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Dötsch-Klerk M, Bruins MJ, Detzel P, Martikainen J, Nergiz-Unal R, Roodenburg AJC, Pekcan AG. Modelling health and economic impact of nutrition interventions: a systematic review. Eur J Clin Nutr 2023; 77:413-426. [PMID: 36195747 PMCID: PMC10115624 DOI: 10.1038/s41430-022-01199-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/17/2022] [Accepted: 08/12/2022] [Indexed: 11/08/2022]
Abstract
Diet related non-communicable diseases (NCDs), as well as micronutrient deficiencies, are of widespread and growing importance to public health. Authorities are developing programs to improve nutrient intakes via foods. To estimate the potential health and economic impact of these programs there is a wide variety of models. The aim of this review is to evaluate existing models to estimate the health and/or economic impact of nutrition interventions with a focus on reducing salt and sugar intake and increasing vitamin D, iron, and folate/folic acid intake. The protocol of this systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016050873). The final search was conducted on PubMed and Scopus electronic databases and search strings were developed for salt/sodium, sugar, vitamin D, iron, and folic acid intake. Predefined criteria related to scientific quality, applicability, and funding/interest were used to evaluate the publications. In total 122 publications were included for a critical appraisal: 45 for salt/sodium, 61 for sugar, 4 for vitamin D, 9 for folic acid, and 3 for iron. The complexity of modelling the health and economic impact of nutrition interventions is dependent on the purpose and data availability. Although most of the models have the potential to provide projections of future impact, the methodological challenges are considerable. There is a substantial need for more guidance and standardization for future modelling, to compare results of different studies and draw conclusions about the health and economic impact of nutrition interventions.
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Affiliation(s)
- Mariska Dötsch-Klerk
- Unilever Foods Innovation Centre, Wageningen, The Netherlands.
- Unilever Foods Innovation Centre, Wageningen, Bronland 14, 6708 WH, The Netherlands.
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Karamagi HC, Berhane A, Ngusbrhan Kidane S, Nyawira L, Ani-Amponsah M, Nyanjau L, Maoulana K, Seydi ABW, Nzinga J, Dangou JM, Nkurunziza T, K Bisoborwa G, Sillah JS, W Muriithi A, Nirina Razakasoa H, Bigirimana F. High impact health service interventions for attainment of UHC in Africa: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000945. [PMID: 36962639 PMCID: PMC10021619 DOI: 10.1371/journal.pgph.0000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/23/2022] [Indexed: 11/19/2022]
Abstract
African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.
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Affiliation(s)
- Humphrey Cyprian Karamagi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Araia Berhane
- Conmmunicable Diseases Control Division, Ministry of Health, Asmara, Eritrea
| | - Solyana Ngusbrhan Kidane
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Lizah Nyawira
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Koulthoume Maoulana
- Ministry of Health, Solidarity, Social Protection and Gender Promotion, Moroni, Comoros
| | - Aminata Binetou Wahebine Seydi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Rodrigues VB, da Silva EN, Santos MLP. Cost-effectiveness of mandatory folic acid fortification of flours in prevention of neural tube defects: A systematic review. PLoS One 2021; 16:e0258488. [PMID: 34673787 PMCID: PMC8530293 DOI: 10.1371/journal.pone.0258488] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/28/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Neural tube defects (NTDs) constitute the most frequent group among congenital malformations and are the main cause of neonatal morbimortality. Folic acid (FA) can reduce the risk of pregnancies affected by NTDs. OBJECTIVE We aimed to investigate whether mandatory folic acid (FA) fortification of flours is cost-effective as compared to non-mandatory fortification, and to verify whether FA dosage, cost composition, and the quality of economic studies influence the cost-effectiveness of outcomes. METHODS We conducted a systematic review. The protocol was registered on PROSPERO (CRD 42018115682). A search was conducted using the electronic databases MEDLINE/PubMed, Web of Science, Embase, Scopus, and EBSCO/CINAHL between January 2019 and October 2020 and updated in February 2021. Eligible studies comprised original economic analyses of mandatory FA fortification of wheat and corn flours (maize flours) compared to strategies of non-mandatory fortification in flours and/or use of FA supplements for NTD prevention. The Drummond verification list was used for quality analysis. RESULTS A total of 7,859 studies were identified, of which 13 were selected. Most (77%; n = 10) studies originated from high-income countries, while three (23%) were from upper-middle-income countries. Results of a cost-effectiveness analysis showed that fortification is cost-effective for NTD prevention, except for in one study in New Zealand. The cost-benefit analysis yielded a median ratio of 17.5:1 (0.98:1 to 417.1:1), meaning that for each monetary unit spent in the program, there would be a return of 17.5 monetary units. Even in the most unfavorable case of mandatory fortification, the investment in the program would virtually payoff at a ratio of 1:0.98. All FA dosages were cost-effective and offered positive health gains, except in one study. The outcomes of two studies showed that FA dosages above 300 μg/100 g have a higher CBA ratio. The studies with the inclusion of "loss of consumer choice" in the analysis may alter the fortification cost-efficacy ratio. CONCLUSION We expect the findings to be useful for public agencies in different countries in decision-making on the implementation and/or continuity of FA fortification as a public policy in NTD prevention.
