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Preventive Nutrition Interventions in the Context of Haiti

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Preventive Nutrition Interventions in the Context of Haiti Preventative Nutrition Interventions Haïti Priorise Reina Engle-Stone Assistant Professor, Department of Nutrition University of California, Davis Christine P. Stewart Associate Professor, Department of Nutrition University of California, Davis Stephen A. Vosti Adjunct Professor, Department of Agricultural and Resource Economics University of California, Davis Katherine P. Adams Assistant Project Scientist, Department of Nutrition University of California, Davis Working paper as of April 11, 2017. © 2017 Copenhagen Consensus Center [email protected] www.copenhagenconsensus.com This work has been produced as a part of the Haiti Priorise project. This project is undertaken with the financial support of the Government of Canada. The opinions and interpretations in this publication are those of the author and do not necessarily reflect those of the Government of Canada. Some rights reserved This work is available under the Creative Commons Attribution 4.0 International license (CC BY 4.0). Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions: Attribution Please cite the work as follows: #AUTHOR NAME#, #PAPER TITLE#, Haiti Priorise, Copenhagen Consensus Center, 2017. License: Creative Commons Attribution CC BY 4.0. Third-party-content Copenhagen Consensus Center does not necessarily own each component of the content contained within the work. If you wish to re-use a component of the work, it is your responsibility to determine whether permission is needed for that re-use and to obtain permission from the copyright owner. Examples of components can include, but are not limited to, tables, figures, or images. Preventative Nutrition Interventions Haïti Priorise Reina Engle-Stone Assistant Professor, Department of Nutrition University of California, Davis Christine P. Stewart Associate Professor, Department of Nutrition University of California, Davis Stephen A. Vosti PhD Candidate, Graduate Group in Epidemiology University of California, Davis Christine P. Stewart Adjunct Professor, Department of Agricultural and Resource Economics University of California, Davis Katherine P. Adams Assistant Project Scientist, Department of Nutrition University of California, Davis Working paper as of April 11, 2017. Acknowledgments: The authors deeply appreciate the input of the following individuals regarding 1) the possible structure of micronutrient distribution programs: Lora Iannotti (Washington University, St Louis), Purnima Menon (IFPRI), Cornelia Loechl (IAEA), and 2) on food fortification: James Reimer (University of Notre Dame Haiti Program), Omar Dary (USAID), Sarah Zimmerman and Helena Pachón (Food Fortification Initiative), Quentin Johnson (Independent Consultant), and Jamie Marks (Les Moulins d’Haiti). In addition, we greatly appreciate the guidance of Jean-Patrick Alfred, several anonymous reviewers, and particularly Brad Wong. Abbreviations: BCR, benefit cost ratio; Copenhagen Consensus, CC; DALY, disability adjusted life year; DHS, Demographic and Health Survey; ECVMAS, L'Enquête sur les Conditions de Vie des Ménages Après Séism; FAPSBA, folic acid-preventable spina bifida and anencephaly; IDA, iron deficiency anemia; IDD, iodine deficiency disorder; MNP, micronutrient powder; PSC, pre-school age children; RR, relative risk; SAC, school-age children; WRA, women of reproductive age. Academic Abstract Anemia and micronutrient deficiencies affect a large proportion of the population in Haiti. Pregnant women and young children are most vulnerable to micronutrient malnutrition, due to their increased nutrient requirements, the small amounts of foods they consume, and the fact that deficiencies during this life stage can lead to life-long disabilities. Anemia in pregnancy is associated with an increased risk of infant mortality, preterm delivery, and low birth weight. Supplementation with multiple micronutrient capsules substantially reduces those risks. Further, women consuming diets low in calcium may be at greater risk of pre-eclampsia or eclampsia, which increases the risk of maternal mortality. The World Health Organization recommends calcium supplementation for women during pregnancy to mitigate that risk. Among children, micronutrient deficiencies can also lead to anemia, increased susceptibility to infection, and higher mortality risk. Provision of micronutrient powders has been found to significantly reduce the risks of anemia. For both pregnant women and young children, fortification of staple food products, such as wheat flour, with iron and folic acid may offer similar benefits with regard to anemia reduction while also reducing the risk of neural tube defects. In