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.

Eggs Are Cost-Efficient in Delivering Several Shortfall Nutrients in the American Diet: A Cost-Analysis in Children and Adults.

The purpose of the current study was to examine the cost of eggs in relation to nutrient delivery in children and adults. The present analysis used dietary intake data from the National Health and Nutrition Examination Survey 2013-2016 (egg consumers: 2-18 years-old, N = 956; 19+ years-old, N = 2424). Inflation adjusted food cost and the cost of nutrients were obtained from the Center for Nutrition Promotion and Policy food cost database. Cost and nutrient profiles for What We Eat in America food categories were compared to whole eggs. Of the 15 main food groups examined, whole eggs ranked third for lowest cost per 100 g (excluding beverages), such that eggs cost 0.35 USD per 100 g, with dairy and grains representing the first and second most cost-efficient foods, at 0.23 USD and 0.27 USD per 100 g, respectively. In children and adults, eggs represented a cost-efficient food for protein delivery, such that eggs provided nearly 2.7% and 3.7% of all protein in the diet, respectively, at a cost of about 0.03 USD per g of protein. Eggs contributed 3.8% and 6.0% of all vitamin A in the diet of children and adults, at a cost of approximately 0.002 USD and 0.003 USD per RAE mcg of vitamin A, respectively. In children 2-18 years-old, nearly 12% of all choline in the diet is delivered from eggs, at a cost of approximately 0.002 USD per mg of choline. Similarly, in adults 19-years-old+, eggs provide nearly 15% of all dietary choline in the diet, at a cost of approximately 0.002 USD per mg of choline. Eggs provide nearly 5% and 9.5% of all vitamin D in the diet of children and adults, at a cost of approximately 0.21 USD and 0.22 USD per mcg of vitamin D, respectively. Overall, eggs ranked as the most cost-efficient food for delivering protein, choline, and vitamin A, second for vitamin E, and third for vitamin D in children. In adults, eggs ranked as the most cost-efficient food for delivering protein and choline, second for vitamin A, and third for vitamin D and vitamin E. In summary, eggs represent an economical food choice for the delivery of protein and several shortfall nutrients (choline, vitamin A, and vitamin D) in the American diet.

Stable isotopes in hair reveal dietary protein sources with links to socioeconomic status and health.

Carbon and nitrogen isotope ratios in hair sampled from 65 communities across the central and intermountain regions of the United States and more intensively throughout 29 ZIP codes in the Salt Lake Valley, Utah, revealed a dietary divergence related to socioeconomic status as measured by cost of living, household income, and adjusted gross income. Corn-fed, animal-derived proteins were more common in the diets of lower socioeconomic status populations than were plant-derived proteins, with individual estimates of animal-derived protein diets as high as 75%; United States towns and cities averaged 57%. Similar patterns were seen across the socioeconomic status spectrum in the Salt Lake Valley. It is likely that corn-fed animal proteins were associated with concentrated animal-feeding operations, a common practice for industrial animal production in the United States today. Given recent studies highlighting the negative impacts of animal-derived proteins in our diets, hair carbon isotope ratios could provide an approach for scaling assessments of animal-sourced foods and health risks in communities across the United States.

A Low-Cost, Intradialytic, Protein-Rich Meal Improves the Nutritional Status in Chinese Hemodialysis Patients.

OBJECTIVE: Short-term administration of oral nutritional supplements can improve the nutritional status of hemodialysis patients. However, such treatment is associated with high cost. The aim of the present trial was to evaluate the benefits of the short-term administration of a low-cost, intradialytic, protein-rich meal on selected parameters of the nutritional status in Chinese patients undergoing hemodialysis. METHODS: This was a 6-month single-center, prospective interventional study. Stable hemodialysis patients aged ≥18 years with a concentration of serum albumin <40 g/L were eligible for inclusion in this study. Patients allocated to the intervention group (IG) received nutritional counseling plus a low-cost, intradialytic, protein-rich meal thrice weekly over a period of 3 months, followed by a treatment-free period of 3 months. Patients allocated to the control group (CG) received nutritional counseling alone. Changes in serum albumin and body composition were investigated. RESULTS: At the start of the study, both groups were similar except for the levels of C-reactive protein (P = .034) and hemoglobin (P = .003). At the end of the study period, the level of serum albumin (P = .001) was significantly increased with increased protein intake in the IG (P = .048). However, this difference was not sustained during the follow-up period after termination of therapy. In the IG, the levels of serum albumin were significantly decreased between months 3 and 6 (P < .001), whereas those in the CG remained unchanged. There were no statistically significant differences observed between the two groups in the levels of C-reactive protein and body composition. CONCLUSION: The short-term administration of a low-cost, intradialytic, protein-rich meal (i.e., 200 mL milk plus two egg whites) resulted in a significant improvement in the levels of serum albumin versus nutritional counseling alone. This inexpensive nutritional intervention was feasible for the treatment of Chinese patients undergoing hemodialysis.

