Assessing the Potential Impact and Cost- Effectiveness of Biofortified Provitamin a Maize in Zambia and High Zinc Rice in Bangladesh.

Objectives: Biofortification is a fast emerging agricultural technology and nutrition strategy for addressing hidden hunger. The impact and cost-effectiveness of biofortified provitamin A maize (VAM) in Zambia and high zinc rice (HZR) in Bangladesh were examined. Methods: In each country, farmers' adoption, production and marketing of the biofortified crops were modeled using empirically-derived estimates of similar varieties. We used the adoption functions to estimate the probability of adoption by farmers using household consumption and expenditure survey (HCES) databases, and, combined with the IFPRI IMPACT model predictions of yearly crop production through 2042, generated annual estimates of the biofortified crop planted and harvested. Using food composition table together with the HCES-reported quantities of foods apparently consumed, we estimated the usual intake of key nutrients and the prevalence of inadequate intakes without biofortified crops. We estimated the additional nutrient intakes as the quantities of biofortified food consumed and its additional nutrient content, and measured changes in the prevalence of inadequate intakes and in the number of Disability-Adjusted Life Years (DALYs) saved. We combined the DALY estimates with cost data to derive cost-effectiveness measures, annually and over the entire 30-year period. Results: Both interventions were highly cost effective. The cost of HZR was half VAM's $23.70 per DALY saved due to HZR's relatively greater added nutrient content, zinc's greater stability, and HZR's higher adoption rate, which reflects Bangladesh's relatively more developed seed market and value chain. Conclusions: Biofortification is a promising new technology. Its impact will vary by micronutrient, crop and country-specific characteristics.

Building on Uganda's Progress in Reducing Anemia among Children: From Evidence to Action.

Objectives: Anemia is a problem of public health significance in Uganda. In 2001, 71% of children under-five were anemic. In 2011, the prevalence of anemia had declined to 50% among children. This large decline in anemia prevalence has prompted questions of what factors have contributed to the reductions in prevalence. The SPRING project with the MOH, undertook a secondary analysis of the Uganda Demographic and Health Surveys (UDHS) to understand changes in anemia prevalence among children. Methods: The study analyzed the trends in anemia prevalence and explored the plausibility of different programs having played a role in the prevalence of anemia in among children 6-59 months using the UDHS 2001, 2006 and 2011. Results: There were broad based reductions of anemia prevalence across all strata of children in country between 2006 and 2011. There was also a striking growth in the number of anemia-relevant programs that Ugandan children engaged in. When participation in deworming, vitamin A supplementation, and bed nets programs was measured-the mean number of programs that children 6-23 months participated in increased from 1.31 in 2006 to 1.63 in 2011, and among 24-59m olds, the number increased from 1.28 to 1.71, an increase of 34%. Conclusions: Although the changes in anemia prevalence cannot be causally linked to changes in anemia-related program coverage due to the limitations of the data, the greatest reductions in anemia prevalence were seen among children engaged in anemia-related programs. Program participation in Uganda seems to be a significant factor in changing anemia prevalence among children in Uganda.

Iron-folic Acid Distribution and Consumption through Antenatal Care: Identifying Barriers across Countries.

Objectives: Despite renewed efforts, the prevalence of maternal anemia is unacceptably high in developing countries. Iron-folic acid (IFA) supplementation and coverage through antenatal care (ANC) is persistently low and remains under-resourced and underutilized. In recognition of these barriers, USAID's SPRING Project developed a rapid, initial assessment tool to help identify constraints within ANC programs that inhibit pregnant women from getting and consuming an ideal minimum number of 180 IFA tablets. Methods: The tool identifies four sequential points at which the ANC system might falter: ANC attendance, IFA receipt or purchase, IFA consumption, and compliance with WHO-recommendations for the ideal minimum number of tablets. Twenty-two high-burden countries were analyzed based on secondary analysis of Demographic and Health Survey (DHS) data. Results: Across all countries, 83% of all pregnant women had at least one ANC visit, and 81% of those women received IFA tablets of which 95% consumed at least one tablet. Overall adherence to daily iron supplementation, however, is low. Only 9% of pregnant women consumed 180 or more IFA tablets. Just two countries had more than 30% of women consume 180 or more tablets during pregnancy. Conclusions: Although the tool cannot isolate the direct causes of a system’s faltering performance, it provides an instrument by which policymakers may investigate its shortcomings. Given the significance of the fourth falter point across all countries, potential areas for investigation include the adequacy of IFA tablet supplies and the technical knowledge, practices, and availability of ANC providers.

