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Teta I, Foudjo BUS, Nielsen JN, Oben J, Nguefack-Tsague G, Ntentie FR, Cakir V, Klemm R, Kang Y. Outcomes of a food voucher program and factors associated with the recovery rate of children with moderate acute malnutrition in Far North Cameroon. J Health Popul Nutr 2023; 42:37. [PMID: 37120648 PMCID: PMC10148527 DOI: 10.1186/s41043-023-00379-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Research on moderate acute malnutrition (MAM) is limited, despite its high prevalence. This study examined outcomes of bi-weekly locally available foods provided via a food voucher program (FVP) on nutritional recovery [mid-upper arm circumference (MUAC) ≥ 125 mm] from MAM (defined as MUAC between 115 and 124 mm) and identified the factors associated with recovery rate in Kaélé health district, Far North Region of Cameroon. METHODS This was a prospective study with 474 MAM children aged 6-59 months. Food voucher distribution and MUAC screening were conducted at 6 bi-weekly visits or until the child was recovered. Time to recovery was evaluated with multivariate Cox proportional regression hazard models with associations quantified using adjusted hazard ratio (aHR). The trend for MUAC, including its determinants, was examined with multivariate linear mixed effect models. RESULTS The recovery rate was 78.3% by 6 weeks after the first food basket; 3.4% remained MAM, and 5.9% were transferred for treatment for severe acute malnutrition (SAM defined as MUAC < 115 mm). Boys were 34% more likely to recover from MAM than girls [aHR = 1.34, 95%CI (1.09, 1.67)]. Children aged 24-53 months were 30% more likely to recover than those aged 6-11 months [aHR = 1.30, 95%CI (0.99, 1.70)]. A one unit increase in weight-for-height Z-score (WHZ) was associated with 1.89-fold greater likelihood of recovery [aHR = 1.89, 95%CI (1.66, 2.14)]. Male children had on average 1.82 mm greater increase in MUAC than female children (p < 0.001). One unit increase in WHZ was associated with 3.42 mm increase in MUAC (p = 0.025). Children aged 12-23 and 24-53 months had 1.03 mm and 2.44 mm, respectively, greater increase in MUAC over the program than children aged 6-11 months (all p < 0.01). CONCLUSION The recovery rate of MAM children treated with the FVP met the Sphere standards for targeted supplementary feeding programs (> 75%). Child's WHZ, gender and age were significant factors associated with MUAC increase and recovery from MAM in the FVP. These findings indicate the FVP approach shows promise as an effective alternative treatment for MAM with consideration of associated factors and merits further evaluation.
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Affiliation(s)
- Ismael Teta
- Helen Keller Intl, Derrière Usine Bastos, 1771 Nv Rte Bastos, Yaoundé, Cameroon.
| | | | | | - Julius Oben
- Faculty of Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | | | | | | | | | - Yunhee Kang
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Vosti SA, Adams KP, Michuda A, Ortiz-Becerra K, Luo H, Haile D, Chou VB, Clermont A, Teta I, Ndjebayi A, Kagin J, Guintang J, Engle-Stone R. Impacts of micronutrient intervention programs on effective coverage and lives saved: Modeled evidence from Cameroon. Ann N Y Acad Sci 2023; 1519:199-210. [PMID: 36471541 DOI: 10.1111/nyas.14937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Policymakers are committed to improving nutritional status and to saving lives. Some micronutrient intervention programs (MIPs) can do both, but not to the same degrees. We apply the Micronutrient Intervention Modeling tool to compare sets of MIPs for (1) achieving dietary adequacy separately for zinc, vitamin A (VA), and folate for children and women of reproductive age (WRA), and (2) saving children's lives via combinations of MIPs. We used 24-h dietary recall data from Cameroon to estimate usual intake distributions of zinc and VA for children 6-59 months and of folate for WRA. We simulated the effects on dietary inadequacy and lives saved of four fortified foods and two VA supplementation (VAS) platforms. We estimated program costs over 10 years. To promote micronutrient-specific dietary adequacy, the economic optimization model (EOM) selected zinc- and folic acid-fortified wheat flour, VA-fortified edible oils, and bouillon cubes, and VAS via Child Health Days in the North macroregion. A different set of cost-effective MIPs emerged for reducing child mortality, shifting away from VA and toward more zinc for children and more folic acid for WRA. The EOM identified more efficient sets of MIPs than the business-as-usual MIPs, especially among programs aiming to save lives.
