Outcomes and Cost-Effectiveness of Integrating HIV and Nutrition Service Delivery: Pilots in Malawi and Mozambique.

This paper provides the first estimates of impact and cost-effectiveness for integrated HIV and nutrition service delivery in sub-Saharan Africa. HIV and undernutrition are synergistic co-epidemics impacting millions of children throughout the region. To alleviate this co-epidemic, UNICEF supported small-scale pilot programs in Malawi and Mozambique that integrated HIV and nutrition service delivery. We use trends from integration sites and comparison sites to estimate the number of lives saved, infections averted and/or undernutrition cases cured due to programmatic activities, and to estimate cost-effectiveness. Results suggest that Malawi's program had a cost-effectiveness of $11-29/DALY, while Mozambique's was $16-59/DALY. Some components were more effective than others ($1-4/DALY for Malawi's Male motivators vs. $179/DALY for Mozambique's One stop shops). These results suggest that integrating HIV and nutrition programming leads to a positive impact on health outcomes and should motivate additional work to evaluate impact and determine cost-effectiveness using an appropriate research design.

Disability-Adjusted Life Years for Maternal, Neonatal, and Nutritional Disorders in Korea.

Maternal and child health is an important issue throughout the world. Given their impact on maternal and child health, nutritional issues need to be carefully addressed. Accordingly, the effect of maternal, child, and nutritional disorders on disability-adjusted life years (DALYs) should be calculated. The present study used DALYs to estimate the burden of disease of maternal, neonatal, and nutritional disorders in the Korean population in 2012. For this purpose, we used claim data of the Korean National Health Insurance Service, DisMod II, and death data of the Statistics Korea and adhered to incidence-based DALY estimation methodology. The total DALYs per 100,000 population were 376 in maternal disorders, 64 in neonatal disorders, and 58 in nutritional deficiencies. The leading causes of DALYs were abortion in maternal disorders, preterm birth complications in neonatal disorders, and iron-deficiency anemia in nutritional deficiencies. Our findings shed light on the considerable burden of maternal, neonatal, and nutritional conditions, emphasizing the need for health care policies that can reduce morbidity and mortality.

The role of cost-effectiveness analysis in developing nutrition policy.

Concern about the overconsumption of unhealthy foods is growing worldwide. With high global rates of noncommunicable diseases related to poor nutrition and projections of more rapid increases of rates in low- and middle-income countries, it is vital to identify effective but low-cost interventions. Cost-effectiveness studies show that individually targeted dietary interventions can be effective and cost-effective, but a growing number of modeling studies suggest that population-wide approaches may bring larger and more sustained benefits for population health at a lower cost to society. Mandatory regulation of salt in processed foods, in particular, is highly recommended. Future research should focus on lacunae in the current evidence base: effectiveness of interventions addressing the marketing, availability, and price of healthy and unhealthy foods; modeling health impacts of complex dietary changes and multi-intervention strategies; and modeling health implications in diverse subpopulations to identify interventions that will most efficiently and effectively reduce health inequalities.

Nutrition economics - food as an ally of public health.

Non-communicable diseases (NCD) are a major and increasing contributor to morbidity and mortality in developed and developing countries. Much of the chronic disease burden is preventable through modification of lifestyle behaviours, and increased attention is being focused on identifying and implementing effective preventative health strategies. Nutrition has been identified as a major modifiable determinant of NCD. The recent merging of health economics and nutritional sciences to form the nascent discipline of nutrition economics aims to assess the impact of diet on health and disease prevention, and to evaluate options for changing dietary choices, while incorporating an understanding of the immediate impacts and downstream consequences. In short, nutrition economics allows for generation of policy-relevant evidence, and as such the discipline is a crucial partner in achieving better population nutritional status and improvements in public health and wellness. The objective of the present paper is to summarise presentations made at a satellite symposium held during the 11th European Nutrition Conference, 28 October 2011, where the role of nutrition and its potential to reduce the public health burden through alleviating undernutrition and nutrition deficiencies, promoting better-quality diets and incorporating a role for functional foods were discussed.

Workshop Report: concepts and methods in the economics of nutrition--gateways to better economic evaluation of nutrition interventions.

