Estimating the health and economic effects of the proposed US Food and Drug Administration voluntary sodium reformulation: Microsimulation cost-effectiveness analysis.

BACKGROUND: Sodium consumption is a modifiable risk factor for higher blood pressure (BP) and cardiovascular disease (CVD). The US Food and Drug Administration (FDA) has proposed voluntary sodium reduction goals targeting processed and commercially prepared foods. We aimed to quantify the potential health and economic impact of this policy. METHODS AND FINDINGS: We used a microsimulation approach of a close-to-reality synthetic population (US IMPACT Food Policy Model) to estimate CVD deaths and cases prevented or postponed, quality-adjusted life years (QALYs), and cost-effectiveness from 2017 to 2036 of 3 scenarios: (1) optimal, 100% compliance with 10-year reformulation targets; (2) modest, 50% compliance with 10-year reformulation targets; and (3) pessimistic, 100% compliance with 2-year reformulation targets, but with no further progress. We used the National Health and Nutrition Examination Survey and high-quality meta-analyses to inform model inputs. Costs included government costs to administer and monitor the policy, industry reformulation costs, and CVD-related healthcare, productivity, and informal care costs. Between 2017 and 2036, the optimal reformulation scenario achieving the FDA sodium reduction targets could prevent approximately 450,000 CVD cases (95% uncertainty interval: 240,000 to 740,000), gain approximately 2.1 million discounted QALYs (1.7 million to 2.4 million), and produce discounted cost savings (health savings minus policy costs) of approximately $41 billion ($14 billion to $81 billion). In the modest and pessimistic scenarios, health gains would be 1.1 million and 0.7 million QALYS, with savings of $19 billion and $12 billion, respectively. All the scenarios were estimated with more than 80% probability to be cost-effective (incremental cost/QALY < $100,000) by 2021 and to become cost-saving by 2031. Limitations include evaluating only diseases mediated through BP, while decreasing sodium consumption could have beneficial effects upon other health burdens such as gastric cancer. Further, the effect estimates in the model are based on interventional and prospective observational studies. They are therefore subject to biases and confounding that may have influenced also our model estimates. CONCLUSIONS: Implementing and achieving the FDA sodium reformulation targets could generate substantial health gains and net cost savings.

Innovative optimization of ready to use food for treatment of acute malnutrition.

Treatment of acute malnutrition typically requires the provision of ready-to-use food (RUF). Common RUF is effective but expensive, being manufactured from costly ingredients, and shipped worldwide from few global suppliers. I developed a linear programming tool to create RUF optimized for low cost using locally grown crops while maintaining necessary nutritional goals and other constraints. My tool utilizes a database of the nutritional value, price, and water efficiency of suitable ingredients and allows adjustment of constraints, including nutrients, flavour, and crop water efficiency. It is designed to (a) address nutrient requirements conforming to current standards and practice; (b) optimize RUF formulae for low cost using a wide range of ingredients for nutritional value and acceptability improvement; (c) ensure protein quality through protein digestibility corrected amino acid score; and (d) adjust RUF formulae according to locally grown crop selection, local prices, and crop water footprint. The tool creates formulae free of expensive dairy ingredients, ensuring desired protein digestibility corrected amino acid score by automatically balancing proteins with complementary quantities of essential amino acids. Using publicly available data with an application to Nigeria, my tool created RUF formulae suitable for local production using local crops to meet all nutrient requirements at a fraction of the ingredient cost and water footprint of current formulae, demonstrating the tool's effectiveness. Optimization of RUF for low cost using locally grown crops will facilitate local production and reduce ingredient as well as transport costs, so more patients can receive lifesaving treatment.

Optimizing Ready-to-Use Therapeutic Foods for Protein Quality, Cost, and Acceptability.

This article describes current research on the development of alternative ready-to-use therapeutic foods (RUTFs) in the treatment of severe acute malnutrition. An innovative and versatile linear programming tool has been developed to facilitate the creation of therapeutic formulas that are determined acceptable on multiple levels: costs, ingredient acceptability, availability and stability, nutrient requirements, and personal preferences. The formulas are analyzed for ease of production by Washington University team members and for organoleptic properties acceptability to target populations. In the future, RUTF products that are cost-effective, acceptable, sustainable, and widely available will become a reality.

