Nutrition defines in great part how many survive infancy & how - - PowerPoint PPT Presentation

Nutrition defines in great part how many survive infancy & how they will live and die

Years of age 25 50 75 100 20 40 60 80 100 120

1930 2000

Foetus / Infants / Children

• LBW/IUGR
• Stunting and wasting
• Micronutrient deficiency (

Vit A,I,Fe,Zn )

• Infection (HIV/AIDS)

Adults / Elderly

• Cardiovascular (CHD,

Stroke )

• Obesity /Diabetes/ dyslipidemia
• Cancer related to diet
• Osteoporosis
• Aging

Ideal

% survival

Nutrition-Infection interactions determine in great part, how we grow physically and develop mentally, Nutrition-Physical activity interactions define how we age and die.

Disability Physical /Mental

Note: for non- commercial purposes

• nly

We grow and develop according to age

Determinants of loss

Deaths attributable to 16 leading risk factors: all countries

3000 6000 7000 8000 1000 2000

Deaths (000)

4000 5000 Low mortality – Developing countries High mortality – Developing countries Developed countries

Adapted from World Health Report 2008 Blood pressure

Tobacco Use

Cholesterol Underweight

Unsafe sex

Fruit & vegetable High body mass Index Physical inactivity Alcohol

Unsafe water, hygiene

Indoor smoke/fuels Iron deficiency

Urban air pollution

Zinc deficiency Vitamin A deficiency

Unsafe health/injections

Underweight for age < 5 yrs (WHO-UNICEF-BM 2012)

Stunting < 5 yrs Globally (WHO-UNICEF-BM 2012)

Wasting low weight for height in < 5 yrs in (WHO-UNICEF-BM 2012)

Prevalence of obesity < 5 yrs globally

(WHO-UNICEF-WB 2012)

14 million premature deaths due to NCDs

Source: WHO, 2008

http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index. html

Source: WHO, 2011 https://apps.who.int/infobase/CountryProfiles.aspx

Premature deaths due to NCDs in developing countries (men)

Premature deaths due to NCDs in developing countries (women)

Source: WHO, 2011 https://apps.who.int/infobase/CountryProfiles.aspx

Pre Pregnancy BMI Maternal Glucose Insulin Placental Fetal blood flow Fetal growth restriction Fetal Macrosomia feeding fast Weight gain Early Adiposity rebound Pubertal Sexual maturation Central Obesity Metabolic syn High BMI Obesity

Hormonal responses

Hormonal responses

Preconceptional Gestational Infant Folic acid Overweight Malnutrition BMI  BMI  Diabetes

Nutrition: Critical Timing

Micronutrients I, Vit A, Fe, EFA, Zn

Assessing Early Life I Interventions I

• Early life interventions to prevent the consequences of

malnutrition are now well established as a priority for global health and human development.

• The prevention of early death is a key component of

the millennium development goals to be met by 2015.

• We now seek to promote optimal growth and mental

development as key for human-social development; the early years lay the biological foundation for productive social and educational investments, building human capital with lifelong returns.

CONSEQUENCES OF UNDERNUTRITION UNDERNUTRITION

Productivity Social Exclusion Unemployment Mortality School performance Morbidity Acute & Chronic Mental Development

Increase Costs

(private– públic)

Malnutrition not only affects those who are malnourished but also affects the whole of society

Martínez R y Fernández A. Modelo de análisis del impacto social y económico de la desnutrición infantil en A.L. CEPAL 08

Malnutrition is both an ethical & a socio-economic issue

Incidental

Age at which effects are documented

Age at which loss occurss or identified

0 - 4 6 - 18 15 - 64 X Health Education Productivity

Prospective

18 2 64 11 4

Retrospective

TWO APPROACHES IN EVALUATING COSTS OF HUNGER

source: Economic Commission for Latin America ECLA 2008

It estimates the health costs of pre-school boys and girls who suffer from under nutrition during the year of analysis, It considers the educational costs stemming from the undernutrition children now in school suffered during the first five years of life Includes economic costs due to lost productivity by working-age individuals who were exposed to under- nutrition before the age of five.

The cost of hunger: Social and economic impact of child undernutrition…

Incidental retrospective dimension (Estimate of the

cost of undernutrition in a country’s population for a given year)

Serves to project the present and future losses incurred as a result of medical treatment, repetition of grades in school, and lower productivity caused by under-nutrition among children under the age of five in each country, in a specific year. Based on that, potential savings derived from actions taken to achieve nutritional objectives can be estimated (for example, to attain MDG1, reducing undernutrition by half by 2015).

The cost of hunger: Social and economic impact of child undernutrition…

Prospective: potential savings approach

Estimated Losses for 13 countries studied was US $ 17 billion or 3.4% of Aggregate GNP

Estimated total cost of childhood malnutrition (US dollars and percent GNP 2004-2005)

Fuente: CEPAL, sobre la base de información oficial y registro de costos de educación de cada país; Ingresos y escolaridad, de encuestas de hogares de cada país

Central America & Dominican Rep (2004) Andean Countries & Paraguay (2005)

Total US $ (Million)

6,659 10,552

Percent GNP

6.4 2.6

500 1000 1500 2000 2500 3000 3500 4000 4500

VEN CRI PAR PAN PER COL ECU RDO NIC BOL ELS HON GUA

0% 2% 4% 6% 8% 10% 12%

Total Cost Percent country GNP Millon US dollars

Impact of malnutrition in Latin America(2004-05)

source: Economic Commission for Latin America ECLA 2008

Higher mortality and lost opportunity for education determine 93% of the cost of hunger.