Juxtaposing Nutrient Intake Estimates from 24-Hour Recall, 7-Day Recall, and Household Income and Expenditure Survey (HIES): Comparing Bangladesh’s Integrated Household Survey (BIHS 2011-12) and Its Income and Expenditure Survey (2010 HIES).

Objectives: Understanding food consumption patterns and nutrient intakes is essential for informing nutrition policymaking. However, there is no consensus on which is the “best” method for measuring them. This study juxtaposes nutrient intake estimates using three alternative dietary assessment methods: A 24-hour recall (24HR) and a household-based 7-day recall (7DR)—both collected in the 2011-2012 BIHS—and a 14-day diary (14DD) collected in the 2010 HIES. Methods: Food Composition Tables (FCTs) were used to estimate the nutrient content of the foods consumed. To calculate individual nutrient intake from household consumption in the 7DR and 14DD, we applied the concept of Adult Male Equivalents (AME). We then compared the estimated values with results from the 24HR. Results: On average, the 7DR estimates of the daily intakes of kilocalories, iron, zinc, and vitamin A were 13%, 15%, and 18% higher, respectively, than 24HR estimates at the national and subnational levels. Vitamin A estimates varied more markedly: they were 32% higher at the national level and up to 58% higher at the subnational level. Comparisons of the same measures will also be made with the 14DD data. Conclusions: With the exception of vitamin A, estimates based on the 7DR are relatively close to measures of individual nutrient intake provided in the 24HR. For many applications, the two methods provide adequately precise measures of nutrient intakes. Further work is needed to determine the sources of variation in the methods, how to improve the precision of the estimates, and how to assess the external validity of these findings.

Zambia's Micronutrient Program Portfolio Options: A Vitamin A Case Study, 2013 to 2042.

Objectives: There is an urgent need to better understand the interactions of multiple nutrition programs so that they can be managed more effectively to improve coverage and impact, reduce costs and protect persons from the risk of excess micronutrient intakes. The objective was to examine Zambia’s micronutrient program portfolio options over the next 30 years. Methods: 2006 Living Conditions Monitoring Survey food consumption and acquisition data and a Zambian food composition table were used to estimate usual intakes of calories and key micronutrients and the prevalence of inadequate intakes. The annual coverage, impact and cost of six vitamin A interventions were analyzed. The interventions included four potentially fortifiable staples, vitamin A supplementation through Child Health Week (CHW) and a biofortified high pro-vitamin A maize. All 62 possible combinations of the six interventions’ annual costs, changes in the prevalence of inadequate intake and the total number of disability-adjust life years (DALYs) saved annually were estimated from 2013-2042, drawing on the IFPRI IMPACT model’s predictions of food production and consumption patterns. Results: Oil and sugar offer the greatest coverage (67%-69%) while biofortification can reach greater than 50%. Supplementation and sugar and oil fortification produce the greatest impacts. The most cost-effective 1, 2, and 3-program interventions portfolios are oil fortification; oil plus biofortification; and oil plus biofortification and supplementation. Conclusions: Each intervention plays a significant role in combating micronutrient deficiency in Zambia. The choice of combinations of the specific vehicles and the order in which interventions are sequenced affects the optimal mix.