The use of oral nutritional supplements in the acute care setting.

Oral nutritional supplements offer support to patients in acute care who are undernourished or at risk of malnutrition. Yet doubts remain over cost and compliance. Omorogieva Ojo, Senior Lecturer in Primary Care at University of Greenwich weighs up the evidence.

Ready-to-use foods for management of moderate acute malnutrition: considerations for scaling up production and use in programs.

Ready-to-use foods are one of the available strategies for the treatment of moderate acute malnutrition (MAM), but challenges remain in the use of these products in programs at scale. This paper focuses on two challenges: the need for cheaper formulations using locally available ingredients that are processed in a safe, reliable, and financially sustainable local production facility; and the effective use of these products in large-scale community-based programs. Linear programming tools can be used successfully to design local compositions that are in line with international guidelines, low in cost, and acceptable, and the efficacy of these local formulations in the treatment of MAM was recently demonstrated in Malawi. The production of local formulations for programs at scale relies on the existence of a reliable and efficient local production facility. Technical assistance may be required in the development of sustainable business models at an early stage in the process, taking into account the stringent product quality and safety criteria and the required investments. The use of ready-to-use products, as of any food supplement, in programs at scale will be affected by the practice of household sharing and diversion of these products for other uses. Additional measures can be considered to account for sharing. These products designed for the treatment and prevention of MAM are to be used in community-based programs and should therefore be used in conjunction with other interventions and designed so that they do not replace the intake of other foods and breastmilk. Remaining challenges and implications for the (operations) research agenda are discussed.

From diets to foods: using linear programming to formulate a nutritious, minimum-cost porridge mix for children aged 1 to 2 years.

BACKGROUND: Linear programming has been used extensively as a tool for nutritional recommendations. Extending the methodology to food formulation presents new challenges, since not all combinations of nutritious ingredients will produce an acceptable food. Furthermore, it would help in implementation and in ensuring the feasibility of the suggested recommendations. OBJECTIVE: To extend the previously used linear programming methodology from diet optimization to food formulation using consistency constraints. In addition, to exemplify usability using the case of a porridge mix formulation for emergency situations in rural Mozambique. METHODS: The linear programming method was extended with a consistency constraint based on previously published empirical studies on swelling of starch in soft porridges. The new method was exemplified using the formulation of a nutritious, minimum-cost porridge mix for children aged 1 to 2 years for use as a complete relief food, based primarily on local ingredients, in rural Mozambique. RESULTS: A nutritious porridge fulfilling the consistency constraints was found; however, the minimum cost was unfeasible with local ingredients only. This illustrates the challenges in formulating nutritious yet economically feasible foods from local ingredients. The high cost was caused by the high cost of mineral-rich foods. A nutritious, low-cost porridge that fulfills the consistency constraints was obtained by including supplements of zinc and calcium salts as ingredients. CONCLUSIONS: The optimizations were successful in fulfilling all constraints and provided a feasible porridge, showing that the extended constrained linear programming methodology provides a systematic tool for designing nutritious foods.

[Study of physicochemical and bacteriological impact of a weekly assembly of automated compounding BAXA(®) Exacta-Mix 2400 on parenteral nutrition admixture manufacturing]. / Étude de l'impact physicochimique et bactériologique d'un montage hebdomadaire de l'automate BAXA(®) Exacta-Mix 2400 sur la fabrication des poches de nutrition parentérale.