Improving health through better nutrition of the population may contribute to enhanced efficiency and sustainability of healthcare systems. A recent expert meeting investigated in detail a number of methodological aspects related to the discipline of nutrition economics. The role of nutrition in health maintenance and in the prevention of non-communicable diseases is now generally recognised. However, the main scope of those seeking to contain healthcare expenditures tends to focus on the management of existing chronic diseases. Identifying additional relevant dimensions to measure and the context of use will become increasingly important in selecting and developing outcome measurements for nutrition interventions. The translation of nutrition-related research data into public health guidance raises the challenging issue of carrying out more pragmatic trials in many areas where these would generate the most useful evidence for health policy decision-making. Nutrition exemplifies all the types of interventions and policy which need evaluating across the health field. There is a need to start actively engaging key stakeholders in order to collect data and to widen health technology assessment approaches for achieving a policy shift from evidence-based medicine to evidence-based decision-making in the field of nutrition.

Burden of disease among the world's poorest billion people: An expert-informed secondary analysis of Global Burden of Disease estimates.

BACKGROUND: The health of populations living in extreme poverty has been a long-standing focus of global development efforts, and continues to be a priority during the Sustainable Development Goal era. However, there has not been a systematic attempt to quantify the magnitude and causes of the burden in this specific population for almost two decades. We estimated disease rates by cause for the world's poorest billion and compared these rates to those in high-income populations. METHODS: We defined the population in extreme poverty using a multidimensional poverty index. We used national-level disease burden estimates from the 2017 Global Burden of Disease Study and adjusted these to account for within-country variation in rates. To adjust for within-country variation, we looked to the relationship between rates of extreme poverty and disease rates across countries. In our main modeling approach, we used these relationships when there was consistency with expert opinion from a survey we conducted of disease experts regarding the associations between household poverty and the incidence and fatality of conditions. Otherwise, no within-country variation was assumed. We compared results across multiple approaches for estimating the burden in the poorest billion, including aggregating national-level burden from the countries with the highest poverty rates. We examined the composition of the estimated disease burden among the poorest billion and made comparisons with estimates for high-income countries. RESULTS: The composition of disease burden among the poorest billion, as measured by disability-adjusted life years (DALYs), was 65% communicable, maternal, neonatal, and nutritional (CMNN) diseases, 29% non-communicable diseases (NCDs), and 6% injuries. Age-standardized DALY rates from NCDs were 44% higher in the poorest billion (23,583 DALYs per 100,000) compared to high-income regions (16,344 DALYs per 100,000). Age-standardized DALY rates were 2,147% higher for CMNN conditions (32,334 DALYs per 100,000) and 86% higher for injuries (4,182 DALYs per 100,000) in the poorest billion, compared to high-income regions. CONCLUSION: The disease burden among the poorest people globally compared to that in high income countries is highly influenced by demographics as well as large disparities in burden from many conditions. The comparisons show that the largest disparities remain in communicable, maternal, neonatal, and nutritional diseases, though NCDs and injuries are an important part of the "unfinished agenda" of poor health among those living in extreme poverty.

Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial.

BACKGROUND: nasogastric tube (NGT) feeding is commonly used after stroke, but its effectiveness is limited by frequent dislodgement. OBJECTIVE: the objective of the study was to evaluate looped NGT feeding in acute stroke patients with dysphagia. METHODS: this was a randomised controlled trial of 104 patients with acute stroke fed by NGT in three UK stroke units. NGT was secured using either a nasal loop (n = 51) or a conventional adhesive dressing (n = 53). The main outcome measure was the proportion of prescribed feed and fluids delivered via NGT in 2 weeks post-randomisation. Secondary outcomes were frequency of NGT insertions, treatment failure, tolerability, adverse events and costs at 2 weeks; mortality; length of hospital stay; residential status; and Barthel Index at 3 months. RESULTS: participants assigned to looped NGT feeding received a mean 17% (95% confidence interval 5-28%) more volume of feed and fluids, required fewer NGTs (median 1 vs 4), and had fewer electrolyte abnormalities than controls. There was more minor nasal trauma in the loop group. There were no differences in outcomes at 3 months. Looped NGT feeding cost 88 pounds sterling more per patient over 2 weeks than controls. CONCLUSION: looped NGT feeding improves delivery of feed and fluids and reduces NGT reinsertion with little additional cost.

Strengthening national nutrition research: rationale and options for a new coordinated federal research effort and authority.

