Search

Background Since 1961, global per capita fish consumption has nearly doubled. Much of the increase has been due to aquaculture. Bangladesh, the world's eighth largest fish producing country, has been part of this transformation. Despite having vitamin A supplementation and fortification programs, the prevalence of inadequate vitamin A intake (IVAI) in Bangladesh is very high, estimated to be 60%. The promotion of a small indigenous fish, high in vitamin A – mola carplet – offers a promising food-based approach to improving vitamin A status of the 98% of Bangladeshis who eat fish. The objective of this paper was to conduct a benefit–cost analysis of a national household pond Mola Promotion Program (MPP) in Bangladesh. Methods Using the 2005 Bangladesh Household Income and Expenditure Survey (HIES) and nutrition and health statistics, we developed baseline estimates of usual vitamin A intake, the prevalence of IVAI and disability-adjusted life years (DALYs) attributable to vitamin A deficiency (VAD). Drawing on a WorldFish project and HIES data, we designed and modeled the implementation of a MPP, and calculated the additional vitamin A intake it would provide, calculated new incidence rates of VAD-related health outcomes and estimated MPP-attributable annual changes in DALYs. The MPP's total health benefits were calculated over the program's 11-year phase-in as the annual sum of DALYs saved. The MPP's costs were estimated as the sum of the costs of a small fish program of the Fisheries Development Program plus the costs of mola brood stock, other inputs and additional farmer training-related costs. Program costs and benefits were combined to produce estimates of the cost-effectiveness of the program. Results An 11-year, $23 million project would increase average daily vitamin A intakes by 7 μg retinol activity equivalent (RAE), reduce the prevalence of IVAI by 1.1 percentage points, and save 3000 lives and 100,000 DALYs, at a cost of $194 per DALY saved. The MPP's impact would be concentrated among homestead pond-fishing households that would consume 60% of the additional mola produced. Among these, it would reduce IVAI prevalence by 7 percentage points. If the MPP was implemented for at least 20 years, it would dominate – have higher health benefits and lower total costs – than a national vitamin A wheat flour fortification program. Conclusion By World Bank and World Health Organization criteria, the MPP is a cost-effective approach to reduce the burden of micronutrient malnutrition in Bangladesh. [ABSTRACT FROM AUTHOR]

Introduction Biofortification is the breeding of new varieties of staple foods for increased micronutrient content. It is seen primarily as a complementary, rural-targeted strategy for better reaching remote populations. This paper presents an ex ante analysis of HarvestPlus’ provitamin A maize (PVAM) in Zambia and highlights an empirical approach based on the Zambian 2005/06 Living Conditions Monitoring Survey (LCMS). Because more than 115 countries regularly conduct a Household Consumption and Expenditure Survey (HCES), the approach developed in this LCMS-based study can be applied in many other countries to analyze varietal adoption and conduct ex ante studies. Methods Data from the LCMS and health statistics were used to characterize baseline indicators of vitamin A intake and Disability Adjusted Life Years (DALYs) lost. The introduction and scaling up of PVAM was modeled based on program plans, expert opinion and data on key adoption parameters. An adoption function was specified and expressed in terms of the percent of farmers expected to adopt PVAM over the next 30 years. A logistic regression adoption function was estimated and used to identify the specific LCMS households adopting, producing and consuming PVAM each year. Information from the IFPRI International Model for Policy Analysis of Agricultural Commodities and Trade (IMPACT) of yearly maize production and demand were used to produce annual estimates of PVAM planted, harvested and consumed. Taking into account an LCMS-empirically-informed, specified market structure, individuals’ additional vitamin A intake was calculated. The number of DALYs saved were estimated using the change in vitamin A intake. Combining these estimates with cost data, the cost-effectiveness of PVAM was calculated. Results Assuming an adoption ceiling of 20% over 30 years, implementation of PVAM will result in average additional intake of 12% of the Estimated Average Requirement (EAR), a 3 percentage point reduction in the prevalence of inadequate intake, and savings of 23% of total DALYs. Impacts are concentrated among farming households that have adopted PVAM and consume it from their own production. Their consumption will result in an average additional vitamin A intake of 172 μg/day, more than 3 times the additional 54 μg/day among the entire population. Among this group, the reduction in the prevalence of inadequate intake will be more than 5 times the national average (17.5 percentage points). Valuing a DALY at $1000, PVAM’s cumulative value of DALYs saved comes to exceed its cumulative total costs starting in 2019. Over 30 years the cost-effectiveness of PVAM in Zambia was estimated to be $24 per DALY saved, making it very cost-effective. Conclusion The methodologies employed in this study provide insights and inputs that can be used to target farmers who are most likely to adopt, to measure their vitamin A intake and to craft messages to promote adoption. PVAM is a long term investment that shows great promise in becoming a highly cost-effective addition to the public health arsenal for combatting micronutrient deficiencies if the 20% adoption rate can be achieved and maintained. Doing so will require effective marketing strategies, including efforts to couple this nutrition-sensitive intervention with nutrition-specific activities, such as targeted nutrition messaging and education, in order to increase the likelihood that adopting farmers will prioritize production for home consumption. [ABSTRACT FROM AUTHOR]