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Affiliation(s)
- Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California Davis, Davis, California, USA
| | - Katherine P Adams
- Institute for Global Nutrition, Department of Nutrition, University of California Davis, Davis, California, USA
| | - Aleksandr Michuda
- Center for Data Science for Enterprise and Society, Cornell University, Ithaca, New York, USA
| | - Karen Ortiz-Becerra
- Department of Agricultural and Resource Economics, University of California Davis, Davis, California, USA
| | - Hanqi Luo
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Demewoz Haile
- Institute for Global Nutrition, Department of Nutrition, University of California Davis, Davis, California, USA.,Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Victoria B Chou
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adrienne Clermont
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ismael Teta
- Helen Keller International, Yaoundé, Cameroon
| | | | | | | | - Reina Engle-Stone
- Institute for Global Nutrition, Department of Nutrition, University of California Davis, Davis, California, USA
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Haile D, Brown KH, McDonald CM, Luo H, Jarvis M, Teta I, Ndjebayi A, Martial GAJ, Vosti SA, Engle-Stone R. Applying Zinc Nutrient Reference Values as Proposed by Different Authorities Results in Large Differences in the Estimated Prevalence of Inadequate Zinc Intake by Young Children and Women and in Cameroon. Nutrients 2022; 14:nu14040883. [PMID: 35215534 PMCID: PMC8879783 DOI: 10.3390/nu14040883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 02/06/2023] Open
Abstract
Nutrient reference values (NRVs) for zinc set by several expert groups differ widely and may affect the predicted prevalence of inadequate zinc intake. We examined this possibility using NRVs published by four different authorities and nationally representative dietary intake data collected among children aged 12–59 months and women in Cameroon. Usual zinc intake was estimated from 24 h recall data using the National Cancer Institute method. Prevalences of total zinc intake below the dietary requirement and of “absorbable zinc intake” below the physiological requirement were estimated using NRVs published by the World Health Organization (WHO), US Institute of Medicine (IOM), International Zinc Nutrition Consultative Group (IZiNCG), and European Food Safety Authority (EFSA). The prevalence of inadequate zinc intake ranged from 10% (IZiNCG—physiological requirement, 95% CI 7–13%) to 81% (EFSA—physiological requirement, 95% CI 78–84%) among children and 9% (WHO—physiological requirement, 95% CI 8–11.0%) to 94% (IOM—physiological requirement, 95% CI 92–95%) among women These differences in the prevalence of inadequate intake translated into sizeable differences in the predicted benefit and cost-effectiveness of zinc fortification programs. Depending on the NRVs applied, assessments differ regarding the need for and design of zinc fortification programs. Efforts are needed to harmonize NRVs for zinc.
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Affiliation(s)
- Demewoz Haile
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Correspondence: ; Tel.: +1-530-601-3869
| | - Kenneth H. Brown
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
| | - Christine M. McDonald
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Departments of Pediatrics, and Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA 94143, USA
| | - Hanqi Luo
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Michael Jarvis
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
| | - Ismael Teta
- Helen Keller International, Yaoundé 1771, Cameroon; (I.T.); (A.N.)
| | - Alex Ndjebayi
- Helen Keller International, Yaoundé 1771, Cameroon; (I.T.); (A.N.)