Different Associations of Socioeconomic Status on Protein Intake in the Korean Elderly Population: A Cross-Sectional Analysis of the Korea National Health and Nutrition Examination Survey.

Socioeconomic status affects food choices. This study examined the relationships between socioeconomic status (SES) and animal and plant protein intake in the Korean elderly population whose protein intake is insufficient. We used cross-sectional data from 3512 Koreans aged 60 years or older, who had participated in the Nutrition Survey of the 2013-14 Korea National Health and Nutrition Examination Survey (KNHANES). One day 24-h recall data was used to estimate the daily total, animal, and plant protein intake. Household income and educational attainment were assessed by trained interviewers. After making adjustment, household income was positively associated with animal protein intake with a statistical significance in females (p = 0.030) and with a marginal significance in males (p = 0.069). However, plant protein intake did not show any significant association. In both sexes, educational attainment was positively associated with animal protein intake (p = 0.007 for males, p = 0.001 for females). Association of educational attainment with plant protein intake was negative in males (p = 0.037) and non-significant in females. (p = 0.945). High SES was associated with higher total protein intake and animal protein intake in the Korean elderly. Health policies and nutrition education are needed to improve protein intake of the vulnerable Korean elderly with low SES.

Cost-Effectiveness of a Specialized Oral Nutritional Supplementation for Malnourished Older Adult Patients in Spain.

Malnutrition has been related to prolonged hospital stays, and to increases in readmission and mortality rates. In the NOURISH (Nutrition effect On Unplanned Readmissions and Survival in Hospitalized patients) study, administering a high protein oral nutritional supplement (ONS) containing beta-hydroxy-beta-methylbutyrate (HP-HMB) to hospitalised older adult patients led to a significant improvement in survival compared with a placebo treatment. The aim of this study was to determine whether HP-HMB would be cost-effective in Spain. We performed a cost-effectiveness analysis from the perspective of the Spanish National Health System using time horizons of 90 days, 180 days, 1 year, 2 years, 5 years and lifetime. The difference in cost between patients treated with HP-HMB and placebo was €332.75. With the 90 days time horizon, the difference in life years gained (LYG) between both groups was 0.0096, resulting in an incremental cost-effectiveness ratio (ICER) of €34,700.62/LYG. With time horizons of 180 days, 1 year, 2 years, 5 years and lifetime, the respective ICERs were €13,711.68, €3377.96, €2253.32, €1127.34 and €563.84/LYG. This analysis suggests that administering HP-HMB to older adult patients admitted to Spanish hospitals during hospitalisation and after discharge could be a cost-effective intervention that would improve survival with a reduced marginal cost.

Composition of legume soaking water and emulsifying properties in gluten-free bread.

Soaking of legumes results in the loss of macronutrients, micronutrients and phytochemicals. Fibre, protein and phytochemicals found in legumes exert emulsifying activity that may improve the structure and texture of gluten-free bread. The legume soaking water of haricot beans, garbanzo chickpeas, whole green lentils, split yellow peas and yellow soybeans were tested in this study for functional properties and use as food ingredients. Composition, physicochemical properties and effect on the quality of gluten-free bread were determined for each legume soaking water. Haricot beans and split yellow peas released the highest amount of solids in the legume soaking water: 1.89 and 2.38 g/100 g, respectively. Insoluble fibre was the main constituent of haricot beans legume soaking water, while water-soluble carbohydrates and protein were the major fraction of split yellow peas. High quantities of phenolics (∼400 µg/g) and saponins (∼3 mg/g) were found in the legume soaking water of haricot beans, whole green lentils and split yellow peas. High emulsifying activity (46 and 50%) was found for the legume soaking water of garbanzo chickpeas and split yellow peas, probably due to their protein content and high ratio of water-soluble carbohydrates to dry matter. Such activity resulted in softer texture of the gluten-free bread. A homogeneous structure of crumb pores was found for split yellow peas, opposing that of whole green lentils. A balance between the contents of yeast nutrients and antinutrients was the likely basis of the different appearances.