Background. Approximately 1.2 million disabilityadjusted life years (DALYs) are lost annually in Bangladesh due to deficiencies of vitamin A, iron, and zinc. Objective. To provide evidence on the coverage, costs, and cost-effectiveness of alternative fortification interventions to inform nutrition policy-making in Bangladesh. Methods. Combining the 2005 Bangladesh Household Income and Expenditure Survey with a Bangladesh food composition table, apparent intakes of energy, vitamin A, iron, and zinc, and the coverage and apparent consumption levels of fortifiable vegetable oil and wheat flour are estimated. Assuming that fortification levels are those established in official regulations, the costs and cost-effectiveness of the two vehicles are assessed independently and as a two-vehicle portfolio. Results. Vegetable oil has a coverage rate of 76% and is estimated to reduce the prevalence of inadequate vitamin A intake from 83% to 64%. The coverage of wheat flour is high (65%), but the small quantities consumed result in small reductions in the prevalence of inadequate intakes: 1.5 percentage points for iron, less than 1 for zinc, and 2 for vitamin A, while reducing average Estimated Average Requirement (EAR) gaps by 8%, 9%, and 15%, respectively. The most cost-effective 10-micronutrient wheat flour formulation costs US$1.91 million annually, saving 129,212 DALYs at a unit cost of US$14.75. Fortifying vegetable oil would cost US$1.27 million annually, saving 406,877 DALYs at an average cost of US$3.25. Sensitivity analyses explore various permutations of the wheat flour formulation. Divisional variations in coverage, cost, and impact are examined. Conclusions. Vegetable oil fortification is the most cost-effective of the three portfolios analyzed, but all three are very cost-effective options for Bangladesh. [ABSTRACT FROM AUTHOR]

Background. Micronutrient deficiencies continue to constitute a major burden of disease, particularly in Africa and South Asia. Programs to address micronutrient deficiencies have been increasing in number, type, and scale in recent years, creating an ever-growing need to understand their combined coverage levels, costs, and impacts so as to more effectively combat deficiencies, avoid putting individuals at risk for excess intakes, and ensure the efficient use of public health resources. Objective. To analyze combinations of the two current programs--sugar fortification and Child Health Week (CHW)--together with four prospective programs--vegetable oil fortification, wheat flour fortification, maize meal fortification, and biofortified vitamin A maize--to identify Zambia's optimal vitamin A portfolio. Methods. Combining program cost estimates and 30-year Zambian food demand projections, together with the Zambian 2005 Living Conditions Monitoring Survey, the annual costs, coverage, impact, and cost-effectiveness of 62 Zambian portfolios were modeled for the period from 2013 to 2042. Results. Optimal portfolios are identified for each of five alternative criteria: average cost-effectiveness, incremental cost-effectiveness, coverage maximization, health impact maximization, and affordability. The most likely scenario is identified to be one that starts with the current portfolio and takes into account all five criteria. Starting with CHW and sugar fortification, it phases in vitamin A maize, oil, wheat flour, and maize meal (in that order) to eventually include all six individual interventions. Conclusions. Combining cost and Household Consumption and Expenditure Survey (HCES) data provides a powerful evidence-generating tool with which to understand how individual micronutrient programs interact and to quantify the tradeoffs involved in selecting alternative program portfolios. [ABSTRACT FROM AUTHOR]