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Affiliation(s)
| | - Everton Nunes da Silva
- Graduate Program Collective Health, University of Brasilia, Brasilia, District federal, Brazil
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Szewczyk Z, Holliday E, Dean B, Collins C, Reeves P. A systematic review of economic evaluations of antenatal nutrition and alcohol interventions and their associated implementation interventions. Nutr Rev 2021; 79:261-273. [PMID: 32712657 DOI: 10.1093/nutrit/nuaa015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
CONTEXT Improving maternal nutrition and promoting alcohol abstinence during pregnancy are key to reducing subsequent economic and social impacts. However, antenatal nutrition and alcohol interventions are underused, partly because economic evidence to support investment is limited. OBJECTIVE The purpose of this systematic literature review was to assess the extent to which economic evaluations have been applied to antenatal public health interventions, and implementation strategies addressing maternal nutrition and alcohol intake. DATA SOURCES Two separate systematic reviews were conducted to address the 2 stated aims. Both reviews adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The searches were conducted using the following databases: Medline, EMBASE, Cochrane, EconLit, CINAHL, and the National Health Service Economic Evaluation Database, accompanied by a handsearch of gray literature. DATA EXTRACTION Review 1 returned 9599 records after duplicates were removed, from which 12 economic evaluations were included. Review 2 returned 136 records after duplicates were removed, with none eligible for inclusion. The articles included in review 1 comprised 10 economic evaluations of nutrition interventions and 2 evaluations of alcohol interventions. DATA ANALYSIS Methodological quality was assessed using the Drummond 10-point quality checklist. Methodological quality was high, with variation in reporting practices and predominance of modeled evaluations. RESULTS Antenatal nutrition and alcohol interventions offer value for money and have potential to considerably reduce healthcare costs. No evidence regarding intervention implementation cost was identified. CONCLUSION The current evidence base has important gaps that limit its value to decision makers. Incorporating health economic principles and methods into health promotion interventions will inform decisions about how to derive value from investment in healthcare.
