Multiple micronutrient supplementation cost-benefit tool for informing maternal nutrition policy and investment decisions.

Antenatal multiple micronutrient supplementation (MMS) is an intervention that can help reach three of the six global nutrition targets, either directly or indirectly: a reduction in low birth weight, stunting, and anaemia in women of reproductive age. To support global guideline development and national decision-making on investments into maternal nutrition, Nutrition International developed a modelling tool called the MMS cost-benefit tool to help users understand whether antenatal MMS is better value for money than iron and folic acid supplementation (IFAS) during pregnancy. The MMS cost-benefit tool can generate estimates on the potential health impact, budget impact, economic value, cost-effectiveness and benefit-cost ratio of investing in MMS compared to IFAS in LMICs. In the 33 countries with data included in the tool, the MMS cost-benefit tool shows that transitioning is expected to generate substantial health benefits in terms of morbidity and mortality averted and can be very cost-effective in multiple scenarios for these countries. The cost per DALY averted averages at US$ 23.61 and benefit-cost ratio ranges from US$ 41-US$ 1304: $1.0, which suggest MMS is good value for money compared with IFAS. With its user-friendly design, open access availability, and online data-driven analytics, the MMS cost-benefit tool can be a powerful resource for governments and nutrition partners seeking timely and evidence-based analyses to inform policy-decision and investments towards the scale-up of MMS for pregnant women globally.

Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study.

BACKGROUND: Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition. METHODS AND FINDINGS: Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability. CONCLUSIONS: In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.

Net benefit and cost-effectiveness of universal iron-containing multiple micronutrient powders for young children in 78 countries: a microsimulation study.

BACKGROUND: Universal home fortification of complementary foods with iron-containing multiple micronutrient powders (MNPs) is a key intervention to prevent anaemia in young children in low-income and middle-income countries. However, evidence that MNPs might promote infection raises uncertainty about whether MNPs give net health benefits and are cost-effective. We aimed to determined country-specific net benefit or harm and cost-effectiveness of universal provision of MNPs to children aged 6 months. METHODS: We developed a microsimulation model to estimate net country-specific disability-adjusted life-years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) due to anaemia, malaria, and diarrhoea averted (or increased) by provision of a 6-month course of MNPs to children aged 6 months, compared with no intervention, who would be followed up for an additional 6 months (ie, to age 18 months). Anaemia prevalence was derived from Demographic and Health Surveys or similar national surveys, and malaria and diarrhoea incidence were sourced from the Global Burden of Disease Study. Programme and health-care costs were modelled to determine cost per DALY averted (US$). Additionally, we explored the effects of reduced MNP coverage in a sensitivity analysis. FINDINGS: 78 countries (46 countries in Africa, 20 in Asia or the Middle East, and 12 in Latin America) were included in the analysis, and we simulated 5 million children per country. 6 months of universal distribution of daily MNPs, assuming 100% coverage, produced a net benefit (DALYs averted) in 54 countries (24 in Africa, 19 in Asia and the Middle East, 11 in Latin America) and net harm in 24 countries (22 in Africa, one in Asia, and one in Latin America). MNP intervention provided a benefit on YLDs associated with anaemia, but these gains were attenuated and sometimes reversed by increases in YLLs associated with malaria and diarrhoea, reducing the benefits seen for DALYs. In the 54 countries where MNP provision was beneficial, the median benefit was 28·1 DALYs averted per 10 000 children receiving MNPs (IQR 20·6-40·4), and median cost per DALY averted was $3576 (IQR 2474-4918). DALY effects positively correlated with moderate and severe anaemia prevalence in Asia, the Middle East, and Latin America, but correlated inversely in Africa. Suboptimal coverage markedly reduced DALYs averted and cost-effectiveness. INTERPRETATION: Net health benefits of MNPs vary between countries, are highest where prevalence of moderate and severe anaemia is greatest but infection prevalence is smallest, and are ameliorated when coverage of the intervention is poor. Our data provide country-specific guidance to national policy makers. FUNDING: International Union of Nutrition Sciences.

Replacing iron-folic acid with multiple micronutrient supplements among pregnant women in Bangladesh and Burkina Faso: costs, impacts, and cost-effectiveness.