INTRODUCTION: The parenteral nutrition admixtures are manufactured with an automated compounding BAXA(®) Exacta-Mix 2400. A 48-hour assembly has been validated. To optimize time and cost, a weekly assembly was tested. MATERIALS AND METHODS: Assembly was made on the first day. Ten identical parenteral nutrition admixtures (different volumes and compositions) were produced each day. A macroscopic examination was done at D0, D7 and D14. Physicochemical controls (electrolytes determinations by atomic absorption spectrophotometry, osmolalities measurements) were performed. Microbiological tests included a filtration membrane sterility test (Steritest(®)) and a plate count agar environmental monitoring. RESULTS: All mixtures were considered stable. The 12 Steritest(®) (H24, H48, D7 and D14) did not show any bacterial or fungal contamination. No microorganism has been detected on the plate count agar at D4 and D7. Concerning the physicochemical parameters of each parental nutrition admixture, no significant difference (Wilcoxon test) with the first day was found. DISCUSSION AND CONCLUSIONS: The automated filling system BAXA(®) Exacta-Mix 2400 improves the quality and safety of production. According to these results, the weekly assembly is validated and permit to save time (80hours/year) and cost (40 000 euros on consumable/year).

Insurance coverage of medical foods for treatment of inherited metabolic disorders.

PURPOSE: Treatment of inherited metabolic disorders is accomplished by use of specialized diets employing medical foods and medically necessary supplements. Families seeking insurance coverage for these products express concern that coverage is often limited; the extent of this challenge is not well defined. METHODS: To learn about limitations in insurance coverage, parents of 305 children with inherited metabolic disorders completed a paper survey providing information about their use of medical foods, modified low-protein foods, prescribed dietary supplements, and medical feeding equipment and supplies for treatment of their child's disorder as well as details about payment sources for these products. RESULTS: Although nearly all children with inherited metabolic disorders had medical coverage of some type, families paid "out of pocket" for all types of products. Uncovered spending was reported for 11% of families purchasing medical foods, 26% purchasing supplements, 33% of those needing medical feeding supplies, and 59% of families requiring modified low-protein foods. Forty-two percent of families using modified low-protein foods and 21% of families using medical foods reported additional treatment-related expenses of $100 or more per month for these products. CONCLUSION: Costs of medical foods used to treat inherited metabolic disorders are not completely covered by insurance or other resources.

Rationale and design of a study using a standardized locally procured macronutrient supplement as adjunctive therapy to HIV treatment in Kenya.

Poor nutritional status at initiation of antiretroviral therapy (ART) is predictive of mortality. Decreased dietary intake is a major determinant of weight loss in HIV. Despite a biological rationale to treat undernutrition in adults receiving ART, few studies have provided data on feasibility, safety, effectiveness, and sustainability of specific macronutrient supplements with HIV treatment in adults, especially supplements such as a food basket, a supplement approach seldom evaluated in spite of its wide use. We present the rationale and design for a study of a locally procured macronutrient supplement given to HIV-infected patients initiating ART with a body mass index (BMI) ≤20.0 kg/m(2). The objective was to determine feasibility of procurement, distribution, safety and to obtain preliminary effectiveness data for a locally procured supplement. The design was a comparative study for 200 adult participants at two Kenya government-supported clinics. The primary outcome was BMI at 24 weeks. Supplement duration was 24 weeks, total follow-up was 48 weeks, and the study included a comparison site. Novel aspects of this study include use of a standardized macronutrient supplement to protect the participant against household food sharing, and a complementary micronutrient supplement. Comprehensive data collected included dietary intake, HIV-related quality-of-life, food security, neuropsychiatric assessments, laboratory studies, and household geomapping. Assessments were made at baseline, at 24 weeks, and at 48 weeks post-ART initiation. Challenges included establishing a partnership with local millers, distribution from the HIV clinic, food safety, and tracking of participants. These findings will help inform nutrition support programming in Kenya and similar settings, and provide needed data regarding use of macronutrient supplements as an adjunctive intervention with ART.

Low-cost, ready-to-use therapeutic foods can be designed using locally available commodities with the aid of linear programming.