Potential application of microalga Spirulina platensis as a protein source.

The high protein level of various microalgal species is one of the main reasons to consider them an unconventional source of this compound. Spirulina platensis stands out for being one of the richest protein sources of microbial origin (460-630 g kg-1 , dry matter basis), having similar protein levels when compared to meat and soybeans. The use of S. platensis in food can bring benefits to human health owing to its chemical composition, since it has high levels of vitamins, minerals, phenolics, essential fatty acids, amino acids and pigments. Furthermore, the development of new protein sources to supply the shortage of this nutrient is an urgent need, and protein from S. platensis plays an important role in this scenario. In this sense, extraction processes that allow maximum protein yield and total utilization of biomass is an urgent need, and ultrasonic waves have proven to be an effective extraction technique. The number of scientific papers related to protein fraction from S. platensis is still limited; thus further studies on its functional and technological properties are needed. © 2016 Society of Chemical Industry.

Patient Survival and Costs on Moderately Restricted Low-Protein Diets in Advanced CKD: Equivalent Survival at Lower Costs?

The indications for delaying the start of dialysis have revived interest in low-protein diets (LPDs). In this observational prospective study, we enrolled all patients with chronic kidney disease (CKD) who followed a moderately restricted LPD in 2007-2015 in a nephrology unit in Italy: 449 patients, 847 years of observation. At the start of the diet, the median glomerular filtration rate (GFR) was 20 mL/min, the median age was 70, the median Charlson Index was 7. Standardized mortality rates for the "on-diet" population were significantly lower than for patients on dialysis (United States Renal Data System (USRDS): 0.44 (0.36-0.54); Italian Dialysis Registry: 0.73 (0.59-0.88); French Dialysis Registry 0.70 (0.57-0.85)). Considering only the follow-up at low GFR (≤15 mL/min), survival remained significantly higher than in the USRDS, and was equivalent to the Italian and French registries, with an advantage in younger patients. Below the e-GFR of 15 mL/min, 50% of the patients reached a dialysis-free follow-up of ≥2 years; 25% have been dialysis-free for five years. Considering an average yearly cost of about 50,000 Euros for dialysis and 1200 Euros for the diet, and different hypotheses of "spared" dialysis years, treating 100 patients on a moderately restricted LPD would allow saving one to four million Euros. Therefore, our study suggests that in patients with advanced CKD, moderately restricted LPDs may allow prolonging dialysis-free follow-up with comparable survival to dialysis at a lower cost.

Early malnutrition screening and low cost protein supplementation in elderly patients admitted to a skilled nursing facility.

BACKGROUND: Malnutrition among skilled nursing facility (SNF) patients can lead to hospital readmissions and multiple complications. PURPOSE: To evaluate the effect of an existing malnutrition screening and management program on prealbumin levels of patients in skilled nursing facilities. METHODS: A retrospective design was used to evaluate baseline admission data including a prealbumin level. Patients with malnutrition received an oral protein supplement according to protocol. A comparison prealbumin level was obtained at 30days. RESULTS: Nearly half of the patients were severely malnourished on admission. Patients receiving the prescribed protocol had significantly increased prealbumin levels at 30days than those patients that did not receive the protocol as prescribed. CONCLUSION: A prealbumin level upon admission at a SNF could represent a reliable tool to evaluate malnutrition. Initiation of an early malnutrition screening and protein supplement program in this setting is essential to identifying and treating at-risk patients before complications occur.

The biological standard of living in Suriname, c. 1870-1975.

The physical stature of Surinamese soldiers is estimated to have increased by more than 3cm between 1870 and 1909. In the subsequent four decades, the increase in adult male and female height amounted to 0.3-0.5cm and 0.9-1.0cm per decade, respectively. This increase in height continued and accelerated during the second half of the twentieth century. Height increase among African and Hindustani Surinamese males and females was similar. Height differences between African and Hindustani Surinamese were therefore fairly constant over time, at 4-5cm. Other indicators of nutritional and health status, such as infant mortality, showed continuous improvement, whereas per capita calorie and protein availability improved in the twentieth century.

Optimisation of a cheap and residential small-scale production of edible crickets with local by-products as an alternative protein-rich human food source in Ratanakiri Province, Cambodia.