Consumption of multiple micronutrient supplements (MMS) during pregnancy offers additional benefits compared with iron-folic acid (IFA) supplementation, but the tablets are more expensive. We estimated the effects, costs, and cost-effectiveness of hypothetically replacing IFA supplements with MMS for 1 year in Bangladesh and Burkina Faso. Using baseline demographic characteristics from LiST and effect sizes from a meta-analysis, we estimated the marginal effects of replacing IFA with MMS on mortality, adverse birth outcomes, and disability-adjusted life years (DALYs) averted. We calculated the marginal tablet costs of completely replacing MMS with IFA (assuming 180 tablets per covered pregnancy). Replacing IFA with MMS could avert over 15,000 deaths and 30,000 cases of preterm birth annually in Bangladesh and over 5000 deaths and 5000 cases of preterm birth in Burkina Faso, assuming 100% coverage and adherence. We estimated the cost per death averted to be US$175-185 in Bangladesh and $112-125 in Burkina Faso. Cost per DALY averted ranged from $3 to $15, depending on the country and consideration of subgroup effects. Our estimates suggest that this policy change would cost-effectively save lives and reduce life-long disabilities. Improvements in program delivery and supplement adherence would be expected to improve the cost-effectiveness of replacing IFA with MMS.

Longitudinal change in the diet's monetary value is associated with its change in quality and micronutrient adequacy among urban adults.

BACKGROUND: Reducing diet costs may lead to the selection of energy-dense foods, such as refined grains or foods high in added sugars and/or fats, which can lower overall dietary quality. We examined the longitudinal association between the monetary value of the diet (MVD) and the overall dietary quality across sex, race and income groups. METHODS AND FINDINGS: Longitudinal data from 1,466 adult urban participants from Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study were used. Healthy Eating Index-2010 (HEI-2010) and Mean Adequacy Ratio (MAR) were computed and a national food price database was used to estimate MVD. Multiple linear regression analyses were conducted linking annual rates of change (Δ) in MVD to ΔHEI-2010 and ΔMAR, stratifying by sex, race and income groups. Among key findings, ΔHEI-2010 was comparable across socio-demographic groups, while ΔMAR was higher among women and individuals above poverty. Adjusting for key covariates, ΔMVD was positively associated with both ΔHEI-2010 and ΔMAR, and with a consistently stronger association among individuals above poverty, specifically for the total proteins and empty calories components of HEI-2010 and several nutrient adequacy ratios (NARs: vitamins C, E, B-6 and Zinc). ΔMVD-ΔMAR association was stronger in women, mainly influenced by ΔMVD's positive associations with B-vitamins, copper, calcium, magnesium and phosphorus NARs. ΔMVD-Δvitamin D NAR's positive relationship was stronger among Whites, while ΔMVD-Δvitamin B-12 NAR's association was stronger among African-Americans. CONCLUSIONS: In sum, a potential increase in MVD may have a stronger impact on dietary quality among urban adult women and above-poverty individuals.

Household demand persistence for child micronutrient supplementation.

Addressing early-life micronutrient deficiencies can improve short- and long-term outcomes. In most contexts, private supply chains will be key to effective and efficient preventative supplementation. With established vendors, we conducted a 60-week market trial for a food-based micronutrient supplement in rural Burkina Faso with randomized price and non-price treatments. Repeat purchases - critical for effective supplementation - are extremely price sensitive. Loyalty cards boost demand more than price discounts, particularly in non-poor households where the father is the cardholder. A small minority of households achieved sufficient supplementation for their children through purely retail distribution, suggesting the need for more creative public-private delivery platforms informed by insights into household demand persistence and heterogeneity.

Local foods can meet micronutrient needs for women in urban Burkina Faso, but only if rarely consumed micronutrient-dense foods are included in daily diets: A linear programming exercise.

Women of reproductive age are at nutritional risk due to their need for nutrient-dense diets. Risk is further elevated in resource-poor environments. In one such environment, we evaluated feasibility of meeting micronutrient needs of women of reproductive age using local foods alone or using local foods and supplements, while minimizing cost. Based on dietary recall data from Ouagadougou, we used linear programming to identify the lowest cost options for meeting 10 micronutrient intake recommendations, while also meeting energy needs and following an acceptable macronutrient intake pattern. We modeled scenarios with maximum intake per food item constrained at the 75th percentile of reported intake and also with more liberal maxima based on recommended portions per day, with and without the addition of supplements. Some scenarios allowed only commonly consumed foods (reported on at least 10% of recall days). We modeled separately for pregnant, lactating, and nonpregnant, nonlactating women. With maxima constrained to the 75th percentile, all micronutrient needs could be met with local foods but only when several nutrient-dense but rarely consumed items were included in daily diets. When only commonly consumed foods were allowed, micronutrient needs could not be met without supplements. When larger amounts of common animal-source foods were allowed, all needs could be met for nonpregnant, nonlactating women but not for pregnant or lactating women, without supplements. We conclude that locally available foods could meet micronutrient needs but that to achieve this, strategies would be needed to increase consistent availability in markets, consistent economic access, and demand.

