evidence-based blog of Filippo Dibari

Posts Tagged ‘science’

Enhancing Nutrition: A New Tool for Ex-Ante Comparison of Commodity-based Vouchers and Food Transfers

In Under-nutrition on September 26, 2013 at 2:25 pm

by David Ryckembusch, Romeo Frega, Marcio Guilherme Silva, Ugo Gentilini, Issa Sanogo, Nils Grede, and Lynn Brown

from World Development, Volume 49, September 2013, Pages 58–67

(download for free here)

Summary

This article presents a new analytical tool for ex-ante comparison of the cost-effectiveness of two transfer modalities in pursuing specific nutritional objectives. It does so by introducing a metric to score the nutrient value of a food basket—the Nutrient Value Score (NVS)—and explains how this metric can be combined with full supply chain analysis and costing to generate a new tool, the Omega Value. The use of the Omega Value allows policy-makers who design a program with nutrition objectives to compare direct food transfers and commodity-based food vouchers in terms of both cost efficiency and cost effectiveness.

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Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial

In Under-nutrition on July 7, 2013 at 12:33 pm

by Irena AH, Bahwere P, Owino VO, Diop EI, Bachmann MO, Mbwili-Muleya C, Dibari F, Sadler K, Collins S.

Matern Child Nutr. 2013 Jun 18.

Abstract

Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto.

This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome.

The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group.

In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.

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In Under-nutrition on May 25, 2013 at 3:04 pm

MSF Scientific Day 2013

Scientific Day presentations are now available here.

2000 people took part. 300 participants from 92 countries

A snapshot summary of the day with challenges for MSF is here.

The presentations and the poster gallery are online.

The Relevance of Micronutrients to the Prevention of Stunting

In Under-nutrition on April 16, 2013 at 9:17 pm

Ellie Souganidis, Johns Hopkins University School of Medicine

(download the paper)

stunted children

Key messages from the paper:

01. Previous studies investigating the role of micronutrient supplements such as vitamin A and zinc in combating stunting have failed to establish a clear connection.

02. The focus of research has therefore expanded to include multiple micronutrient interventions and other comprehensive approaches.

03. It has been proposed that in populations with multiple micronutrient deficiencies, the effect of multiple micronutrient supplementation on linear growth will be more significant than single nutrient supplementation.

04. However, the results of multiple micronutrient intervention studies have also been mixed.

05. The variable success of single and multiple micronutrient interventions in improving linear growth have encouraged the development of new multifaceted approaches.

06. These strategies typically address holistic nutritional issues, as well as combating disease.

07. Because stunting is more difficult to reverse after 36 months of age, such comprehensive approaches require participation from the mother and the child.

08. Further research is necessary to better understand the various factors that contribute to stunting.

09. Ultimately, stunting cannot be adequately addressed without taking into account socioeconomic factors such as disease and poverty.

10. Nonetheless, the role of nutrition continues to warrant additional attention.

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Children successfully treated for moderate acute malnutrition remain at risk for malnutrition and death in the subsequent year after recovery

In Under-nutrition on February 27, 2013 at 7:50 pm

J Nutr. 2013 Feb;143(2):215-20. doi: 10.3945/jn.112.168047. Epub 2012 Dec 19.

by Chang CYTrehan IWang RJThakwalakwa CMaleta KDeitchler MManary MJ.

Abstract

Moderate acute malnutrition (MAM) affects 11% of children <5 y old worldwide and increases their risk for morbidity and mortality. It is assumed that successful treatment of MAM reduces these risks.

A total of 1967 children aged 6-59 mo successfully treated for MAM in rural Malawi following randomized treatment with corn-soy blend plus milk  and oil (CSB++), soy ready-to-use supplementary food (RUSF), or soy/whey RUSF were followed for 12 mo. The initial supplementary food was given until the child reached a weight-for-height Z-score (WHZ) >-2. The median duration of feeding was 2 wk, with a maximum of 12 wk.

The hypothesis tested was that children treated with either RUSF would be more likely to remain well-nourished than those treated with CSB++.The primary outcome, remaining well-nourished, was defined as mid-upper arm circumference ≥12.5 cm or WHZ ≥-2 for the entire duration of follow-up.

During the 12-mo follow-up period, only 1230 (63%) children remained well-nourished, 334 (17%) relapsed to MAM, 190 (10%) developed severe acute malnutrition, 74 (4%) died, and 139 (7%) were lost to follow-up.

Children who were treated with soy/whey RUSF were more likely to remain well-nourished (67%) than those treated with CSB++ (62%) or soy RUSF (59%) (P = 0.01).

A seasonal pattern of food insecurity and adverse clinical outcomes was observed. This study demonstrates that children successfully treated for MAM with soy/whey RUSF are more likely to remain well-nourished; however, all children successfully treated for MAM remain vulnerable.

 

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World largest child nutrition program: all is not well?

