Net benefit and cost-effectiveness of universal iron-containing multiple micronutrient powders for young children in 78 countries: a microsimulation study.

BACKGROUND: Universal home fortification of complementary foods with iron-containing multiple micronutrient powders (MNPs) is a key intervention to prevent anaemia in young children in low-income and middle-income countries. However, evidence that MNPs might promote infection raises uncertainty about whether MNPs give net health benefits and are cost-effective. We aimed to determined country-specific net benefit or harm and cost-effectiveness of universal provision of MNPs to children aged 6 months. METHODS: We developed a microsimulation model to estimate net country-specific disability-adjusted life-years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) due to anaemia, malaria, and diarrhoea averted (or increased) by provision of a 6-month course of MNPs to children aged 6 months, compared with no intervention, who would be followed up for an additional 6 months (ie, to age 18 months). Anaemia prevalence was derived from Demographic and Health Surveys or similar national surveys, and malaria and diarrhoea incidence were sourced from the Global Burden of Disease Study. Programme and health-care costs were modelled to determine cost per DALY averted (US$). Additionally, we explored the effects of reduced MNP coverage in a sensitivity analysis. FINDINGS: 78 countries (46 countries in Africa, 20 in Asia or the Middle East, and 12 in Latin America) were included in the analysis, and we simulated 5 million children per country. 6 months of universal distribution of daily MNPs, assuming 100% coverage, produced a net benefit (DALYs averted) in 54 countries (24 in Africa, 19 in Asia and the Middle East, 11 in Latin America) and net harm in 24 countries (22 in Africa, one in Asia, and one in Latin America). MNP intervention provided a benefit on YLDs associated with anaemia, but these gains were attenuated and sometimes reversed by increases in YLLs associated with malaria and diarrhoea, reducing the benefits seen for DALYs. In the 54 countries where MNP provision was beneficial, the median benefit was 28·1 DALYs averted per 10 000 children receiving MNPs (IQR 20·6-40·4), and median cost per DALY averted was $3576 (IQR 2474-4918). DALY effects positively correlated with moderate and severe anaemia prevalence in Asia, the Middle East, and Latin America, but correlated inversely in Africa. Suboptimal coverage markedly reduced DALYs averted and cost-effectiveness. INTERPRETATION: Net health benefits of MNPs vary between countries, are highest where prevalence of moderate and severe anaemia is greatest but infection prevalence is smallest, and are ameliorated when coverage of the intervention is poor. Our data provide country-specific guidance to national policy makers. FUNDING: International Union of Nutrition Sciences.

Florets of sunflower (Helianthus annuus L.): potential new sources of dietary fiber and phenolic acids.

Ray florets (Rf) and disc florets (Df) are agricultural byproducts of sunflower seeds. Their nutrition-related compounds were determined. The dietary fiber contents in Rf and Df were 42.90 mg/100 g and 58.97 mg/100 g. In both florets, palmitic, linoleic, and linolenic acids were identified as the three most abundant fatty acids, and the saturated ones constitute approximately two-thirds (w/w) of the total fatty acids. Lysine was the limiting amino acid in both florets by World Health Organization standards. Sixteen phenolic compounds, nine free and eight bound, mainly depsides, were identified in florets by RP-HPLC-DAD/ESI-TOF-MS. The free and bound phenolic compounds in Df were higher than in Rf. 1,5-di-O-caffeoylquinic acid was the predominant free phenolic compound in both florets. The present study revealed that the florets of sunflower are rich sources of dietary fiber, Fe, and phenols.

Fortification of staple cereal flours with iron and other micronutrients: cost implications of following World Health Organization-endorsed recommendations.

BACKGROUND: Wheat and maize flours are widely used delivery vehicles for mass fortification. In lower-income countries, most, if not all, national-level cereal flour fortification programs routinely fortify with iron; however, cofortification with other micronutrients is common. Little information is available on the cost implications programs face when considering current fortification practices versus what the World Health Organization (WHO) interim consensus statement recommends. OBJECTIVE: The objectives of the present paper are to provide information on the costs of adding different chemical forms of iron and/or other micronutrients to premix formulations, and to discuss some of the issues that should be considered regarding which micronutrients to include in the premix. METHODS: Nine countries in Latin America, Africa, and Asia (three countries per region) that currently cofortify with multiple micronutrients including iron were selected based on low (< 75 g/day), medium (75 to 149 g/day), and high (> or = 150 g/day) mean population flour consumption levels. Premix costs per metric ton of flour produced were estimated for improving iron formulations and for following WHO recommendations for other micronutrients. RESULTS: For the selected programs to maintain current premix formulations and improve iron compounds, premix costs would increase by between 155% and 343% when the iron compound was switched from electrolytic iron to sodium iron ethylenediaminetetraacetate (NaFeEDTA), by 6% to 50% when it was switched from electrolytic iron to ferrous sulfate, and by 4% to 13 when iron addition rates were adjusted without switching the compound. To meet WHO recommendations for other micronutrients, premix costs would increase the most when the amounts of vitamins B12 and A were increased. CONCLUSIONS: For programs that currently cofortify with iron and additional micronutrients, the quality of the iron fortificant should not be overlooked simply to be able to afford to add more micronutrients to the premix. Micronutrients should be selected according to population needs, costs, and potential beneficial synergistic reactions the added micronutrients may have.

Effective utilization of erythropoietin with intravenous iron therapy.

INTRODUCTION: Iron replacement therapy reduces the demand for erythropoietin (EPO) in some dialysis patients. It has been postulated that iron supply to the bone marrow is a rate-limiting step in the process of erythropoiesis under erythropoietin stimulation. METHODS: We evaluated the economic benefit of intravenous iron therapy for this purpose in a prospective, non-blinded study of 22 haemodialysis patients, 16 male, six female, mean age 62 years (range 24-80 years). All patients had a serum ferritin (SF) of < or = 60 microg/L, despite oral iron therapy. Patients with high aluminium and/or parathyroid hormone (PTH) levels, underlying bleeding/haematological disorders or active inflammatory diseases were excluded. Patients were established on subcutaneous EPO and given intravenous iron over seven consecutive dialysis sessions (total dose 1050 mg) and supplemental monthly doses with regular monitoring for 4 months. RESULTS: The median EPO dose was 4000 units/week (mean 6050 units/week) pre-treatment and 2000 units/week (mean 3700 units) at 6 weeks post intravenous iron therapy (P=0.03). No serious adverse events occurred in the 154 treatment sessions of intravenous iron. Mean haemoglobin (Hb) level remained constant at 6 and 12 weeks (P=0.087). Serum ferritin levels (P< 0.0001) rose significantly, while a reduction in transferrin saturation (TS) became significant at the end of the study (P=0.0047). The use of intravenous iron allowed a substantial monthly cost saving per patient in our unit. CONCLUSION: Intravenous iron therapy is a safe and cost-effective method for maintaining or improving Hb levels with a more effective utilization of EPO in patients with low SF levels despite oral iron therapy.