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Affiliation(s)
- Zoe Szewczyk
- School of Medicine and Public Health, The University of Newcastle, University Drive, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), Lot 1, Kookaburra Circuit, New Lambton Heights, NSW, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW, Australia
| | - Brittany Dean
- the School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW, Australia
| | - Clare Collins
- the School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW, Australia
| | - Penny Reeves
- Hunter Medical Research Institute (HMRI), Lot 1, Kookaburra Circuit, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW, Australia
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Wilson N, Davies A, Brewer N, Nghiem N, Cobiac L, Blakely T. Can cost-effectiveness results be combined into a coherent league table? Case study from one high-income country. Popul Health Metr 2019; 17:10. [PMID: 31382954 PMCID: PMC6683509 DOI: 10.1186/s12963-019-0192-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 07/23/2019] [Indexed: 12/31/2022] Open
Abstract
Background Doubts exist around the value of compiling league tables for cost-effectiveness results for health interventions, primarily due to methods differences. We aimed to determine if a reasonably coherent league table could be compiled using published studies for one high-income country: New Zealand (NZ). Methods Literature searches were conducted to identify NZ-relevant studies published in the peer-reviewed journal literature between 1 January 2010 and 8 October 2017. Only studies with the following metrics were included: cost per quality-adjusted life-year or disability-adjusted life-year or life-year (QALY/DALY/LY). Key study features were abstracted and a summary league table produced which classified the studies in terms of cost-effectiveness. Results A total of 21 cost-effectiveness studies which met the inclusion criteria were identified. There were some large methodological differences between the studies, particularly in the time horizon (1 year to lifetime) but also discount rates (range 0 to 10%). Nevertheless, we were able to group the incremental cost-effectiveness ratios (ICERs) into general categories of being reported as cost-saving (19%), cost-effective (71%), and not cost-effective (10%). The median ICER (adjusted to 2017 NZ$) was ~ $5000 per QALY/DALY/LY (~US$3500). However, for some interventions, there is high uncertainty around the intervention effectiveness and declining adherence over time. Conclusions It seemed possible to produce a reasonably coherent league table for the ICER values from different studies (within broad groupings) in this high-income country. Most interventions were cost-effective and a fifth were cost-saving. Nevertheless, study methodologies did vary widely and researchers need to pay more attention to using standardised methods that allow their results to be included in future league tables. Electronic supplementary material The online version of this article (10.1186/s12963-019-0192-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nick Wilson
- BODE³ Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand.
| | - Anna Davies
- BODE³ Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Naomi Brewer
- BODE³ Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand.,Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Nhung Nghiem
- BODE³ Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Linda Cobiac
- BODE³ Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand.,Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tony Blakely
- BODE³ Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand
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Saing S, Haywood P, van der Linden N, Manipis K, Meshcheriakova E, Goodall S. Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:243-254. [PMID: 30617458 DOI: 10.1007/s40258-018-00454-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14-49 NTDs each year. OBJECTIVE Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. METHODS We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs. RESULTS We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers. CONCLUSIONS This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.
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Affiliation(s)
- Sopany Saing
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW, 2007, Australia.
| | - Phil Haywood
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW, 2007, Australia
| | - Naomi van der Linden
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Kathleen Manipis
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW, 2007, Australia
| | - Elena Meshcheriakova
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW, 2007, Australia
| | - Stephen Goodall
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW, 2007, Australia
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Effects of folic acid food fortification scenarios on the folate intake of a multi-ethnic pregnant population. Public Health Nutr 2018; 22:738-749. [PMID: 30518437 DOI: 10.1017/s1368980018003026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To simulate effects of different scenarios of folic acid fortification of food on dietary folate equivalents (DFE) intake in an ethnically diverse sample of pregnant women. DESIGN A forty-four-item FFQ was used to evaluate dietary intake of the population. DFE intakes were estimated for different scenarios of food fortification with folic acid: (i) voluntary fortification; (ii) increased voluntary fortification; (iii) simulated bread mandatory fortification; and (iv) simulated grains-and-rice mandatory fortification. SETTING Ethnically and socio-economically diverse cohort of pregnant women in New Zealand.ParticipantsPregnant women (n 5664) whose children were born in 2009-2010. RESULTS Participants identified their ethnicity as European (56·0 %), Asian (14·2 %), Māori (13·2 %), Pacific (12·8 %) or Others (3·8 %). Bread, breakfast cereals and yeast spread were main food sources of DFE in the two voluntary fortification scenarios. However, for Asian women, green leafy vegetables, bread and breakfast cereals were main contributors of DFE in these scenarios. In descending order, proportions of different ethnic groups in the lowest tertile of DFE intake for the four fortification scenarios were: Asian (39-60 %), Others (41-44 %), European (31-37 %), Pacific (23-26 %) and Māori (23-27 %). In comparisons within each ethnic group across scenarios of food fortification with folic acid, differences were observed only with DFE intake higher in the simulated grains-and-rice mandatory fortification v. other scenarios. CONCLUSIONS If grain and rice fortification with folic acid was mandatory in New Zealand, DFE intakes would be more evenly distributed among pregnant women of different ethnicities, potentially reducing ethnic group differences in risk of lower folate intakes.