| | | | - Stephen A. Vosti
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Department of Agricultural and Resource Economics, University of California, Davis, CA 95616, USA
| | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
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Noshirvan A, Wu B, Luo H, Kagin J, Vosti SA, Ndjebayi A, Assiene JG, Teta I, Nankap M, Engle-Stone R. Predicted Effects and Cost-Effectiveness of Wheat Flour Fortification for Reducing Micronutrient Deficiencies, Maternal Anemia, and Neural Tube Defects in Yaoundé and Douala, Cameroon. Food Nutr Bull 2021; 42:551-566. [PMID: 34350785 DOI: 10.1177/03795721211020716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Policy makers aiming to reduce micronutrient deficiencies (MNDs) and their health effects must choose among alternative definitions of impact when evaluating cost-effectiveness. OBJECTIVE Estimate the cost-effectiveness of a mandatory wheat flour fortification program for reducing cases of MNDs (iron, zinc, folate, vitamin B12), anemia and neural tube defects (NTDs) averted, and disability-adjusted life years (DALYs) averted in urban Cameroon. METHODS A 13-year predictive model was developed, including a 3-year start-up period and 10 years of program activity. Costs were estimated using historical program budgets. Effects were calculated based on observed changes in prevalence of MND and anemia 1 year postfortification and predicted reductions in NTDs based on NTD burden and wheat flour intake. Total DALYs averted were estimated for anemia and NTDs. RESULTS The program cost ∼$2.4 million over 13 years and averted an estimated ∼95 000 cases of maternal anemia and ∼83 500 cases of iron deficiency among children after 1 year. Cost/case-year averted for MNDs ranged from $0.50 for low plasma folate to $3.30 for iron deficiency and was $2.20 for maternal anemia. The program was predicted to avert 1600 cases of NTDs over 10 years at ∼$1500 per case averted. Estimated cost/DALY averted was $50 for NTDs and $115 for anemia. CONCLUSIONS In Cameroon, cost-effectiveness of wheat flour fortification varied by the measure of impact employed, but was classified as "very cost-effective" for all outcomes using World Health Organization criteria. Policy makers and their advisors must determine how best to use information on program costs and benefits to inform their decisions.
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Affiliation(s)
- Arram Noshirvan
- University of California Davis School of Medicine, Sacramento, CA, USA
| | - Brenda Wu
- University of California Davis School of Medicine, Sacramento, CA, USA
| | - Hanqi Luo
- Department of Nutrition, University of California Davis, Davis, CA, USA
| | | | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California Davis, Davis, CA, USA
| | | | | | - Ismael Teta
- Helen Keller International, Yaoundé, Cameroon
| | | | - Reina Engle-Stone
- Department of Nutrition, University of California Davis, Davis, CA, USA
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Abstract
Background: Water represents the core of food-energy nexus and is vital for human survival. In developing countries, contaminated water and lack of basic water services undermine efforts to improve nutritional status and related health issues. In the rural areas of Central Africa, a majority of the population lacks access to improved water sources and has to devote considerable efforts to obtain water. Objectives: Using the following definition of water insecurity, i.e. it exists when access to adequate amount of safe and clean water does not occur all the times for the entirety of household members to lead a healthy and active life, the study aimed to develop and test a household-level experiential water insecurity scale for rural households in Central Africa. Methods: The research was conducted in three phases: 1) the formative data collection; 2) the scale development; and, 3) the scale testing. In the third Phase, the scale was tested with 250 women who were water managing person of their households. Statistical analysis included items reduction, reliability, as well as criterion and construct validity assessment. The testing led to a final scale of 17 statements (WATINE-17), covering three domains of water insecurity: 1) psychosocial distress; 2) quantity; 3) quality of water. Results: The scale showed an excellent reliability (Cronbach’s alpha = 0.92) and was significantly associated with lower frequency of water intake among women (p = 0.007, concurrent validity). In assessing WATINE-17’s predictive validity, it was found that water insecurity was positively related to food insecurity (p < 0.001) and the level of water insecurity was the highest among severely food insecure households [F (3, 246) = 22.469, p < 0.001]. Conclusion: The WATINE-17 is able to capture key elements of water insecurity and can be used to monitor and evaluate SDG# 6 and water-related programs, such as WASH, in Central Africa.
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Affiliation(s)
| | - Kenneth J Gruber
- Center for Housing and Community Studies, The University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Joseph Kamgno
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Director of the Centre for Research on Filariasis and other Tropical Diseases (CRFilMT), Yaoundé, Cameroon
| | - Ismael Teta
- Hellen Keller International Cameroon, Yaoundé, Cameroon
| | - Jigna Morarji Dharod
- Department of Nutrition, University of North Carolina at Greensboro, Greensboro, NC, USA
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Vosti S, Adams K, Michuda A, Luo H, Woldegebreal D, Chou V, Clermont A, Teta I, Ndjebayi A, Guintang J, Engle-Stone R. Selecting Micronutrient Intervention Programs to Save Lives: Evidence From Cameroon. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab045_075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
We use the Micronutrient Intervention Modeling (MINIMOD) tool to identify and compare economically optimal sets of micronutrient (MN) programs that focus on two objectives: increasing the number of individuals achieving adequate intake of specific life-saving MNs, and saving children's lives using sets of MNs.