Background. Since fortification of sugar with vitamin A was mandated in 1998, Zambia's fortification program has not changed, while the country remains plagued by high rates of micronutrient deficiencies. Objective. To provide evidence-based fortification options with the hope of reinvigorating the Zambian fortification program. Methods. Zambia's 2006 Living Conditions Monitoring Survey is used to estimate the apparent intakes of vitamin A, iron, and zinc, as well as the apparent consumption levels and coverage of four fortification vehicles. Fourteen alternative food fortification portfolios are modeled, and their costs, impacts, average cost-effectiveness, and incremental cost-effectiveness are calculated using three alternative impact measures. Results. Alternative impact measures result in different rank orderings of the portfolios. The most costeffective portfolio is vegetable oil, which has a cost per disability-adjusted life-year (DALY) saved ranging from 12% to 25% of that of sugar, depending on the impact measure used. The public health impact of fortified vegetable oil, however, is relatively modest. Additional criteria beyond cost-effectiveness are introduced and used to rank order the portfolios. The size of the public health impact, the total cost, and the incremental cost-effectiveness of phasing in multiple vehicle portfolios over time are analyzed. Conclusions. Assessing fortification portfolios by measuring changes in the prevalence of inadequate intakes underestimates impact. A more sensitive measure, which also takes into account change in the Estimated Average Requirement (EAR) gap, is provided by a dose-response-based approach to estimating the number of DALYs saved. There exist highly cost-effective fortification intervention portfolios with substantial public health impacts and variable price tags that could help improve Zambians' nutrition status. [ABSTRACT FROM AUTHOR]

Background. Zambia was a pioneer when it started fortifying sugar with vitamin A in 1998. Micronutrient deficiencies--especially among young children--have changed little over the past decade. In 2008 an initiative to introduce fortified flours was halted when last-hour questions about the program could not be answered. Objective. To provide information about the need, coverage, and impact of alternative fortification portfolio options to help Zambia overcome its fortification impasse. Methods. Using household data from the 2006 Living Conditions Monitoring Survey, apparent micronutrient intake levels and apparent consumption levels of sugar, vegetable oil, wheat flour and maize meal were estimated. The household level data were used to estimate individual intakes by assuming that food was distributed among household members in direct proportion to their share of the household's total adult consumption equivalent. Intake adequacy was measured relative to age- and gender-specific Estimated Average Requirements. Combining information on the industrial structure and estimated fortifiable quantities consumed of each food, and assuming the nutrient content is that specified in official regulations, simulations were conducted of the coverage and impact of 14 fortification portfolios. Results. Maize, the most commonly consumed food, is consumed in a fortifiable form by only 23% of the population. Sugar fortification is estimated to have reduced inadequate intake of vitamin A from 87% to 79%. Introducing oil fortification could reduce the prevalence of inadequate vitamin A intake to 61%, and fortifying roller and breakfast maize meal would further reduce it to 57%, and reduce inadequate iron and zinc intakes by 2.2% and 5.5%, respectively. Implementing WHO flour guidelines would triple the potential iron and zinc impacts. Conclusion. Analysis of LCMS apparent consumption data have helped address important information gaps and provide better understanding of the coverage and impacts of alternative fortification portfolios. [ABSTRACT FROM AUTHOR]