According to the United Nations (UN), 25 million children <5 y of age are currently affected by severe acute malnutrition and need to be treated using special nutritional products such as ready-to-use therapeutic foods (RUTF). Improved formulations are in demand, but a standardized approach for RUTF design has not yet been described. A method relying on linear programming (LP) analysis was developed and piloted in the design of a RUTF prototype for the treatment of wasting in East African children and adults. The LP objective function and decision variables consisted of the lowest formulation price and the weights of the chosen commodities (soy, sorghum, maize, oil, and sugar), respectively. The LP constraints were based on current UN recommendations for the macronutrient content of therapeutic food and included palatability, texture, and maximum food ingredient weight criteria. Nonlinear constraints for nutrient ratios were converted to linear equations to allow their use in LP. The formulation was considered accurate if laboratory results confirmed an energy density difference <10% and a protein or lipid difference <5 g · 100 g(-1) compared to the LP formulation estimates. With this test prototype, the differences were 7%, and 2.3 and -1.0 g · 100 g(-1), respectively, and the formulation accuracy was considered good. LP can contribute to the design of ready-to-use foods (therapeutic, supplementary, or complementary), targeting different forms of malnutrition, while using commodities that are cheaper, regionally available, and meet local cultural preferences. However, as with all prototype feeding products for medical use, composition analysis, safety, acceptability, and clinical effectiveness trials must be conducted to validate the formulation.

Cost-effectiveness of using an extensively hydrolysed formula compared to an amino acid formula as first-line treatment for cow milk allergy in the UK.

OBJECTIVE: To estimate the cost-effectiveness of using an extensively hydrolysed formula (eHF; Nutramigen) compared with an amino acid formula (AAF; Neocate) as first-line treatment for cow milk allergy (CMA) in the UK, from the perspective of the National Health Service (NHS). METHOD: A decision model was constructed depicting the treatment paths and associated resource use attributable to first-line management of CMA with the two formulae. The model was based on the case records of 145 AAF-treated infants and 150 matched eHF-treated patients from The Health Improvement Network (THIN) database [a nationally representative database of patients registered with general practitioners (GPs) in the UK]. The model estimated the costs and consequences of patient management over 12 months following their initial GP visit for CMA. RESULTS: Patients presenting with a combination of gastrointestinal symptoms and eczema accounted for 44% of all patients in both groups. Those with gastrointestinal symptoms alone and eczema alone accounted for up to a further 39% and 13%, respectively. Those with urticaria and faltering growth accounted for <5% and ≤6% of all patients, respectively. Patients' age and weight at presentation was a mean 2.6-2.8 months and 4.4 kg, respectively. It took a mean 2.2 months to start a formula after initially seeing a GP. Time to symptom resolution following the start of treatment was 1.2 months in both groups; hence, the mean number of symptom-free months during the 12 months following the initial GP visit was estimated to be 8.6 months in both groups. Patients treated with an eHF had a mean 13.1 GP visits over the 12 months compared to 17.5 visits made by AAF-treated patients (p < 0.001). The NHS cost of managing a CMA infant over the first 12 months following initial presentation to a GP was estimated to be £1853 and £3161 for an eHF-treated and AAF-treated patient, respectively. CONCLUSION: Starting treatment for CMA with an eHF was the cost-effective option, as there were no significant differences in clinical outcomes between the two groups. A prospective, randomized controlled trial would allow a definitive confirmation of these findings.

Factors associated with peptide-based formula prescription in a pediatric intensive care unit.

OBJECTIVES: There is no evidence-based consensus on the use of peptide-based formulas for critically ill children. The present study aimed to identify the factors associated with the choice of peptide-based formulas in the first enteral nutrition prescription for critically ill children and to compare the direct costs of the enteral formulas used in a pediatric intensive care unit. METHODS: In a prospective study, children admitted to the intensive care unit and receiving tube feeding for ≥48 hours were evaluated. The potential exposure variables for the use of peptide-based formulas as the first nutrition prescription were age, sex, malnutrition, sepsis/septic shock, fasting period >2 days, use of α-adrenergic drugs before initiating first diet, and the revised Pediatric Index of Mortality score. A direct cost comparison of prescribed formulas was performed. RESULTS: Of 291 patients included, 85 (29.2%) were given peptide-based formulas in the first nutrition prescription. This choice was independently associated with malnutrition (odds ratio [OR] 2.94; 95% confidence interval [CI] 1.60%-5.39%; P < 0.01), fasting period >2 days (OR 3.46; 95% CI 1.93%-6.20%; P < 0.01), and use of α-adrenergic drugs (OR 2.32; 95% CI 1.24%-4.31%; P < 0.01). Peptide-based formula costs were up to 10 times higher than standard polymeric formula costs. CONCLUSIONS: The choice of peptide-based formula as the first enteral nutrition prescription is associated with the greater severity of patients' clinical status-patients receiving α-adrenergic drugs, those who are malnourished, and those with longer fasting periods. These prescriptions engender costs higher than those associated with standard polymeric formula.