A review of economic evaluations for beneficial health outcomes of micronutrient and long-chain omega-3 fatty acid supplementation.

A comprehensive review of the literature identified 13 papers exploring economic evaluations of supplementation with micronutrients or long-chain omega-3 fatty acids in developed countries. Evidence of efficacy included single-study-based estimates and estimates based on published meta-analyses or data synthesis. Results suggest that supplementation with specific micronutrients or long-chain omega-3 fatty acids for specific health outcomes, and targeted at particular population groups, may be cost-effective or deliver cost savings for health care providers. While the quality of the analyses was variable and some authors reported considerable uncertainty of the results, the approaches adopted were in the main conservative. This suggests that investigating the potential economic impact of supplementation, particularly where there is good evidence of efficacy and predicted clinical benefit, is informative. Economic evaluations may also be useful to assess whether further nutritional research into particular health outcomes is a good investment of funds.

Situation analysis of procurement and production of multiple micronutrient supplements in 12 lower and upper middle-income countries.

Globally, there are few vitamin and mineral ingredient manufacturers. To support local, in-country or regional procurement and production of multiple micronutrient supplements (MMS), the following production scenarios are possible: (a) straight ingredients of vitamins and minerals forms imported or locally produced that are mixed, tableted, or encapsulated and packaged by a local manufacturer; (b) import or local production of a vitamin and minerals premix that is tableted or encapsulated and packaged locally; (c) import of a bulk, finished product (tablets or capsules) that is packaged and branded; and (d) or import of a branded packaged product. This paper is a situation analysis of the market, manufacturing, and policy factors that are driving the production of MMS in 12 lower and upper middle-income countries. Key informants completed a self-administered structured questionnaire, which examined the local context of products available in the market and their cost, regulations and policies, in Brazil, Colombia, Guatemala, Mexico, Peru, Bangladesh, India, Vietnam, Ghana, Kenya, Nigeria, and South Africa. Our study found that although most countries have the capacity to produce locally MMS, the major barriers observed for sustainable and affordable production include (a) poor technical capacity and policies for ensuring quality along the value chain and (b) lack of policy coherence to incentivize local production and lower the manufacture and retail price of MMS. Also, better guidelines and government oversight will be required because not one country had an MMS formulation that matched the globally recommended formulation of the United Nations Multiple Micronutrient Preparation (UNIMMAP).

Position of the Academy of Nutrition and Dietetics: Food Insecurity in the United States.

It is the position of the Academy of Nutrition and Dietetics that systematic and sustained action is needed to achieve food and nutrition security in the United States. To achieve food security, effective interventions are needed, along with adequate funding for, and increased utilization of, food and nutrition assistance programs; inclusion of nutrition education in such programs; strategies to support individual and household economic stability; and research to measure impact on food insecurity- and health-related outcomes. Millions of individuals living in the United States experience food insecurity. Negative nutritional and non-nutritional outcomes are associated with food insecurity across the lifespan, including substandard academic achievement, inadequate intake of key nutrients, increased risk for chronic disease, and poor psychological and cognitive functioning. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, play key roles in addressing food insecurity and are uniquely positioned to make valuable contributions through competent and collaborative practice, provision of comprehensive food and nutrition education and training, innovative research related to all aspects of food insecurity, and advocacy efforts at the local, state, regional, and national levels.

The Prevalence of Micronutrient Deficiencies and Inadequacies in the Middle East and Approaches to Interventions.

Micronutrient deficiencies and inadequacies constitute a global health issue, particularly among countries in the Middle East. The objective of this review is to identify micronutrient deficits in the Middle East and to consider current and new approaches to address this problem. Based on the availability of more recent data, this review is primarily focused on countries that are in advanced nutrition transition. Prominent deficits in folate, iron, and vitamin D are noted among children/adolescents, women of childbearing age, pregnant women, and the elderly. Reports indicate that food fortification in the region is sporadic and ineffective, and the use of dietary supplements is low. Nutrition monitoring in the region is limited, and gaps in relevant information present challenges for implementing new policies and approaches to address the problem. Government-sponsored initiatives are necessary to assess current dietary intakes/patterns, support nutrition education, and to reduce food insecurity, especially among vulnerable population groups. Public-private partnerships should be considered in targeting micronutrient fortification programs and supplementation recommendations as approaches to help alleviate the burden of micronutrient deficiencies and inadequacies in the Middle East.