the present analysis, we have presented the evidence and rationale for considering each of these three intervention strategies: multiple micronutrients and calcium delivered to pregnant women, wheat flour fortification with iron and folic acid, and micronutrient powder delivery to children 6- 23 months of age. We estimated costs to deliver and scale up the programs. We estimated benefits based on years of life saved (reductions in maternal mortality, deaths due to neural tube defects, low birth weight, and preterm birth), disability-adjusted life year losses averted (due to the current and future effects of anemia, low birth weight, and preterm birth), and future productivity gains due to the prevention of low birth weight. For all three of the interventions considered, benefit cost ratio estimates were well above 1. Specifically, assuming a 5% discount rate and valuation of DALYs at 3XGDP, the benefit cost ratios were: 10 for provision of multiple micronutrient and calcium supplementation to women, 24 for wheat flour fortification with iron and folic acid, and 8 for provision of micronutrient powders to young children. Sensitivity analyses suggested that benefit cost ratios would remain favorable under various assumptions related to costs and program delivery effectiveness (e.g., coverage). Limitations of the foregoing analysis are discussed, including the important caveat that the modeled program scenarios are not additive. We consider the quality of evidence suggesting that the selected interventions would have the predicted impact to be strong. Policy Abstract Overview and context Anemia and micronutrient deficiencies affect a large proportion of the population in Haiti. Pregnant women and young children are most vulnerable to micronutrient malnutrition, due to their increased nutrient requirements and the fact that deficiencies during this life stage can lead to life-long disabilities. Anemia in pregnancy is associated with an increased risk of infant mortality, preterm delivery, and low birth weight. Supplementation with multiple micronutrient capsules substantially reduces those risks. Further, women consuming diets low in calcium may be at greater risk of pre-eclampsia or eclampsia, which increases the risk of maternal mortality. The World Health Organization recommends calcium supplementation for women during pregnancy to mitigate that risk. Among children, micronutrient deficiencies can also lead to anemia, increased susceptibility to infection, and higher mortality risk. Provision of micronutrient powders has been found to significantly reduce the risk of anemia. For both pregnant women and young children, fortification of staple food products, such as wheat flour, may offer similar benefits with regard to anemia reduction while also reducing the risk of neural tube defects by increasing folic acid intake in early pregnancy. In the present analysis, we have presented the evidence and rationale for considering each of these three intervention strategies: multiple micronutrient supplements and calcium supplements delivered to pregnant women, industrial fortification of wheat flour with iron and folic acid, and provision of multiple micronutrient powders to children 6-23 months of age. Implementation considerations We estimated initial costs for intervention planning and scale-up and recurring costs for intervention delivery thereafter. In these scenarios, multiple micronutrient capsules and calcium supplements are provided by health workers to pregnant women who attend antenatal care visits, with home visits to pregnant women in rural areas who receive less than the recommended number of antenatal care contacts. In these projections, micronutrient powders are provided to children 6-23 months of age (as per WHO guidelines) who attend health clinics or rally posts to receive vaccinations or other health services by health workers. Fortification of wheat flour with micronutrients is implemented by wheat millers and wheat flour importers, with external support for program planning, monitoring, and evaluation. Rationale for Intervention For delivery of micronutrients to pregnant women, we estimated benefits based on years of life saved due to reductions in maternal mortality and reductions in infant mortality due to low birth weight and preterm birth, and disability-adjusted life year losses averted were estimated for current effects of maternal anemia, and future effects of low birth weight and preterm birth, and future productivity gains due to the prevention of low birth weight. For large-scale fortification of wheat flour, we estimated benefits in terms of years of life saved due to reduction in neural tube defects following folic acid fortification, and disability- adjusted life year losses averted due to reductions
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