A Global Scoping Review on Alternative Ready-to-Use Therapeutic Foods

Alternative ready-to-use therapeutic foods (RUTF) formulations provide an opportunity to lower costs, facilitate local or national ingredient use, and enhance the availability and acceptability of RUTF. This scoping review aimed to identify and categorise the available evidence on alternative RUTF formulations developed and tested globally, assess their compliance with international standards and summarise evidence on acceptability, cost, effectiveness, cost-effectiveness and adverse events, highlighting evidence gaps to guide future research. Searches of three databases and extensive grey literature were conducted covering the period from 1999 to June 2023. Fifty-four articles, 42 peer-reviewed articles and 12 grey literature sources were included. Fifty-three RUTF formulations at various development stages for the treatment of severe acute malnutrition (SAM) without medical complications in children 6-59 months were identified. Numerous ingredients have undergone testing to replace primarily peanuts and/or milk, demonstrating consistent acceptance and promising results in terms of effectiveness. Evidence on outcomes beyond anthropometric recovery, such as higher iron status, and effects on cognitive and developmental outcomes or gut microbiome, is also limited. Few studies evaluated the cost implications, revealing potential savings in production costs while no significant differences were found in terms of safety. Additional evidence is required on how reduced or milk-free formulations within the innovation and novel categories can achieve compliance with the required protein digestibility-corrected amino acid score (PDCAAS) recommendations. Further research is also needed with specific focus on outcomes beyond anthropometric recovery such as cost-effectiveness, accessibility, macro and micronutrient deficiencies, sustainability of recovery and longer term health outcomes.