BACKGROUND: The US faces remarkable food and nutrition challenges. A new federal effort to strengthen and coordinate nutrition research could rapidly generate the evidence base needed to address these multiple national challenges. However, the relevant characteristics of such an effort have been uncertain. OBJECTIVES: Our aim was to provide an objective, informative summary of 1) the mounting diet-related health burdens facing our nation and corresponding economic, health equity, national security, and sustainability implications; 2) the current federal nutrition research landscape and existing mechanisms for its coordination; 3) the opportunities for and potential impact of new fundamental, clinical, public health, food and agricultural, and translational scientific discoveries; and 4) the various options for further strengthening and coordinating federal nutrition research, including corresponding advantages, disadvantages, and potential executive and legislative considerations. METHODS: We reviewed government and other published documents on federal nutrition research; held various discussions with expert groups, advocacy organizations, and scientific societies; and held in-person or phone meetings with >50 federal staff in executive and legislative roles, as well as with a variety of other stakeholders in academic, industry, and nongovernment organizations. RESULTS: Stark national nutrition challenges were identified. More Americans are sick than are healthy, largely from rising diet-related illnesses. These conditions create tremendous strains on productivity, health care costs, health disparities, government budgets, US economic competitiveness, and military readiness. The coronavirus disease 2019 (COVID-19) outbreak has further laid bare these strains, including food insecurity, major diet-related comorbidities for poor outcomes from COVID-19 such as diabetes, hypertension, and obesity, and insufficient surveillance on and coordination of our food system. More than 10 federal departments and agencies currently invest in critical nutrition research, yet with relatively flat investments over several decades. Coordination also remains suboptimal, documented by multiple governmental reports over 50 years. Greater harmonization and expansion of federal investment in nutrition science, not a silo-ing or rearrangement of existing investments, has tremendous potential to generate new discoveries to improve and sustain the health of all Americans. Two identified key strategies to achieve this were as follows: 1) a new authority for robust cross-governmental coordination of nutrition research and other nutrition-related policy and 2) strengthened authority, investment, and coordination for nutrition research within the NIH. These strategies were found to be complementary, together catalyzing important new science, partnerships, coordination, and returns on investment. Additional complementary actions to accelerate federal nutrition research were identified at the USDA. CONCLUSIONS: The need and opportunities for strengthened federal nutrition research are clear, with specific identified options to help create the new leadership, strategic planning, coordination, and investment the nation requires to address the multiple nutrition-related challenges and grasp the opportunities before us.

Connected Community and Household Food-Based Strategy (CCH-FBS): its importance for health, food safety, sustainability and security in diverse localities.

In this article, I argue that Connected Community and Household Food-Based Strategy (CCH-FBS) could contribute to the resolution of outstanding nutritionally-related health problems. The 1995 Food-Based Dietary Guidelines (FBDGs) have been customized in regions and nations, encouraging integrated food systems and culturally-sensitive food-health relationships with economic development. Climate change and diminishing fuel and food affordability have made their role in promoting food security critical. Localities with their eco-systems, communities and households, could apply FBDGs to correct mismatches between food systems, individual health needs, and environmental integrity. Improved infrastructure should allow communities and households to be usefully connected and operate with CCH-FBSs.

Keystones affecting sub-Saharan Africa's prospects for achieving food security through balanced diets.

Socio-economic dynamics determine the transition from diets characterized by the risk of famine, to those characterized by the risk of diet-related non-communicable disease (DR-NCD). This transition is of particular concern in Sub-Saharan Africa (SSA) in which key socio-economic interactions that influence diet include economic growth and rapid urbanization; inequality and a growing middle class; and obesogenic food environments and an increasing prevalence of DR-NCD. In each case, countries in SSA are among those experiencing the most rapid change in the world. These interactions, styled as 'keystones', affect the functioning of other components of the food system and the diets that result. Data from the wealthiest quartile of countries in SSA suggest that these keystones may be increasing the risk of DR-NCD, widening inequalities in health outcomes due to unbalanced diets. To address this, new consumer and government capabilities that address these keystones are required. Food sensitive urban planning, supporting food literacy and fiscal management of consumption are examples.

Considerations for Secondary Prevention of Nutritional Deficiencies in High-Risk Groups in High-Income Countries.

Surveys in high-income countries show that inadequacies and deficiencies can be common for some nutrients, particularly in vulnerable subgroups of the population. Inadequate intakes, high requirements for rapid growth and development, or age- or disease-related impairments in nutrient intake, digestion, absorption, or increased nutrient losses can lead to micronutrient deficiencies. The consequent subclinical conditions are difficult to recognize if not screened for and often go unnoticed. Nutrient deficiencies can be persistent despite primary nutrition interventions that are aimed at improving dietary intakes. Secondary prevention that targets groups at high risk of inadequacy or deficiency, such as in the primary care setting, can be a useful complementary approach to address persistent nutritional gaps. However, this strategy is often underestimated and overlooked as potentially cost-effective means to prevent future health care costs and to improve the health and quality of life of individuals. In this paper, the authors discuss key appraisal criteria to consider when evaluating the benefits and disadvantages of a secondary prevention of nutrient deficiencies through screening.