BACKGROUND: The health status of the indigenous people of Ratanakiri Province, Cambodia, is significantly lower compared with that of the rest of the nation. The domestication and mass production of insects may represent a sustainable, cost effective and high quality alternative source of protein to traditional livestock. This study aimed to optimise a cheap and residential cricket breeding system based on unused wild resources. The development of crickets, Teleogryllus testaceus (Walker), under seven diets composed of taro aerial parts, young cassava leaves, young cashew leaves and brown rice flour (with or without banana slices), versus a traditionally used broiler feed diet was studied. RESULTS: Cricket mortality was low in all diets, except the two cashew-based diets. Total biomass was significantly higher under the broiler feed, in addition to the two diets containing a combination of cassava leaf powder and brown rice. Yet, crickets fed with the taro diet had the highest percentage of protein. Concerning the breeding system cost, units using cassava leaves were the cheapest. CONCLUSION: Diets based on cassava leaves seem to be the most promising. Nevertheless, to produce crickets with a high body mass and a high protein level, a new experiments must be devised in which cassava leaf maturity will be adapted to fit with the cricket growth stage. Moreover, to reduce the cost of the breeding units, handmade local products should be used instead of purchased components.

The Maillard reaction of a shrimp by-product protein hydrolysate: chemical changes and inhibiting effects of reactive oxygen species in human HepG2 cells.

Recently, much attention has been given to improving the antioxidant activity of protein hydrolysates via the Maillard reaction, but little is known about the cellular antioxidant activity of Maillard reaction products (MRPs) from protein hydrolysates. We first investigated chemical characterization and the cellular antioxidant activity of MRPs in a shrimp (Litopenaeus vannamei) by-product protein hydrolysate (SBH)-glucose system at 110 °C for up to 10 h of heating. Solutions of SBH and glucose were also heated alone as controls. The Maillard reaction greatly resulted in the increase of hydroxymethylfurfural (HMF) and browning intensity, high molecular weight fraction, and reduction of the total amino acid in SBH with the heating time, which correlated well with the free radical scavenging activity of MRPs. MRPs had stronger inhibiting effects on oxidative stress of human HepG2 cells than the original SBH, and its cellular antioxidant activity strongly correlated with free radical scavenging activity, but less affected by the browning intensity and HMF level. The caramelization of glucose partially affected the HMF level and free radical scavenging activity of MRPs, but it was not related to the cellular antioxidant activity. The cellular antioxidant activity of MRPs for 5 h of heating time appeared to reach a maximum level, which was mainly due to carbonyl ammonia condensation reaction. In conclusion, the Maillard reaction is a potential method to increase the cellular antioxidant activity of a shrimp by-product protein hydrolysate, but the higher HMF levels and the lower amino acid content in MRPs should also be considered.

Effects of the comminution rate and microbial contamination of particles in the rumen on in situ estimates of protein and amino acid digestion of expeller palm kernel and rapeseed meal.

BACKGROUND: Microbial corrected effective in situ estimates of ruminal undegraded fraction (RU) and intestinal effective digestibility (IED) of dry matter (DM), crude protein (CP) and amino acids (AA) of expeller palm kernel (EPK) and rapeseed meal (RSM) were measured on three rumen- and duodenum-cannulated wethers using ¹5N labelling techniques and considering ruminal rates of comminution (k(c)) and outflow (k(p)) of particles. RESULTS: The lack of k(c) and microbial correction overestimated the RU of DM by 4.91% (EPK) and 9.88% (RSM). The lack of this correction also overestimated in both feeds the RU of CP, individual and total (TAA) AA as well as the IED of DM, CP, TAA and most AA. RU estimates were higher for CP than for TAA, but the opposite was observed for IED. The intestinal digested fraction was higher for CP than for TAA: 17.4% (EPK) and 13.8% (RSM). Digestion led to large changes in the essential AA profile in both feeds. CONCLUSION: The lack of k(c) and microbial correction as well as CP-based results leads to considerable overestimations in the protein use of both feeds. Digestion aggravates the lysine deficiency of EPK but has global positive effects in the absorbed profile of RSM.

Application of taste sensing system for characterisation of enzymatic hydrolysates from shrimp processing by-products.