Identifying acceptability and price points for purchasing micronutrient powders for children 2 to 5 years old in Nepal.

BACKGROUND AND OBJECTIVE: Little is known about purchasing micronutrient powders (MNP) for children 2-5 years. We describe acceptability for purchasing and price points for MNP for children 2-5 years among caregivers living in districts where free MNP are distributed for children 6-23 months. METHODS AND STUDY DESIGN: Crosssectional surveys conducted 3 months after MNP program implementation in 2 districts; 15 months after implementation in 2 different districts. Chi square tests and logistic regression describe associations among sociodemographics and program exposure factors and acceptability of purchasing MNP among 1,261 mothers of children 6-23 months who had heard of MNP. RESULTS: Overall, 77.5% and 86.1% of mothers reported acceptability for purchasing MNP in the 3 and 15 month surveys, respectively. Positive pricing attitude (PPA) about paying 150 Nepali rupees for 60 sachets of MNP was reported by 66.3% and 73.4% of mothers. Acceptability for purchasing MNP in both time periods increased with higher wealth quintile and higher maternal education; PPA increased with higher maternal education. Controlling for socio-demographics, program exposure factors associated with acceptability for purchasing MNP included: lack of perceived barriers to MNP intake and health worker counselling (3 month surveys); knowledge of benefits of MNP intake and lack of perceived barriers to MNP intake (15 month surveys). CONCLUSIONS: Mothers reported acceptability for purchasing MNP and PPA for older children in Nepal. Differences in acceptability were found across socio-demographics and program exposures. Use of these results and further exploration into actual purchasing behaviour can inform future MNP distribution methods in Nepal.

A rapid assessment and response approach for socially marketed nutrition commodities in Viet Nam.

BACKGROUND: The leading cause of death in children in developing countries is protein-energy malnutrition. In Viet Nam, 25.9% of children under 5 experience stunted growth and 6.6% are moderately wasted. Iron deficiency anaemia and vitamin A deficiency contribute to these and other malnutrition conditions. OBJECTIVES: Given these factors, more evidence based approaches are required to improve understanding of current attitudes, opinions and behaviours of mothers with young children, in order to operationalise social marketing of nutrition commodities in Viet Nam. METHODS AND STUDY DESIGN: A literature review supported a rapid assessment and response method involving semi-structured interviews with 77 stakeholders and focus group discussions with 80 program beneficiaries from four geographic locations in the north and south of Viet Nam. Discussion agendas were developed to address key program issues with grounded theory utilized for data analysis. RESULTS: Data analysis highlighted challenges and opportunities within the six Ps of social marketing: Supply and demand side issues included: cost and the quality of products, the limited scale of interventions and promotional activities. Policy issues identified related to current policies that inhibited the broader promotion and distribution of micronutrient products, and opportunities for improved dialogue with policy partners. Partnerships further emphasized the need for public private partnerships to support the social change process. CONCLUSION: Implications for theory, policy, and practice indicates that rapid assessment and response is a cost-effective, pragmatic method of public health research, in resource constrained settings, to explore policies and behaviours amenable to change and build stakeholder engagement in the program.

Fluctuations in money availability within an income cycle impacts diet quality of remote Indigenous Australians.

OBJECTIVE: To consider the plausible nutritional impacts of fluctuations in money availability within an income cycle for remote Indigenous Australians. DESIGN: Community-level dietary intake (energy, micro/macronutrients) and expenditure on foods and beverages (F&B) were estimated over one year for three remote Indigenous Australian communities (Northern Territory, Australia) using monthly F&B transaction data. F&B that were likely to be consumed during a period within an income cycle when money was relatively limited (low money period (LMP) foods) were identified by panel consensus and scenario modelling was conducted to simulate the nutritional outcomes of a range of F&B selection responses to having an LMP. RESULTS: All scenarios resulted in reduced diet quality during the LMP relative to overall average diet values. Protein and fat energy percentages were reduced and carbohydrate energy percentage increased. Despite reduced expenditure, declines in energy intake were typically buffered due to the reduced energy cost ($AU/MJ) of the LMP diet. The micronutrient profile of the LMP diet was substantially poorer, such that additional key micronutrients dropped below population-weighted Estimated Average Requirements/Adequate Intakes. CONCLUSIONS: The modelling undertaken herein suggests that even a short period of low money within an income cycle may noticeably contribute to the reduced diet quality of remote Indigenous Australians and exacerbate lifestyle disease risk. Dietary strategies that are designed to respond to diets and expenditure during different income cycle periods, rather than the overall average diet and expenditure, should be considered for improving diet quality and reducing cardiometabolic disease risk in remote Indigenous Australians.