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Reynolds AN, Skeaff SA. Maternal adherence with recommendations for folic acid and iodine supplements: A cross-sectional survey. Aust N Z J Obstet Gynaecol 2017; 58:125-127. [PMID: 28990157 DOI: 10.1111/ajo.12719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/23/2017] [Indexed: 11/29/2022]
Abstract
We conducted a survey of 535 New Zealand women to determine supplement use pre-pregnancy, during pregnancy and while breastfeeding to evaluate adherence with national recommendations for folic acid and iodine supplementation. Our findings suggest that despite these women being well-educated and motivated to complete an online survey, there was low adherence to recommendations for folic acid and iodine supplements. Only 38% of women reported supplement intake that met both folic acid and iodine recommendations. This cross-sectional survey provides information useful to policy makers, clinicians and researchers seeking to protect and promote maternal and infant health.
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Affiliation(s)
- Andrew N Reynolds
- Department of Human Nutrition, University of Otago, Otago, New Zealand.,Edgar National Centre for Diabetes and Obesity Research, University of Otago, Otago, New Zealand
| | - Sheila A Skeaff
- Department of Human Nutrition, University of Otago, Otago, New Zealand
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Sadler MJ. A review of economic evaluations for beneficial health outcomes of micronutrient and long-chain omega-3 fatty acid supplementation. Int J Food Sci Nutr 2017; 69:262-282. [DOI: 10.1080/09637486.2017.1365825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wang H, De Steur H, Chen G, Zhang X, Pei L, Gellynck X, Zheng X. Effectiveness of Folic Acid Fortified Flour for Prevention of Neural Tube Defects in a High Risk Region. Nutrients 2016. [PMID: 27005659 DOI: 10.3390/nu80301529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2023] Open
Abstract
Despite efforts to tackle folate deficiency and Neural Tube Defects (NTDs) through folic acid fortification, its implementation is still lacking where it is needed most, highlighting the need for studies that evaluate the effectiveness of folic acid fortified wheat flour in a poor, rural, high-risk, NTD region of China. One of the most affected regions, Shanxi Province, was selected as a case study. A community intervention was carried out in which 16,648 women of child-bearing age received fortified flour (eight villages) and a control group received ordinary flour (three villages). NTD birth prevalence and biological indicators were measured two years after program initiation at endline only. The effect on the NTD burden was calculated using the disability-adjusted life years (DALYs) method. In the intervention group, serum folate level was higher than in the control group. NTDs in the intervention group were 68.2% lower than in the control group (OR = 0.313, 95% CI = 0.207-0473, p < 0.001). In terms of DALYs, burden in intervention group was approximately 58.5% lower than in the control group. Flour fortification was associated with lower birth prevalence and burden of NTDs in economically developing regions with a high risk of NTDs. The positive findings confirm the potential of fortification when selecting an appropriate food vehicle and target region. As such, this study provides support for decision makers aiming for the implementation of (mandatory) folic acid fortification in China.
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Affiliation(s)
- Haochen Wang
- Institute of Population Research/WHO Collaborating Center on Reproductive Health and Population Science, Peking University, Beijing 100871, China.
| | - Hans De Steur
- Department of Agricultural Economics, Faculty of Bio-Science engineering, Ghent University. Ghent 9000, Belgium.
| | - Gong Chen
- Institute of Population Research/WHO Collaborating Center on Reproductive Health and Population Science, Peking University, Beijing 100871, China.
| | - Xiaotian Zhang
- Institute of Population Research/WHO Collaborating Center on Reproductive Health and Population Science, Peking University, Beijing 100871, China.
| | - Lijun Pei
- Institute of Population Research/WHO Collaborating Center on Reproductive Health and Population Science, Peking University, Beijing 100871, China.
| | - Xavier Gellynck
- Department of Agricultural Economics, Faculty of Bio-Science engineering, Ghent University. Ghent 9000, Belgium.
| | - Xiaoying Zheng
- Institute of Population Research/WHO Collaborating Center on Reproductive Health and Population Science, Peking University, Beijing 100871, China.