Rainer Gross Award Lecture 2016: A Laboratory in Your Pocket: Enabling Precision Nutrition.

The need for improving methods of nutritional assessment and delivering primary health care globally cannot be overemphasized. While advances in medical technology typically create more disparities because of access being limited to resource-rich settings, a transition of health care to a mobile platform is increasingly leveling the field. Technological advances offer opportunities to scale laboratory procedures down to mobile devices, such as smartphones and tablets. Globalization also provides the required infrastructure and network capacity to support the use of mobile health devices in developing settings where nutritional deficiencies are most prevalent. Here, we discuss some of the applications and advantages provided by expanding markets of biomarker measurement coupled with primary health care and public health systems and how this is enhancing access and delivery of health services with significant global impact.

Maternal employment and income affect dietary calorie adequacy in households in Sri Lanka.

Nutritional deficiencies among children and mothers in lower-income households in Sri Lanka continue to be a major obstacle to the country's social and economic development. This study investigates the factors affecting dietary caloric adequacy in Sri Lanka, paying special attention to maternal income. An econometric analysis was performed using a household data set collected from a sample of 183 low-income households in the urban, rural, and estate sectors. The results showed that on average, mothers and children in the sample did not consume adequate levels of calories according to the recommendations of the Medical Research Institute of Sri Lanka. The mother's income and educational status, the number of children and adults in the family, and the ages, sexes, and birth orders of the children significantly influenced household and individual caloric adequacy. Specifically, the mother's income had a significant positive effect on the total caloric intake (CI) and caloric adequacy ratio (CAR) of the household, mother, and children and a significant negative effect on the relative caloric allocation (RCA) of the children. The results imply that when maternal employment generates extra income, the CIs of all individuals increase, yet the allocation of calories to the children of the household is reduced. Thus, provision of employment opportunities for mothers, along with adequate child-care facilities and nutritional educational programs, is a possible strategy to improve caloric adequacy among low-income households in Sri Lanka.

Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges.

This study was intended to characterize a rural population of older persons through nutrition screening and relate screening items to functional limitations and health care charges. There were 5373 participants (2522 males and 2851 females, mean age 71 y) screened over a 22-mo period by using a self-administered questionnaire adapted from the Nutrition Screening Initiative. Height and weight and cholesterol and albumin concentrations were measured, and health care claims data were obtained. The most frequent screening items reported were use of > or = 3 medications (41%) and food group intakes below recommended frequencies (> 50%). There were significant (P < 0.05) sex differences in affirmative responses to screening items and in likelihood of exceeding proposed threshold values for risk status assigned for body mass index (BMI; in kg/m2), albumin, or cholesterol. Overweight status was notable, with one-half of all subjects having BMIs > 27. Stepwise modeling procedures were used to identify screening items with the ability to predict self-reported functional limitation (logistic regression) and monthly average recorded health care charges (linear regression on logged charges). Age > or = 75 y, use of > or = 3 medications, and an albumin concentration < 35.0 g/L were significant predictors of both functional limitation and health care charges. Poor appetite, eating problems, income < $6000/y, eating alone, and depression were significant predictors of functional limitation but not health care charges. Being male, loss of 10 lb (4.5 kg), BMI > 27, cholesterol concentration < 4.14 or > 6.21 mmol/L, and functional limitation were significant predictors of health care charges only. These findings suggest that selected screening items may have be useful in the identification of subjects at potential risk for these outcomes.

Trends in diet, nutritional status, and diet-related noncommunicable diseases in China and India: the economic costs of the nutrition transition.

Undernutrition is being rapidly reduced in India and China. In both countries the diet is shifting toward higher fat and lower carbohydrate content. Distinct features are high intakes of foods from animal sources and edible oils in China, and high intakes of dairy and added sugar in India. The proportion of overweight is increasing very rapidly in China among all adults; in India the shift is most pronounced among urban residents and high-income rural residents. Hypertension and stroke are relatively higher in China and adult-onset diabetes is relatively higher in India. Established economic techniques were used to measure and project the costs of undernutrition and diet-related noncommunicable diseases in 1995 and 2025. Current WHO mortality projections of diet-related noncommunicable diseases, dietary and body composition survey data, and national data sets of hospital costs for healthcare, are used for the economic analyses. In 1995, China's costs of undernutrition and costs of diet-related noncommunicable diseases were of similar magnitude, but there will be a rapid increase in the costs and prevalence of diet-related noncommunicable diseases by 2025. By contrast with China, India's costs of undernutrition will continue to decline, but undernutrition costs did surpass overnutrition diet-related noncommunicable disease costs in 1995. India's rapid increase in diet-related noncommunicable diseases and their costs projects similar economic costs of undernutrition and overnutrition by 2025.