Local versus offshore production of ready-to-use therapeutic foods and small quantity lipid-based nutrient supplements.

Manufacturers on four continents currently produce ready-to-use therapeutic foods (RUTF). Some produce locally, near their intended users, while others produce offshore and ship their product long distances. Small quantity lipid-based nutrient supplements (SQ-LNS) such as Nutriset's Enov'Nutributter are not yet in widespread production. There has been speculation whether RUTF and SQ-LNS should be produced primarily offshore, locally, or both. We analyzed The United Nations Children's Fund (UNICEF) Supply Division data, reviewed published literature, and interviewed local manufacturers to identify key benefits and challenges to local versus offshore manufacture of RUTF. Both prices and estimated costs for locally produced product have consistently been higher than offshore prices. Local manufacture faces challenges in taxation on imported ingredients, low factory utilization, high interest rates, long cash conversion cycle, and less convenient access to quality testing labs. Benefits to local economies are not likely to be significant. Although offshore manufacturers offer RUTF at lower cost, local production is getting closer to cost parity for RUTF. UNICEF, which buys the majority of RUTF globally, continues to support local production, and efforts are underway to narrow the cost gap further. Expansion of RUTF producers into the production of other ready-to-use foods, including SQ-LNS in order to reach a larger market and achieve a more sustainable scale, may further close the cost and price gap. Local production of both RUTF and SQ-LNS could be encouraged by a favorable tax environment, assistance in lending, consistent forecasts from buyers, investment in reliable input supply chains, and local laboratory testing.

A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in community and care home settings.

BACKGROUND & AIMS: Despite the clinical benefits of using standard (non-disease specific) oral nutritional supplements (ONS) in the community and care homes, there is uncertainty about their economic consequences. METHODS: A systematic review was undertaken according to recommended procedures to assess whether ONS can produce cost savings and cost-effective outcomes. RESULTS: 19 publications with and without a hospital component were identified: 9 full text papers, 9 abstracts, and 1 report with retrospective analyses of 6 randomised controlled trials. From these publications a total of 31 cost and 4 cost-effectiveness analyses were identified. Most were retrospective analyses based on clinical data from randomised controlled trials (RCTs). In 9 studies/economic models involving ONS use for <3 months, there were consistent cost savings compared to the control group (median cost saving 9.2%; P < 0.01). When used for ≥3 months, the median cost saving was 5% (P > 0.05; 5 studies). In RCTs, ONS accounted for less than 5% of the total costs and the investment in the community produced a cost saving in hospital. Meta-analysis indicated that ONS reduced hospitalisation significantly (16.5%; P < 0.001; 9 comparisons) and mortality non-significantly (Relative risk 0.86 (95% CI, 0.61, 1.22); 8 comparisons). Many clinically relevant outcomes favouring ONS were reported: improved quality of life, reduced infections, reduced minor post-operative complications, reduced falls, and functional limitations. Of the cost-effectiveness analyses involving quality adjusted life years or functional limitations, most favoured the ONS group. The care home studies (4 cost analyses; 2 cost-effectiveness analyses) had differing aims, designs and conclusions. CONCLUSIONS: Overall, the reviewed studies, mostly based on retrospective cost analyses, indicate that ONS use in the community produce an overall cost advantage or near neutral balance, often in association with clinically relevant outcomes, suggesting cost effectiveness. There is a need for prospective studies designed to examine primary economic outcomes.

A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in the hospital setting.