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Effectiveness of Folic Acid Fortified Flour for Prevention of Neural Tube Defects in a High Risk Region. Nutrients 2016; 8:152. [PMID: 27005659 PMCID: PMC4808880 DOI: 10.3390/nu8030152] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 02/21/2016] [Accepted: 02/25/2016] [Indexed: 11/16/2022] Open
Abstract
Despite efforts to tackle folate deficiency and Neural Tube Defects (NTDs) through folic acid fortification, its implementation is still lacking where it is needed most, highlighting the need for studies that evaluate the effectiveness of folic acid fortified wheat flour in a poor, rural, high-risk, NTD region of China. One of the most affected regions, Shanxi Province, was selected as a case study. A community intervention was carried out in which 16,648 women of child-bearing age received fortified flour (eight villages) and a control group received ordinary flour (three villages). NTD birth prevalence and biological indicators were measured two years after program initiation at endline only. The effect on the NTD burden was calculated using the disability-adjusted life years (DALYs) method. In the intervention group, serum folate level was higher than in the control group. NTDs in the intervention group were 68.2% lower than in the control group (OR = 0.313, 95% CI = 0.207-0473, p < 0.001). In terms of DALYs, burden in intervention group was approximately 58.5% lower than in the control group. Flour fortification was associated with lower birth prevalence and burden of NTDs in economically developing regions with a high risk of NTDs. The positive findings confirm the potential of fortification when selecting an appropriate food vehicle and target region. As such, this study provides support for decision makers aiming for the implementation of (mandatory) folic acid fortification in China.
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El-Shabrawi MH, Kamal NM, Elhusseini MA, Hussein L, Abdallah EAA, Ali YZA, Azab AA, Salama MA, Kassab M, Krawinkel M. Folic Acid Intake and Neural Tube Defects: Two Egyptian Centers Experience. Medicine (Baltimore) 2015; 94:e1395. [PMID: 26376380 PMCID: PMC4635794 DOI: 10.1097/md.0000000000001395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Neural tube defects (NTDs) are a group of congenital malformations with worldwide distribution and complex etiopathogenesis. Folic acid plays a pivotal role in their prevention. We aimed to identify the protective effect of folic acid intake against NTDs and its dependence on different socioeconomic and environmental factors in a cohort of mothers in Egypt. A cross-sectional study was carried over a period of 12 months on mothers who gave birth to babies with NTDs (group 1) and a control group with healthy offsprings (group 2). Both groups completed 2 questionnaires: food frequency questionnaire targeting the daily folate intake, and socioeconomic status and medical history questionnaire. Both groups of mothers received folate <800 μg/day, recommended for pregnant women. A strong association was detected between NTDs and urban residency with medium educated mothers, with negative consanguinity, who had folate intake < 400 μg daily, and who had their food long cooked. Each of these factors separately had a limited impact to cause NTDs, but when present together they did augment each other. Interestingly enough is the role of fava bean, cauliflower, spinach, and mango in predisposing of NTDs in the presence of the above-mentioned factors. The protective effect of folic acid intake against NTDs may depend on the synergism of different socioeconomic and environmental factors (which differ from country to another). In Egypt, females especially the medium-educated who live in urban areas should be well-informed with the value of folate intake in the periconceptional period.