Background. Observed-Weighed Food Record Surveys (OWFR) are regarded as the most precise dietary assessment methodology, despite their recognized shortcomings, which include limited availability, high cost, small samples with uncertain external validity that rarely include all household members, Hawthorne effects, and using only 1 or 2 days to identify "usual intake." Although Household Consumption and Expenditures Surveys (HCES) also have significant limitations, they are increasingly being used to inform nutrition policy. Objective. To investigate differences in fortification simulations based on OWFR and HCES from Bangladesh. Methods. The pre- and postfortification nutrient intake levels from the two surveys were compared. Results. The total population-based rank orderings of oil, wheat flour, and sugar coverage were identical for the two surveys. OWFR found differences in women's and children's coverage rates and average quantities consumed for all three foods that were not detected by HCES. Guided by the Food Fortification Formulator, we found that these differences did not result in differences in recommended fortification levels. Differences were found, however, in estimated impacts: although both surveys found that oil would be effective in reducing the prevalence of inadequate vitamin A intake among both subpopulations, only OWFR also found that sugar and wheat flour fortification would significantly reduce inadequate vitamin A intake among children. Conclusions. Despite the less precise measure of food consumption from HCES, the two surveys provide similar guidance for designing a fortification program. The external validity of these findings is limited. With relatively minor modifications, the precision of HCES in dietary assessment and the use of HCES in fortification programming could be strengthened. [ABSTRACT FROM AUTHOR]

Background. The dearth of 24-hour recall and observedweighed food record data--what most nutritionists regard as the gold standard source of food consumption data--has long been an obstacle to evidence-based food and nutrition policy. There have been a steadily growing number of studies using household food acquisition and consumption data from a variety of multipurpose, nationally representative household surveys as a proxy measure to overcome this fundamental information gap. Objective. To describe the key characteristics of these increasingly available Household Consumption and Expenditures Surveys (HCES) in order to help familiarize food and nutrition analysts with the strengths and shortcomings of these data and thus encourage their use in low- and middle-income countries; and to identify common shortcomings that can be readily addressed in the near term in a country-by-country approach, as new HCES are fielded, thereby beginning a process of improving the potential of these surveys as sources of useful data for better understanding food- and nutritionrelated issues. Methods. Common characteristics of key food and nutrition information that is available in HCES and some basic common steps in processing HCES data for food and nutrition analyses are described. Results. The common characteristics of these surveys are documented, and their usefulness in addressing major food and nutrition issues, as well as their shortcomings, is demonstrated. Conclusions. Despite their limitations, the use of HCES data constitutes a generally unexploited opportunity to address the food consumption information gap by using survey data that most countries are already routinely collecting. [ABSTRACT FROM AUTHOR]

Background. Globally, there is a scarcity of national food consumption data that could help to assess food patterns and nutrient intakes of population groups. Estimates of food consumption patterns and apparent intakes of energy and nutrients could be obtained from national Household Consumption and Expenditures Surveys (HCES). Objective. To use the HCES conducted in Bangladesh in 2005 (HIES2005) to estimate apparent intakes of vitamin A, iron, and zinc. Methods. Food acquisition data from HIES2005, which surveyed 10,080 households, were transformed into standard measurement units. Intrahousehold food and nutrient distribution was estimated with Adult Male Equivalent (AME) units. Adequacy of intake was assessed by comparing individual nutrient intakes with requirements and was then aggregated by households. Results. The weighted mean energy intake for the population was 2,151 kcal/person/day, with a range among divisions from 1,950 in Barisal to 2,195 in Dhaka division. The apparent intakes of vitamin A and iron were insufficient to satisfy the recommended intakes for more than 80% of the population in Bangladesh, while apparent intakes of zinc, adjusted by bioavailability, satisfied the requirements of approximately 60% of the population Conclusions. Using the HIES2005, we were able to produce estimates of apparent food consumption and intakes of some key micronutrients for the Bangladeshi population and observed wide differences among divisions. However, the methodological approaches reported here, although feasible and promising, need to be validated with other dietary intake methods [ABSTRACT FROM AUTHOR]