Methods
We used 24-hour dietary intake data from Cameroon to estimate usual intake of zinc and vitamin A for children 1–5 y (n = 872) and of folate for women of reproductive age (WRA) (n = 902), as well as the prevalence of inadequate intake (below the Estimated Average Requirement) for each. We simulated the effects on inadequate MN intake of single or combined fortification of wheat flour, oil, and/or bouillon cubes, as well as two delivery platforms for vitamin A supplementation (VAS). The Lives Saved Tool (LiST) was used to estimate the number of lives saved by each program, and by all combinations of them. We estimated program costs for each scenario, nationally and subnationally, over a 10-year planning time horizon. The economic optimization model was run twice to identify the most cost-effective combination of programs based on two
objectives
achieving adequate intake for each MN, and increasing lives saved by all MNs.
Results
When the policy focus is on adequate intake of specific life-saving MNs, the following national and subnational programs are most cost-effective: wheat flour fortified with zinc (95 ppm, at target level), edible oils (9 mg/kg, 75% of target) and bouillon cubes (80 ppm) both fortified with vitamin A, and VAS provided to children in the northern part of Cameroon via Child Health Days. For meeting the folate needs of WRA, wheat flour fortified with folic acid (5 mg/kg, 33% of standard) is the most cost-effective option. When the primary focus is saving lives, a very similar set of economically optimal programs emerges, which saves over 26,000 lives over 10 years.
Conclusions
Policymakers in Cameroon who promote mortality-reducing MN programs using adequate intake and economic efficiency as their guides can expect to save child lives in a cost-effective way.
Funding Sources
This work was funded by a grant from the Bill & Melinda Gates Foundation to the UC Davis, and by a gift from Mars Inc. to UC Davis to support interdisciplinary research and training in economics and nutrition.
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Engle-Stone R, Adams K, Kumordzie S, Luo H, Wessells KR, Adu-Afarwuah S, Ndjebayi A, Teta I, Régis YL, Haskell M, Vosti S. Analyses Using National Survey Data From Cameroon, Haiti, and Ghana Indicate the Potential for Bouillon Fortification to Help Fill Dietary Gaps for 5 Nutrients. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab045_022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
We modeled the potential impacts of bouillon fortification with different levels of vitamin A, folic acid, vitamin B12, iron, and zinc on dietary micronutrient adequacy to inform multi-stakeholder discussions around bouillon fortification programs.
Methods
We used individual dietary intake data in Cameroon from women of reproductive age (WRA) and children 1–5 y (n = 902 and 872), and household (HH) survey data in Cameroon (n = 11,384 HH), Ghana (n = 11,870 HH), and Haiti (n = 4,951 HH) to estimate micronutrient (MN) intake. The Adult Male Equivalent method was applied to estimate “apparent intake” of WRA, children, and men from HH surveys. We examined intake of bouillon and calculated prevalence of inadequate (below the estimated average requirement) and high (above the tolerable upper intake level, UL) micronutrient
intake. Analyses included the contributions of mandatory fortification of oil or wheat flour at estimated current micronutrient levels. We simulated the impacts of bouillon fortification with varying levels of vitamin A, folic acid, vitamin B12, iron, and zinc on inadequate and high intakes of each nutrient.
Results
Bouillon was commonly consumed in all countries, with any reported consumption ranging from 67–81% in Ghana to over 90% in Cameroon and Haiti. Median (apparent) bouillon consumption ranged from 1.6–2.1 g/d for women, 0.7–1.0 g/d for children, and 1.8–2.2 g/d for men. Bouillon fortification with vitamins was predicted to reduce dietary inadequacy (120 μg/g vitamin A: 15–33 percentage points, pp, depending on the country and target group; 80 μg/g folate: 11–33 pp; 1.2 μg/g B12: 12–67 pp) with minimal risk of high intake. In contrast, predicted effects on dietary iron inadequacy were modest (5–12 pp reduction at 5 mg iron/g, assuming 2% absorption). Simulated zinc fortification showed reductions in inadequate absorbable zinc intake (14–42 pp at 3 mg/g), but children's intakes commonly exceeded the UL.
Conclusions
Modeling suggests that bouillon fortification could reduce inadequate MN intakes in these countries. Further work is needed to identify fortification levels that will meet criteria for nutritional benefits, technical feasibility, and cost-effectiveness.
Funding Sources
This analysis was supported by a grant to UC Davis from Helen Keller International.
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