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Affiliation(s)
- Mortada H El-Shabrawi
- From the Professor of Pediatrics and Pediatric Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt (MHE-S); Associate Professor of Pediatrics and Pediatric Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt (NMK); Consultant Obstetrician and Gynecologist, Red Crescent Hospital, Ministry of Health and Population, Cairo, Egypt (MAE); Professor of Nutrition, Institute of Nutritional Sciences, University of Giessen, Giessen, Germany (MK); Professor of Nutrition, National Research Center, Cairo, Egypt (LH); Lecturer of Pediatrics and Neonatology, Faculty of Medicine, Cairo University, Cairo, Egypt (EAAA); Lecturer of Obstetrics and Gynecology, Faculty of Medicine, Fayoum University, Fayoum, Egypt (YZAA); Associate Professor of Pediatrics and Neonatology, Faculty of Medicine, Benha University, Egypt (AAA, MAS); Fellow in nutrition, Institute of Nutritional Sciences, University of Giessen, Giessen, Germany (MK); and Professor of Nutrition, Institute of Nutritional Sciences, University of Giessen, Giessen, Germany (MK)
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Segal L, Opie RS. A nutrition strategy to reduce the burden of diet related disease: access to dietician services must complement population health approaches. Front Pharmacol 2015; 6:160. [PMID: 26321951 PMCID: PMC4531228 DOI: 10.3389/fphar.2015.00160] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/20/2015] [Indexed: 11/13/2022] Open
Abstract
Poor diet quality is implicated in almost every disease and health issue. And yet, in most advanced market economies diet quality is poor, with a minority meeting guidelines for healthy eating. Poor diet is thus responsible for substantial disease burden. Societies have at their disposal a range of strategies to influence diet behaviors. These can be classified into: (i) population level socio-educational approaches to enhance diet knowledge; (ii) pricing incentives (subsidies on healthy foods, punitive taxes on unhealthy foods); (iii) regulations to modify the food environment, and (iv) the provision of clinical dietetic services. There is little evidence that societies are active in implementing the available strategies. Advertising of "junk foods" is largely unchecked, contrasting with strict controls on advertising tobacco products, which also attract punitive taxes. Access to dieticians is restricted in most countries, even in the context of universal health care. In Australia in 2011 there were just 2,969 practicing dieticians/nutritionists or 1.3 clinicians per 10,000 persons, compared with 5.8 physiotherapists per 10,000 persons, 14.8 general practitioners (family physicians) per 10,000 persons or 75 nurses per 10,000 persons. It is time to implement comprehensive national nutrition strategies capable of effecting change. Such strategies need to be multi-component, incorporating both public health approaches and expanded publicly funded dietetic services. Access to individualized dietetic services is needed by those at risk, or with current chronic conditions, given the complexity of the diet message, the need for professional support for behavior change and to reflect individual circumstances. The adoption of a comprehensive nutrition strategy offers the promise of substantial improvement in diet quality, better health and wellbeing and lower health care costs.
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Affiliation(s)
- Leonie Segal
- Health Economics and Social Policy Group, Division of Health Sciences, University of South Australia , Adelaide, SA, Australia
| | - Rachelle S Opie
- School of Allied Health, College of Science, Health and Engineering, La Trobe University , Melbourne, VIC, Australia
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Goldhaber-Fiebert JD, Brandeau ML. Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters. Med Decis Making 2015; 35:818-46. [PMID: 25926281 DOI: 10.1177/0272989x15583845] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 04/01/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes. METHODS We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing. RESULTS We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic. CONCLUSIONS Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.
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Affiliation(s)
- Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDGF)
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA (MLB)
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Cobiac LJ, Veerman L, Vos T. The role of cost-effectiveness analysis in developing nutrition policy. Annu Rev Nutr 2013; 33:373-93. [PMID: 23642205 DOI: 10.1146/annurev-nutr-071812-161133] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Linda J Cobiac
- School of Population Health, The University of Queensland, Herston, Queensland, 4006 Australia.
