future scale-up and ongoing support for interventions like iTEFF could significantly reduce global under-five mortality rates associated with SAM and improve the health and livelihoods of future generations in developing countries.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCMAM: Community Management of Acute Malnutrition\u003c/p\u003e\n\u003cp\u003eEDHS: Ethiopian Demographic Health Survey\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFCDO: Foreign, Commonwealth and Development Office\u003c/p\u003e\n\u003cp\u003eHSTP-II: Ethiopian Health Sector Transformation Plan II\u003c/p\u003e\n\u003cp\u003eEPHI: Ethiopian Public Health Institute\u003c/p\u003e\n\u003cp\u003eIYCF: Infant and Young Child Feeding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLBW: Low Birth Weight\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMND: Micronutrient Deficiency\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNNP: National Nutrition Programme\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOTP: Outpatient Therapeutic Programme\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e\n\u003cp\u003ePICO: Population, Intervention, Comparison, Outcome\u003c/p\u003e\n\u003cp\u003eRUTF: Ready-to-Use Therapeutic Food\u003c/p\u003e\n\u003cp\u003eSAM: Severe Acute Malnutrition\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDG: Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eTFR: Tailored-Functional Recipe\u003c/p\u003e\n\u003cp\u003eU5MR: Under-Five Mortality Rate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUNICEF: United Nations International Children\u0026rsquo;s Emergency Fund\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.M. and I.T. collaborated on scoping review, research protocol, literature search,\u003c/p\u003e\n\u003cp\u003edata extraction, and synthesis of findings, with C.M. leading and I.T. guiding,\u003c/p\u003e\n\u003cp\u003edrafting, revising, and approving the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they did not receive any funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data generated during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Westminster, in accordance with the code of practice governing the ethical conduct of research and the institution\u0026apos;s code of good research practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors state that they possess no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 School of Life Sciences, University of Westminster, 115 New Cavendish Street, London W1W 6UW, UK.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdi, F.A., Gemede, H.F. and Olika Keyata, E. 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Available at: https://iris.who.int/handle/10665/95584 (Accessed: May 13 2025).\u003c/li\u003e\n\u003cli\u003eWorld Vision International (2021) \u003cem\u003eAddressing malnutrition through avocados in Peru. \u003c/em\u003eAvailable at: https://www.wvi.org/stories/hunger-crisis/more-than-a-meal/addressing-malnutrition-through-avocados-peru (Accessed: 6 June 2025).\u003c/li\u003e\n\u003cli\u003eYemane, G.D. (2022) \u0026apos;The factors associated with under-five mortality in Ethiopia\u0026apos;, \u003cem\u003eAnnals of Medicine \u0026amp;amp; Surgery, \u003c/em\u003e79 Available at: https://doi.org/10.1016/j.amsu.2022.104063.\u003c/li\u003e\n\u003cli\u003eYitayew, Y.A., Yalew, Z.M., Nebiyu, S. and Jember, D.A. (2024) \u0026apos;Acute malnutrition relapse and associated factors among 6\u0026ndash;59 months old children treated in the community-based management of acute malnutrition in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia\u0026apos;, \u003cem\u003eFrontiers in Public Health, \u003c/em\u003e11 Available at: https://doi.org/10.3389/fpubh.2023.1273594.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bulletin-of-the-national-research-centre","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnrc","sideBox":"Learn more about [Bulletin of the National Research Centre](https://BNRC.springeropen.com)","snPcode":"42269","submissionUrl":"https://submission.springernature.com/new-submission/42269/3","title":"Bulletin of the National Research Centre","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Severe acute malnutrition, tailored-functional recipe (TFR), children 6 to 59 months, Ethiopia, nutrient","lastPublishedDoi":"10.21203/rs.3.rs-8997306/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8997306/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Severe acute malnutrition (SAM) remains a critical public health crisis in Ethiopia, affecting 1.2 million children in 2023 alone. This study aimed to conceptualise a nutrient-dense, tailored-functional recipe (TFR) to modulate SAM in children 6 to 59 months in Waliso, Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe study was conducted in two phases: a literature review and fieldwork for data collection and recipe development. A scoping review, based on the Campbell systematic review protocol, identified current approaches to SAM intervention. A market survey was conducted to assess local food security, including availability, pricing and seasonality of ingredients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe literature review highlighted best practices in SAM treatment, including nutrient requirements, recovery indicators, and relapse prevention, such as maternal support and access to health services. Guided by this evidence, a nutrient-dense recipe prototype, iTEFF, was developed. Ingredient selection was based on nutritional value, availability, and affordability. The final recipe included mangoes (50 g), avocados (100 g), kale (40 g), red kidney beans (60 g), and teff (50 g), with a total of 300 g per serving, costing £0.53 per serving.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe study identified key gaps in current SAM interventions, particularly the need for sustainable, locally sourced solutions to reduce dependence on foreign aid. The iTEFF recipe provides at least 50% of the recommended nutrient intakes (RNIs) for essential nutrients needed for recovery in children under five. It represents a culturally appropriate, cost-effective, and scalable option for SAM management. Future research should focus on testing iTEFF in community settings to evaluate efficacy and expanding the market surveys to support broader implementation.\u003c/p\u003e","manuscriptTitle":"Design and optimisation of a tailored nutrient-dense functional recipe to modulate severe acute malnutrition in children aged 6–59 months in Waliso, Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 15:10:36","doi":"10.21203/rs.3.rs-8997306/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-28T18:56:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T16:00:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T17:59:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78208673004973801694745943165300795617","date":"2026-04-15T17:20:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117964703768553488828816842236637430193","date":"2026-04-15T16:45:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6752330451168090698323644725421810778","date":"2026-04-11T16:54:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-09T19:14:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T13:40:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-03T23:50:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Bulletin of the National Research Centre","date":"2026-02-28T18:04:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bulletin-of-the-national-research-centre","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnrc","sideBox":"Learn more about [Bulletin of the National Research Centre](https://BNRC.springeropen.com)","snPcode":"42269","submissionUrl":"https://submission.springernature.com/new-submission/42269/3","title":"Bulletin of the National Research Centre","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8cd0e5e-e6e7-4495-aaf4-68f295ab7694","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T19:08:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 15:10:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8997306","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8997306","identity":"rs-8997306","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}