In Under-nutrition on February 24, 2013 at 7:41 am

by Mukta Singhvi, Sarvjeet Kaur, and Suman Kumari

Introduction

click here for to download this paper

A country truly concerned about its development would put its children’s health on a higher priority than the GDP. For, population of over a billion can add strength to a country, only, if it is healthy and productive.

In India about 42% of the children are under weight. It has been reported by that on in every three most malnourished children of the world live in India. It is cause worry because such a populace can become a liability in the coming years. The problem of malnutrition is a matter of shame. Despite impressive growth in our GDP, the level of under nutrition in the country is unacceptably high . India has not succeeded in reducing malnutrition fast enough, though the integrated child development services (ICDS) programme continues to be our most important tool to fight malnutrition.

The global community has designated halving the prevalence of under weigh children by 2015 as a key indicator of progress towards the millennium development goal (MDG) of eradicating extreme poverty and hunger. However, it appears that that economic growth alone, though impressive, will not reduce malnutrition sufficiently to meet the MDG. Nutrition target. India’s main early child development and nutrition intervention , the ICDS program has expanded steadily across the country during the last more than three and half decade of its existence. It is one of the World’s largest, most unique well designed and well placed programme to address many of the underlying cause of under nutrition in India. However, it faces a range of implementation difficulties that prevent it from fully realizing its potential.

This article is an attempt to critically examine the World largest programme and identifies the most important weakness in the implementation of ICDS and suggest a way out that can be taken to improve the impact of the programme.

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Six-Month Mortality among HIV-Infected Adults Presenting for Antiretroviral Therapy with Unexplained Weight Loss, Chronic Fever or Chronic Diarrhea in Malawi

In Under-nutrition on November 25, 2012 at 8:14 am

by Monique van Lettow, Ann Åkesson, Alexandra L. C. Martiniuk, Andrew Ramsay, Adrienne K. Chan, Suzanne T. Anderson, Anthony D. Harries, Elizabeth Corbett, Robert S. Heyderman, Rony Zachariah, Richard A. Bedell

from PLOs November 19, 2012

(downlowad the paper)

 

Abstract

Background

In sub-Saharan Africa, early mortality is high following initiation of antiretroviral therapy (ART). We investigated 6-month outcomes and factors associated with mortality in HIV-infected adults being assessed for ART initiation and presenting with weight loss, chronic fever or diarrhea, and with negative TB sputum microscopy.

Methods

A prospective cohort study was conducted in Malawi, investigating mortality in relation to ART uptake, microbiological findings and treatment of opportunistic infection (OIs), 6 months after meeting ART eligibility criteria.

Results

Of 469 consecutive adults eligible for ART, 74(16%) died within 6 months of enrolment, at a median of 41 days (IQR 20–81). 370(79%) started ART at a median time of 18 days (IQR 7–40) after enrolment. Six-month case-fatality rates were higher in patients with OIs; 25/121(21%) in confirmed/clinical TB and 10/50(20%) with blood stream infection (BSI) compared to 41/308(13%) in patients with no infection identified. Median TB treatment start was 27 days (IQR 17–65) after enrolment and mortality [8 deaths (44%)] was significantly higher among 18 culture-positive patients with delayed TB diagnosis compared to patients diagnosed clinically and treated promptly with subsequent culture confirmation [6/34 (18%);p = 0.04]. Adjusted multivariable analysis, excluding deaths in the first 21 days, showed weight loss >10%, low CD4 count, severe anemia, laboratory-only TB diagnosis, and not initiating ART to be independently associated with increased risk of death.

Conclusions

Mortality remains high among chronically ill patients eligible for ART. Prompt initiation of ART is vital: more than half of deaths were among patients who never started ART. Diagnostic and treatment delay for TB was strongly associated with risk of death. More than half of deaths occurred without identification of a specific infection. ART programmes need access to rapid point-of-care-diagnostic tools for OIs. The role of early empiric OI treatment in this population requires further evaluation in clinical trials.

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Predictors of stunting, wasting and underweight among Tanzanian children born to HIV-infected women

In Under-nutrition on October 24, 2012 at 7:52 am

McDonald CMKupka RManji KPOkuma JBosch RJAboud SKisenge RSpiegelman DFawzi WWDuggan CP.

Eur J Clin Nutr. 2012 Oct 3

Abstract

Background/Objectives: Children born to human immunodeficiency virus (HIV)-infected women are susceptible to undernutrition, but modifiable risk factors and the time course of the development of undernutrition have not been well characterized.

The objective of this study was to identify maternal, socioeconomic and child characteristics that are associated with stunting, wasting and underweight among Tanzanian children born to HIV-infected mothers, followed from 6 weeks of age for 24 months.

Subjects/Methods: Maternal and socioeconomic characteristics were recorded during pregnancy, data pertaining to the infant’s birth were collected immediately after delivery, morbidity histories and anthropometric measurements were performed monthly. Multivariate Cox proportional hazards methods were used to assess the association between potential predictors and the time to first episode of stunting, wasting and underweight.