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Polymorphism 677C → T MTHFR gene in Mexican mothers of children with complex congenital heart disease. Pediatr Cardiol 2013; 34:46-51. [PMID: 22660520 DOI: 10.1007/s00246-012-0380-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 05/08/2012] [Indexed: 02/02/2023]
Abstract
Congenital heart defects (CHD) are the third leading cause of death in children <1 year of age in Mexico where there is a high prevalence of the 677C → T polymorphism of the MTHFR gene. This is important because the homozygous 677T/T MTHFR gene and deficiency of folic acid (FA) intake have been associated with CHD. Our objective was to analyze the possible association between the genotype 677T/T of the MTHFR gene and supplementation of FA in Mexican women with the presence of complex CHD in their children. We analyzed genotypes of 31 mothers of children with complex CHD (group I) and 62 mothers of healthy children (group II) and investigated FA supplementation during pregnancy in both study groups. Allele frequencies in group I were 41.9 % for C and 58.1 % for T and 22.6 % for genotype frequencies CC, 38.7 % for CT, and 38.7 % for TT. Allele frequencies in group II were 63.7 % for C and 36.3 % for T and 38.7 % for genotype frequencies CC, 50 % for CT and 11.3 % for TT. Both populations are in Hardy-Weinberg equilibrium. Odds ratio for having a child with a complex CHD was 5.9, p = 0.008 (95 % CI 1.67; 20.63) for the TT genotype. FA supplementation at any time during pregnancy was 90.3 and 87.9 % in groups II and I respectively (p > 0.05). Association was found between the maternal genotype (677/TT MTHFR) with the presence of complex CHD in their offspring. No differences in FA supplementation during any stage were found between groups.
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Rabovskaja V, Parkinson B, Goodall S. The cost-effectiveness of mandatory folic acid fortification in Australia. J Nutr 2013; 143:59-66. [PMID: 23223683 DOI: 10.3945/jn.112.166694] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The Australian government recently introduced mandatory folic acid fortification of bread to reduce the incidence of neural tube defects (NTDs). The economic evaluation of this policy contained a number of limitations. This study aimed to address the limitations and to reconsider the findings. Cost-effectiveness analysis was used to assess the cost and benefits of mandatory versus voluntary folic acid fortification. Outcomes measures were quality-adjusted life-years (QALYs), life-years gained (LYG), avoided NTD cases, and additional severe neuropathy cases. Costs considered included industry costs and regulatory costs to the government. It was estimated that mandatory fortification would prevent 31 NTDs, whereas an additional 14 cases of severe neuropathy would be incurred. Overall, 539 LYG and 503 QALYs would be gained per year of mandatory compared with voluntary fortification. Mandatory fortification was cost-effective at A$10,723 per LYG and at A$11,485 per QALY. Probabilistic sensitivity analysis showed that at A$60,000 and A$151,000 per QALY, the probability that mandatory fortification was the most cost-effective strategy was 79% and 85%, respectively. Threshold analysis of loss of consumer choice indicated that with a compensation value above A$1.21 [assuming a willingness to pay (WTP) threshold of A$60,000 per QALY] or A$3.19 (assuming a WTP threshold of A$151,000 per statistical life-year) per capita per year mandatory fortification would not be cost-effective. Mandatory fortification was found to be cost-effective; however, inclusion of the loss of consumer choice can change this result. Even with mandatory fortification, mean folate intake will remain below the recommended NTD preventive level.
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Affiliation(s)
- Viktoria Rabovskaja
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, Australia.