Nutraceuticals and botanicals: overview and perspectives.

The discovery, development and marketing of food supplements, nutraceuticals and related products are currently the fastest growing segments of the food industry. Functional foods can be considered part or borderline to these products and may be defined as foods or food ingredients that have additional health or physiological benefits over and above the normal nutritional value they provide. This trend is driven by several factors, mainly due to the current consumer perceptions: the first and dominant being 'Natural is good', and other secondary, such as the increasing cost of many pharmaceuticals and their negative secondary effects, the insistent marketing campaign, the increasing perception of the need of a healthy diet and its importance in the health and homeostasis organism conditions. However, the central point is that nutraceuticals, botanicals and other herbal remedies, including the entry of new functional foods, are important because of their acceptance as the novel and modern forms to benefit of natural substances. Due to the rapid expansion in this area, the development of several aspects is considered as it could influence the future of the market of these products negatively: an imbalance existing between the increasing number of claims and products on the one hand, the development of policies to regulate their application and safety on the other, rapid and valuable controls to check the composition, including the plant extracts or adulteration to improve efficacy, like the presence of synthetic drugs. It is interesting to see that, from the negative factors reported by the market analysts, a change in consumers preferences is absent. The functional properties of many plant extracts, in particular, are being investigated for potential use as novel nutraceuticals and functional foods. Although the availability of scientific data is rapidly improving, the central aspect concerns the validation of these products. The first step of this crucial aspect is the security of the composition, obtained by the useful and adapted analytical approach. On the other hand, in the first instance, security is assured by the millenary use as food of the great majority of these plants. The importance and the novelty of functional food are inherent in the possibility to renew the secure use of plants to maintain healthiness of man in novel forms of use adapted to modern times. The market of 'other substances', after the emergence of the first period of enthusiastic explosion, is entering into the maturation period, with three important arguments to face: (a) security in composition, production and sale, avoiding easy conversions or convenient approaches and favouring competence and professionalism, (b) definition of influence of metabolic aspects, including scientific validation and (c) regulatory aspects, e.g. the claims definition and relative influences. The last aspect seams to be in primis the most crucial and fundamental to the future of all the sectors. The role of European Food and Safety Authority (EFSA) in the EU market must be considered and consequences if negative decisions on 'other substances' claim will be adopted in each country's legislation.

Effectiveness and cost-effectiveness of 4 supplementary foods for treating moderate acute malnutrition: results from a cluster-randomized intervention trial in Sierra Leone.

BACKGROUND: Moderate acute malnutrition (MAM) affects 33 million children annually. Investments in formulations of corn-soy blended flours and lipid-based nutrient supplements have effectively improved MAM recovery rates. Information costs and cost-effectiveness differences are still needed. OBJECTIVES: We assessed recovery and sustained recovery rates of MAM children receiving a supplementary food: ready-to-use supplementary food (RUSF), corn soy whey blend with fortified vegetable oil (CSWB w/oil), or Super Cereal Plus with amylase (SC + A) compared to Corn Soy Blend Plus with fortified vegetable oil (CSB+ w/oil). We also estimated differences in costs and cost effectiveness of each supplement. METHODS: In Sierra Leone, we randomly assigned 29 health centers to provide a supplement containing 550 kcal/d for ∼12 wk to 2691 children with MAM aged 6-59 mo. We calculated cost per enrollee, cost per child who recovered, and cost per child who sustained recovery each from 2 perspectives: program perspective and caregiver perspective, combined. RESULTS: Of 2653 MAM children (98.6%) with complete data, 1676 children (63%) recovered. There were no significant differences in the odds of recovery compared to CSB+ w/oil [0.83 (95% CI: 0.64-1.08) for CSWB w/oil, 1.01 (95% CI: 0.78-1.3) for SC + A, 1.05 (95% CI: 0.82-1.34) for RUSF]. The odds of sustaining recovery were significantly lower for RUSF (0.7; 95% CI 0.49-0.99) but not CSWB w/oil or SC + A [1.08 (95% CI: 0.73-1.6) and 0.96 (95% CI: 0.67-1.4), respectively] when compared to CSB+ w/oil. Costs per enrollee [US dollars (USD)/child] ranged from $105/child in RUSF to $112/child in SC + A and costs per recovered child (USD/child) ranged from $163/child in RUSF to $179/child in CSWB w/oil, with overlapping uncertainty ranges. Costs were highest per sustained recovery (USD/child), ranging from $214/child with the CSB+ w/oil to $226/child with the SC + A, with overlapping uncertainty ranges. CONCLUSIONS: The 4 supplements performed similarly across recovery (but not sustained recovery) and costed measures. Analyses of posttreatment outcomes are necessary to estimate the full cost of MAM treatment. This trial was registered at clinicaltrials.gov as NCT03146897.