BACKGROUND & AIMS: There is limited information about the economic impact of nutritional support despite its known clinical benefits. This systematic review examined the cost and cost effectiveness of using standard (non-disease specific) oral nutritional supplements (ONS) administered in the hospital setting only. METHODS: A systematic literature search of multiple databases, data synthesis and analysis were undertaken according to recommended procedures. RESULTS: Nine publications comprising four full text papers, two abstracts and three reports, one of which contained 11 cost analyses of controlled cohort studies, were identified. Most of these were based on retrospective analyses of randomised controlled trials designed to assess clinically relevant outcomes. The sample sizes of patients with surgical, orthopaedic and medical problems and combinations of these varied from 40 to 1.16 million. Of 14 cost analyses comparing ONS with no ONS (or routine care), 12 favoured the ONS group, and among those with quantitative data (12 studies) the mean cost saving was 12.2%. In a meta-analysis of five abdominal surgical studies in the UK, the mean net cost saving was £746 per patient (se £338; P = 0.027). Cost savings were typically associated with significantly improved outcomes, demonstrated through the following meta-analyses: reduced mortality (Risk ratio 0.650, P < 0.05; N = 5 studies), reduced complications (by 35% of the total; P < 0.001, N = 7 studies) and reduced length of hospital stay (by ∼2 days, P < 0.05; N = 5 surgical studies) corresponding to ∼13.0% reduction in hospital stay. Two studies also found ONS to be cost effective, one by avoiding development of pressure ulcers and releasing hospital beds, and the other by gaining quality adjusted life years. CONCLUSION: This review suggests that standard ONS in the hospital setting produce a cost saving and are cost effective. The evidence base could be further strengthened by prospective studies in which the primary outcome measures are economic.

Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh.

BACKGROUND: Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid. METHODS: Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 µgm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 µgm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 µgm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study. RESULTS: By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively. CONCLUSIONS: Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints. TRIAL REGISTRATION: Maternal and Infant Nutrition Interventions, Matlab; ISRCTN16581394 ; Date of registration: Feb 16, 2009.

Micronutrient program costs: sources of variations and noncomparabilities.

BACKGROUND: Micronutrient interventions are contributing to substantial reductions in global morbidity and mortality. As the diversity and coverage of these interventions expand, it is increasingly important to understand their distinct roles and contributions, and the resources they require. To date, comparing program resource use has been hampered by several noncomparabilities in cost studies relating to diverse intervention activities and service delivery pathways, along with differences in methodological approaches. OBJECTIVE: To promote better understanding of the variations and noncomparabilities in costs and cost structures of micronutrient interventions. METHODS: Cost studies on supplementation, fortification and biofortification programs from the published and gray literature were reviewed (n = 130). RESULTS: Specific areas of noncomparability identified include intervention characteristics and country context, as well as differences in methodological considerations, including data sources and definition of cost centers. Moreover, analyses vary significantly in terms of types of costs included. Implications and practical recommendations for standardizing future costing studies are provided. CONCLUSIONS: Methodological variations and non-comparabilities do much more than limit the ability to make direct comparisons of costing studies; they carry important implications for the adoption, design, and implementation of interventions in countries suffering from micronutrient deficiencies. This study synthesizes evidence on the level of support required (both financial and otherwise) for programs to achieve desirable levels of coverage and performance. Having comparable and accurate estimates of costs is a necessary first step in planning for and implementing interventions that are of adequate scale and adequately resourced.

Effects of a food-based intervention on markers of micronutrient status among Indian women of low socio-economic status.

Intakes of micronutrient-rich foods are low among Indian women of reproductive age. We investigated whether consumption of a food-based micronutrient-rich snack increased markers of blood micronutrient concentrations when compared with a control snack. Non-pregnant women (n 222) aged 14-35 years living in a Mumbai slum were randomised to receive a treatment snack (containing green leafy vegetables, dried fruit and whole milk powder), or a control snack containing foods of low micronutrient content such as wheat flour, potato and tapioca. The snacks were consumed under observation 6 d per week for 12 weeks, compliance was recorded, and blood was collected at 0 and 12 weeks. Food-frequency data were collected at both time points. Compliance (defined as the proportion of women who consumed ≥ 3 snacks/week) was >85 % in both groups. We assessed the effects of group allocation on 12-week nutrient concentrations using ANCOVA models with respective 0-week concentrations, BMI, compliance, standard of living, fruit and green leafy vegetable consumption and use of synthetic nutrients as covariates. The treatment snack significantly increased ß-carotene concentrations (treatment effect: 47·1 nmol/l, 95 % CI 6·5, 87·7). There was no effect of group allocation on concentrations of ferritin, retinol, ascorbate, folate or vitamin B12. The present study shows that locally sourced foods can be made into acceptable snacks that may increase serum ß-carotene concentrations among women of reproductive age. However, no increase in circulating concentrations of the other nutrients measured was observed.