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Gyles CL, Lenoir-Wijnkoop I, Carlberg JG, Senanayake V, Gutierrez-Ibarluzea I, Poley MJ, Dubois D, Jones PJ. Health economics and nutrition: a review of published evidence. Nutr Rev 2012. [DOI: 10.1111/j.1753-4887.2012.00514.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Mallard SR, Gray AR, Houghton LA. Periconceptional bread intakes indicate New Zealand's proposed mandatory folic acid fortification program may be outdated: results from a postpartum survey. BMC Pregnancy Childbirth 2012; 12:8. [PMID: 22333513 PMCID: PMC3305569 DOI: 10.1186/1471-2393-12-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 02/14/2012] [Indexed: 12/25/2022] Open
Abstract
Background In September 2009, a folic acid fortification mandate (135 μg/100 g bread) was to be implemented in New Zealand. However, due to political and manufacturer objection, fortification was deferred until May 2012. Based on estimates of bread consumption derived from a 1997 nationally representative survey, this program was intended to deliver a mean additional intake of 140 μg folic acid/d to women of childbearing age. Little is known about current bread consumption patterns in this target group. The aim of this study was to assess bread consumption among women prior to and during pregnancy with the intent to estimate periconceptional folic acid intakes that would be derived from bread if mandatory fortification were implemented as currently proposed. Methods A retrospective survey of 723 postpartum women in hospitals and birthing centres across New Zealand was conducted using a self-administered questionnaire on bread intake prior to and during pregnancy and maternal socio-demographic and obstetric characteristics. Results Median bread intake before conception (2 slices/d) was below that of previous data upon which the current fortification proposal was modeled (3-4 slices/d). If mandatory fortification is implemented as proposed, only 31% (95% CI = 24%-37%) of childbearing-age women would attain an additional folic acid intake of ≥ 140 μg/d, with a mean of 119 μg/d (95% CI = 107 μg/d-130 μg/d). Based on these data, a fortification level of 160 μg/100 g bread is required to achieve the targeted mean of 140 μg folic acid/d. Nonetheless, under the current proposal additional folic acid intakes would be greatest among the least advantaged segments of the target population: Pacific and indigenous Māori ethnic groups; those with increased parity, lower income and education; younger and single mothers; and women with unplanned pregnancies. Subgroups predicted to derive less than adequate folic acid intakes from the proposed policy were women of Asian descent and those with a postgraduate education. Conclusions This study provides insight on the ability of a fortification policy to benefit the groups at highest risk of poor folate intakes in a population. However, bread consumption among the target group of childbearing women appears to have declined since the data used in previous dietary modeling were collected. Thus, it seems prudent to re-model dietary folic acid intakes based on more recent national survey data prior to the implementation of a mandatory folic acid fortification policy.
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Mallard SR, Gray AR, Houghton LA. Delaying mandatory folic acid fortification policy perpetuates health inequalities: results from a retrospective study of postpartum New Zealand women. Hum Reprod 2011; 27:273-82. [DOI: 10.1093/humrep/der387] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Considering consumer choice in the economic evaluation of mandatory health programmes: A review. Health Policy 2011; 101:236-44. [DOI: 10.1016/j.healthpol.2010.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 09/03/2010] [Accepted: 09/13/2010] [Indexed: 11/22/2022]
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Yi Y, Lindemann M, Colligs A, Snowball C. Economic burden of neural tube defects and impact of prevention with folic acid: a literature review. Eur J Pediatr 2011; 170:1391-400. [PMID: 21594574 PMCID: PMC3197907 DOI: 10.1007/s00431-011-1492-8] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 05/04/2011] [Indexed: 11/29/2022]
Abstract
Neural tube defects (NTDs) are the second most common group of serious birth defects. Although folic acid has been shown to reduce effectively the risk of NTDs and measures have been taken to increase the awareness, knowledge, and consumption of folic acid, the full potential of folic acid to reduce the risk of NTDs has not been realized in most countries. To understand the economic burden of NTDs and the economic impact of preventing NTDs with folic acid, a systematic review was performed on relevant studies. A total of 14 cost of illness studies and 10 economic evaluations on prevention of NTDs with folic acid were identified. Consistent findings were reported across all of the cost of illness studies. The lifetime direct medical cost for patients with NTDs is significant, with the majority of cost being for inpatient care, for treatment at initial diagnosis in childhood, and for comorbidities in adult life. The lifetime indirect cost for patients with spina bifida is even greater due to increased morbidity and premature mortality. Caregiver time costs are also significant. The results from the economic evaluations demonstrate that folic acid fortification in food and preconception folic acid consumption are cost-effective ways to reduce the incidence and prevalence of NTDs. This review highlights the significant cost burden that NTDs pose to healthcare systems, various healthcare payers, and society and concludes that the benefits of prevention of NTDs with folic acid far outweigh the cost. Further intervention with folic acid is justified in countries where the full potential of folic acid to reduce the risk of NTDs has not been realized.
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Affiliation(s)
- Yunni Yi
- Mapi Values, Bollington, Cheshire SK10 5JB, UK.
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