Cost and effectiveness analysis using nursing staff-prepared thickened liquids vs. commercially thickened liquids in stroke patients with dysphagia.

The purpose of this study was to evaluate the entire cost of nursing staff-prepared thickened liquids with Resource ThickenUp vs. utilizing commercially prepared thickened liquids in an acute care hospital. Time, cost, and effectiveness were studied in a 37-bed adult acute care neuroscience patient care unit in a large urban community hospital. Registered nurses and patient care technicians experienced in mixing thickened liquids for patients with dysphagia created liquids thickened to the consistency of nectar and honey from water, milk, and orange juice. Commercially prepared thickened liquids were 44% to 59% less expensive than the cost of manually creating the thickened liquids. Commercially prepared thickened liquids were more effective and of consistent viscosity than manually prepared thickened liquids due to variability in the skill of the preparer, alteration in the viscosity of the product based on acidity, protein, or sit-time from preparation to consumption.

Effect of flaxseed gum on reduction of blood glucose and cholesterol in type 2 diabetic patients.

The effects of ingestion of flaxseed gum on blood glucose and cholesterol, particularly low-density lipoprotein cholesterol, in type 2 diabetes were evaluated. Flaxseed gum was incorporated in wheat flour chapattis. Sixty patients of type 2 diabetes were fed a daily diet for 3 months, along with six wheat flour chapattis containing flaxseed gum (5 g), as per the recommendations of the American Diabetic Association. The control group (60 individuals) consumed an identical diet but the chapattis were without gum. The blood biochemistry profiles monitored before starting the study and at monthly intervals showed fasting blood sugar in the experimental group decreased from 154 ± 8 mg/dl to 136 ± 7 mg/dl (P=0.03) while the total cholesterol reduced from 182 ± 11 mg/dl to 163 ± 9 mg/dl (P=0.03). Results showed a decrease in low-density lipoprotein cholesterol from 110 ± 8 mg/dl to 92 ± 9 mg/dl (P=0.02). The study demonstrated the efficacy of flax gum in the blood biochemistry profiles of type 2 diabetes.

Use and Costs of Medical Foods and Convenience-Packaged Drugs in the California Workers' Compensation System.