Results: A total of 2387 infants (54.0% male) were enrolled and followed for a median duration of 21.2 months. The respective prevalence of prematurity (<37 weeks) and low birth weight (<2500 g) was 15.2% and 7.0%; 11.3% of infants were HIV-positive at 6 weeks. Median time to first episode of stunting, wasting and underweight was 8.7, 7.2 and 7.0 months, respectively. Low maternal education, few household possessions, low infant birth weight, child HIV infection and male sex were all independent predictors of stunting, wasting and underweight. In addition, preterm infants were more likely to become wasted and underweight, whereas those with a low Apgar score at birth were more likely to become stunted.

Conclusions: Interventions to improve maternal education and nutritional status, reduce mother-to-child transmission of HIV, and increase birth weight may lower the risk of undernutrition among children born to HIV-infected women.

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Nutrition e-Education – Univ. of Southampton / Fac. of Medicine

In Over-nutrition, Under-nutrition on October 23, 2012 at 7:43 am

From the University of Southampton, Faculty of Medicine

 

Nutrition Portal is the first eLearning site dedicated to nutrition and public health nutrition learning in the UK. It is hosted by the Faculty of Medicine at the University of Southampton.

“The Portal has enabled comprehensive training needs analyses to be undertaken with front line public health practitioners for whom nutrition is a component of their work, and discussion between the Department of Health and academics to ensure the courses meet workforce needs.

“The Portal evolved out of the recognition that nutrition is central to health promotion, disease prevention and effective care and is a key element of government policy. Policy, however, can only be effective if the workforce is able to meet the needs and deliver effective nutrition in public health. Current and future health care professionals, be they doctors, nurses, community pharmacists or other health care professionals, must be equipped to deliver consistent and standardised information.

“The eLearning is delivered through interactive, multimedia courses that are validated by key professional bodies. They been developed to train health care professionals in the underlying principles of nutrition and to develop their competency in applying their knowledge to their workplace setting.”

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Two charities challenge company’s patent on Plumpy’Nut

In Under-nutrition on October 18, 2012 at 2:56 pm

by Clare Dyer

from the British Medical Journal (BMJ) 2010;340:c2510

“The US patent for a peanut based food product that has transformed the treatment of acute malnutrition in Africa has come under challenge by two US not for profit organisations that say they could produce similar products more cheaply.

“The California based Mama Cares Foundation and Breedlove Foods in Texas have filed a joint suit in the US District Court in the District of Columbia to try to overturn the patent held by the French company Nutriset.

“Nutriset’s Plumpy’Nut, a blend of peanut butter, powdered milk, vegetable oil, and sugar fortified with vitamins and minerals, is said by some experts to have revolutionised aid agencies’ response to malnutrition and become the standard “ready to use therapeutic food” (RUTF).

“It achieved dramatic results in Niger in 2005. Because it doesn’t need to be mixed with water, children who would previously have to be taken to hospital can be treated much more cheaply at home.

“Nutriset and its partners around the world provide the bulk of the world’s supply, but Mike Mellace, executive director of Mama Cares, said it was poised to ship its rival Re:vive product to Africa, Honduras, South East Asia, and other regions.

“The patent lawyer Robert Chiaviello is giving his services free of charge to the two organisations. Mr Mellace said that their main claim was that the patent should not have been granted because Plumpy’Nut was not novel or unique.

“If you grab a jar of Nutella and compare it to the ingredients statement on Plumpy’Nut you’ll find that it’s virtually identical. All that they’ve done is change the mixture round and have a higher vitamin and mineral mix to get to the proper WHO specifications, which anybody could do.”

“He said that Mama Cares, a non-profit offshoot of his family snack business, had managed to reduce its costs to $0.4 (£0.27; €0.78) a unit; Plumpy’Nut costs 0.55 a unit. “If you simply took the same aid dollars you could treat 30% more children because the product is cheaper.”

“Nutriset has recently started manufacturing Plumpy’Nut in the United States, in partnership with a non-profit body called Edesia. Its network of partner manufacturers also produce Plumpy’Nut locally in Niger, Ethiopia, Malawi, the Democratic Republic of the Congo, the Dominican Republic, India, Madagascar, and Mozambique.

“The company, which has registered patents in the European Union, the US, Canada, and 32 other countries, has sent legal letters to other producers of nut based RUTFs. It was criticised in an open letter last November by the international humanitarian organisation Médecins Sans Frontières for sending a letter asserting its intellectual property rights to the Indian and Norwegian manufacturer Compact.

“Adeline Lescanne, deputy general manager of Nutriset, said: “Some may pretend they are able to produce the equivalent of Plumpy’Nut at a cheaper price, but we fear that those solutions may not be [long lasting]. What should be the goal: to have companies manufacturing an RUTF in the North or to have them helping to develop local nutrition capacities, working with local health authorities, transferring competences to the South?

“It’s interesting to see the plaintiffs working on new products. Our patent on Plumpy’Nut gave them motivation to seek something else. What is really needed are increased efforts to prevent malnutrition. There are lots of things to do in the prevention field.”

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