The objective of this study was to investigate the potential of an instrumental taste-sensing system to distinguish between shrimp processing by-products hydrolysates produced using different proteases and hydrolysis conditions, and the possible association of taste sensor outputs with human gustatory assessment, salt content, and bioactivity. Principal component analysis of taste sensor output data categorised samples according to the proteases used for hydrolysis. High umami sensor outputs were characteristic of bromelain- and Flavourzyme-produced hydrolysates, compared to low saltiness and high bitterness outputs of Alcalase-produced hydrolysates, and high saltiness and low umami outputs of Protamex-produced hydrolysates. Extensively hydrolysed samples showed higher sourness outputs. Saltiness sensor outputs were correlated with conductivity and sodium content, while umami sensor responses were related to gustatory sweetness, bitterness and umami, as well as angiotensin-I converting enzyme inhibitory activity. Further research should explore the dose dependence and sensitivity of each taste sensor to specific amino acids and peptides.

Evaluation of Camelina sativa (L.) Crantz meal as an alternative protein source in ruminant rations.

BACKGROUND: Camelina sativa (CS) is an oilseed crop used for biofuel production. By-products from oil extraction are high in protein and can be used in ruminant rations; more information about their nutritive value is required also considering the antinutrional factor content of the by-products. The aim of this study was to evaluate the nutritive value of CS meal genotypes in comparison with canola. RESULTS: Ten CS genotypes and one canola cultivar were evaluated. Meals were obtained from seeds after solvent oil extraction. CS average crude protein (CP) content (g kg⁻¹ dry matter) was 457. Numerical differences in lysine and sulfur amino acid content were observed among CS genotypes. Glucosinolate (mmol kg⁻¹) content was higher for CS (23.1) than canola (7.2). Sinapine content (g kg⁻¹) was lower for CS (2.79) than for canola (4.32). Differences were observed among CS genotypes for rumen undegraded protein (RUP). Average RUP (g kg⁻¹ CP) was 316 for CS and 275 for canola. CONCLUSIONS: CS meal has potential for use in ruminant rations as a high-quality protein source. In vivo studies are needed to compare CS with other protein sources used in cattle rations. Implementation of breeding programs for improved meal quality is recommend.

Isolation and characterization of pepsin-solubilized collagen from the integument of sea cucumber (Stichopus vastus).

BACKGROUND: Sea cucumber (Stichopus vastus) is considered an underutilized resource, since only its stomach and intestines are eaten raw as salad in a few countries and the remaining parts, especially the integument rich in collagen, is discarded. Hence a valuable by-product having potential nutraceutical and pharmaceutical applications is wasted. In the present investigation, pepsin-solubilized collagen (PSC) from the integument of S. vastus was isolated, purified and characterized. RESULTS: Sodium dodecyl sulfate-polyacrylamide gel electrophoretic analysis showed that the purified collagen was of type I, consisting of three α1 chains of approximately 122 kDa each. The peptide map of PSC digested by V8 protease was different from that of calf skin type I collagen. Fourier transform infrared spectroscopy revealed that the triple helical structure was well preserved in isolated collagen. The denaturation temperature of PSC was 21.23 °C and showed good gel-forming capability at pH 6.5 and 300 mmol L⁻¹ NaCl. CONCLUSION: It is inferred that the collagen isolated from S. vastus integument has potential for use as an alternative to land-based mammalian collagen in food, nutraceuticals and pharmaceutical industries.

Effects of high hydrostatic pressure on physicochemical and functional properties of walnut (Juglans regia L.) protein isolate.

BACKGROUND: Walnut (Juglans regia L.) is a good source of protein that has potential application in new product formation and fortification. The main objectives of this study were to investigate the effects of high hydrostatic pressure (HHP) treatment (300-600 MPa 20 min) on physicochemical and functional properties of walnut protein isolate (WPI) using various analytical techniques at room temperature. RESULTS: The results showed significant modification of solubility, free sulfhydryl content and surface hydrophobicity with increased levels of HHP treatment, indicating partial denaturation and aggregation of proteins. Differential scanning calorimetry and fluorescence spectrum analyses demonstrated that HHP treatment resulted in gradual unfolding of protein structure. Emulsifying activity index was significantly (P < 0.05) increased after HHP treatment at 400 MPa, but significantly decreased (P < 0.05) relative to the untreated WPI with further increase in pressure. HHP treatment at 300-600 MPa significantly decreased emulsion stability index. Additionally, HHP-treated walnut proteins showed better foaming properties and in vitro digestibility. CONCLUSION: These results suggest that HHP treatment could be applied to modify the properties of walnut proteins by appropriate of pressure levels, which will help in using walnut protein as a potential food ingredient.