BACKGROUND: Sales of medical foods (MFs) and convenience packages (CPs) are projected to exceed $2 billion in the United States, with an annual growth rate of 10%. Several studies have highlighted the rapid growth of MF use within the California Workers' Compensation System (CAWCS). To curb this growth, California implemented Assembly Bill 378 (AB 378) in 2012 to regulate physicians' incentives to dispense MFs and CPs. AB 378's regulation on only physician-dispensed MFs and CPs and not pharmacy-dispensed MFs and CPs generated a setting for evaluating the differential effect of the bill on MF and CP use and cost. OBJECTIVES: To (a) examine the use and cost of MFs and CPs in the CAWCS that are not for inborn errors of metabolism and (b) evaluate the regulatory effect of AB 378. METHODS: This study adopted a quantitative approach and employed descriptive statistics and t-tests. The analyses used the most recent complete annual claims data from the Workers' Compensation Information System dataset to evaluate MF and CP claims frequencies and dollar amounts reimbursed from 2011 to 2013 and to compare the difference between physician-dispensed and pharmacy-dispensed products. RESULTS: Of 151,107 MFs and CPs billed, 95,528 (63.2%) prescriptions were reimbursed. The reimbursed MFs and CPs accounted for approximately $19 million paid to pharmacies and physicians over 3 years. Physician-dispensed MFs, which were regulated by AB 378 in January 2012, experienced a reduction in mean amount reimbursed by $9.95 (P < 0.001)-from $195.64 to $185.68-compared with the mean amount reimbursed in 2011. Conversely, physician-dispensed CPs, as well as pharmacy-dispensed MFs and CPs, did not experience a decrease in mean amount reimbursed. CONCLUSIONS: The results indicated that AB 378 was associated with a statistically significant reduction in physician-dispensed MFs. Concomitantly, the results from t-tests showed no statistically significant difference in mean amount reimbursed for MFs and CPs to pharmacies before and after AB 378. The finding was expected and as hypothesized because AB 378 did not regulate pharmacy-dispensed MFs and CPs. Legislative measures, such as AB 378 in California, may influence rising costs and use of MFs and CPs in general. Other workers' compensation systems could adopt similar legislation to affect the behavior of physician prescribing of non-inborn errors of metabolism MFs and further test these findings. DISCLOSURES: Funding for this study was contributed by the California Workers' Compensation System. The authors have nothing to disclose.

A Survey of Home Enteral Nutrition Practices and Reimbursement in the Asia Pacific Region.

Literature regarding the use of home enteral nutrition (HEN) and how it is reimbursed in the Asia Pacific region is limited. This research survey aims to determine the availability of HEN, the type of feeds and enteral access used, national reimbursement policies, the presence of nutrition support teams (NSTs), and clinical nutrition education in this region. An electronic questionnaire was sent to 20 clinical nutrition societies and leaders in the Asia Pacific region in August 2017, where thirteen countries responded. Comparison of HEN reimbursement and practice between countries of different income groups based on the World Bank's data was investigated. Financial support for HEN is only available in 40% of the countries. An association was found between availability of financial support for HEN and health expenditure (r = 0.63, p = 0.021). High and middle-upper income countries use mainly commercial supplements for HEN, while lower-middle income countries use mainly blenderized diet. The presence of NSTs is limited, and only present mainly in acute settings. Sixty percent of the countries indicated an urgent need for funding and reimbursement of HEN. This survey demonstrates the varied clinical and economic situation in the Asia Pacific region. There is a lack of reimbursement, clinical support, and inadequate educational opportunities, especially for the lower-middle income countries.

The promise of a community-based approach to managing severe malnutrition: A case study from Ethiopia.

BACKGROUND: Community-based therapeutic care (CTC) is a new strategy in the arsenal of techniques to manage complex nutritional emergencies in rural communities. The CTC approach uses a newly developed ready-to-use therapeutic food, Plumpynut, to rehabilitate severely malnourished children in their home communities. Emerging literature has suggested the CTC strategy yielded results that were superior to those of programs limited to therapeutic feeding centers, as measured by rates of coverage and numbers of children rehabilitated. OBJECTIVE: To compare the effectiveness of the CTC strategy in combination with conventional treatments for acute malnutrition. The expectation was that this program would support the growing consensus on the effectiveness of CTC strategies. METHODS: Data from monitoring the initial phase of program implementation were reviewed to ascertain program impact. The number of children participating and the outcome of their participation were assessed. RESULTS: Families became key participants in the rehabilitation of their children, and communities became strengthened through the mobilization of local networks and the improved knowledge base of local health workers. Recovery rates were comparable with international standards, and coverage far exceeded that of traditional center-based care. CONCLUSIONS: CTC is an important tool to effectively address nutritional emergencies and may be a valuable entry point for long-term development, since it fosters capacity building and improvement in local communities. CTC programs may eventually be viewed as the entry point for more sustained development-oriented interventions, thus helping make the transition from relief to development.