Low nutrient intake contributes to adverse clinical outcomes in hospitalized elderly patients.

A prospective cohort study on hospitalized elderly patients revealed that inadequate nutrient intake during hospitalization was associated with adverse clinical outcomes and increased morbidity. Because this occurred in patients who were initially assessed as being in good health, it emphasizes the need for continuous nutritional surveillance of hospitalized elderly patients.

Supportive nutritional management of the patient with pancreatic cancer.

Progressive weight loss and nutritional deterioration are commonly found in the patient with pancreatic cancer. The combined effects of the central anatomic location of the pancreas, endocrine and exocrine hormonal insufficiency, and treatment toxicity place patients with pancreatic cancer at high risk for developing symptoms that affect their ability to consume and absorb adequate calories and protein. The use of standardized nutritional assessment and an algorithmic approach for nutritional intervention fosters determination of the patient's nutritional risk status early in the course of disease, fosters early detection of treatable symptoms that interfere with nutritional intake/absorption, and can assess the effect of nutritional interventions. Supportive nutritional efforts can decrease complications, shorten hospital stays, reduce costs, and improve the patient's sense of well-being.

Elder insecurities: poverty, hunger, and malnutrition.

Between 8% and 16% (2.5 to 4.9 million) of the elder population have experienced food insecurity within a 6-month period. Federal programs to combat food insecurity reach only one-third of needy elders. While hunger and poverty are linked directly to malnutrition, the multifaceted nature of elderly malnutrition cuts across all economic, racial, and ethnic groups. Malnourished patients experience 2 to 20 times more complications, have up to 100% longer hospital stays, and compile hospital costs $2,000 to $10,000 higher per stay. Dietitians can advocate routine nutrition screening to target elders at highest risk and lobby for expansion of appropriate nutrition services in home, community, and institutional settings.

Malnutrition and clinical outcomes: the case for medical nutrition therapy.

Malnutrition is not a new or a rare problem. In studies involving more than 1,327 hospitalized adult patients, 40% to 55% were found to be either malnourished or at risk for malnutrition, and up to 12% were severely malnourished. Surgical patients with likelihood of malnutrition are two to three times more likely to have minor and major complications as well as increased mortality; and their length of stay can be extended by 90% compared with the stay of well-nourished patients. Hospital charges are reported to be from 35% to 75% higher for malnourished patients than for well-nourished patients. Obtaining data to assess the nutritional status of patients is essential to optimal patient care, especially for patients at high risk for malnutrition. Nutrition assessment can be done with readily available and relatively inexpensive methods. But it is not enough to assess and identify malnutrition. Outcomes are improved and costs are saved only when appropriate intervention follows. This article identifies many well-conducted, published studies that support the findings that health outcomes of malnourished patients can be improved and that overall use of resources can be reduced by nutrition counseling, oral diet and oral supplements, enteral formula delivered via tube, and parenteral nutrition support via central or peripheral line. Early nutrition assessment and appropriate nutrition intervention must be accepted as essential for the delivery of quality health care. Appropriately selected nutrition support can address the problem of malnutrition, improve clinical outcomes, and help reduce the costs of health care.

Improving malnutrition documentation enhances reimbursement.

Diagnosis coding for malnutrition can positively affect hospital reimbursements. Our goal was to quantify the possible increase in reimbursements when the diagnosis of malnutrition was identified and appropriately coded. A sample of 234 cases representing 14% of Medicare patients seen from March 1991 through February 1992 at Allenmore Hospital in Tacoma, Wash, was retrospectively reviewed. Malnutrition diagnoses (using ICD-9-CM codes) were assessed according to established criteria. Ninety-four cases (39.7%) met the criteria for malnutrition. Seven demonstrated increased reimbursement, totaling $12,326 for the sample. Length of hospital stay was significantly longer in the malnourished group (P = .001). The results indicated a need for an improved system of documenting and coding malnutrition diagnoses for improved identification and reimbursement enhancement purposes. An example of criteria used for each malnutrition ICD-9-CM diagnosis code and a policy defining the criteria usage are shown. A nutrition assessment form, which includes each malnutrition ICD-9-CM code title for enhanced interdisciplinary communication leading to improved coding of malnutrition diagnoses, is also shown. We conclude that effective identification of malnutrition leading to enhanced reimbursement strengthens the leadership potential of hospital dietitians and improves hospital revenues. Additionally, we suggest that such a system initiates a process that may lead to improved, cost-effective treatment of persons identified as being malnourished and provide a foundation for surviving within the future health care reform environment.