Health is only 6.5% and school repetition less than 1%.

Health (Morbidity) 7% Education (Repetition) 1% Productivity (Education ) 41% Productivity (Mortality) 52%

lost productivity based on poor linear growth

Stunting: nting: the hidde den n impact act

The missing normal rapid growers Probable disrupted growth. Children might have Normal or Above average growth.

• 1.5 S.D.

Very High Average Low Very Low

Height ght for r Age

Classi sified ed as Stunt nted ed

13% 13% 39% 39% 54% 54%

14% at risk +2.0 S.D. +1.5 S.D.

• 2.0 S.D.

The normal al range e of childh dhood d growth th Sub-Sa Sahar haran an Africa ca

• S. Asia

Those classified as Stunted fall below the lowest limit (-2.0 S.D.) of normal linear growth.

South th Ameri rica ca

DEATHS ATTRIBUTABLE TO 16 LEADING RISK FACTORS:

3000 6000 7000 8000 1000 2000

Deaths (000)

4000 5000 Low mortality – Developing countries High mortality – Developing countries Developed countries

Adapted from World Health Report 2008 Blood pressure

Tobacco Use

Cholesterol Underweight

Unsafe sex

Fruit & vegetable High body mass Index Physical inactivity Alcohol

Unsafe water, hygiene

Indoor smoke/fuels Iron deficiency

Urban air pollution

Zinc deficiency Vitamin A deficiency

Unsafe health/injections

WHO Chronic Disease report 2005

% of total DALYs lost OBESITY Under nutrition

Body size in the French population

• ----- 1705 -1975

(Fogel 1997) Secular trends in developing countries 1970-2000

Stature m BMI

Ideal trends

Surface plots relating stature, weight, BMI and RISK of DEATH

Impact of Early Life Interventions II

• We recognize that the interventions required to

prevent stunting and improve brain development are complementary but differ from those needed to reduce underweight & wasting.

• The issue is not about choosing between

addressing under-nutrition in the poor versus treating obesity in the affluent; but how to maximize human development potential preventing death/disability in the early years with a life course perspective.

Assessing Impact of Early Life Interventions III

• We need to assess the biological, social and economic

impact of the various options beyond counting lives saved.

• We must include the quality of life of those that survive

and the resulting economic benefits to individuals and society.

• The economic cost of preventable “adult non

communicable chronic diseases” (NCDs) must be integrated in our impact analysis of early nutrition

Assessing Impact of Early Life Interventions IV

• The largest fraction of these losses relate to

poorer brain development and lower educational achievement followed by early death/disability of adults, all impact economic productivity and national development.

• We should be talking to the Ministry of Finance

and National Development and not only to the ministers of Health and Education

Health Policy. 2007 Mar 13; 83:295-303

Background

In January 2000, the Chilean Ministry of Health mandated required fortification with folic acid (FA) at the level of 2.2 mg per kg of wheat flour to reduce the risk of neural tube defects (NTD) This policy would result in a mean additional intake of approximately 400 μg/d based on consumption of fortified bread. Program effectiveness was established documenting increased plasma and RBC folate content and lower incidence of NTD.

Pre – fortification (n:120,636 livebirths) Post – fortificaction (n: 117,101 livebirths) Risk Reduction Health Outcome Rate Rate RR (95%CI) Anencephaly 0.61 0.37 0.39 (0.10 – 0.59) Encephalocele 0.24 0.19 0.22 ( (-0.44) – 0.57) Spina Bífida 0.86 0.45 0.48 (0.26 – 0.63) NTD live births 1.33 0.89 0.33 (0.14 – 0.49)

.

Assessment of Effectiveness in NTD Reduction

Base Based on

• n da

data ta fr from

• m evalua

valuation tion of

• f NTD

NTD be befor

• re (19

(1999 99-20 2000 00) ) an and d afte after (20 (2001 01-20 2002 02) ) implemen implementa tation tion of

• f whe

heat flour flour for

• rtifi

tifica cation tion.

MEDICAL AND REHABILITATION COST ESPINA BIFIDA

Cost/Case Espina Bifida (2002 $ US)

Surgical correction 2,450 Rehabilitation (1 year) 4,555 Extended to 20 ys 100,209 Extended to 20 ys (3% Discounted) 74,763

PROGRAM COST

Cost Mill Industry ($US)

Flour fortification 211,865 Quality Control 63,600 Total Cost 275,465

EFFECTIVENESS

• Women reaching target intake.

FA intake estimated from consumption of fortified bread suggest that 45% of women of reproductive age reached > 400 ug/day. Population of women of reproductive age (15-45 yrs) in Chile 3 591 688 (Vital Statistics INE, 2002).

• Number of NTD cases prevented.

Incidence of NTD 2 yrs before and 2 yrs after intervention (evaluation in 9 Hospitals in Santiago; 60,000 births per year). Vital statistic of total live birth and fetal death. (INE, 2002).

RESULTS

• From a total population of 3,591,688

women of reproductive age, 1,724, 010 reached the target intake of FA.

• Cost per woman

16 $ US cents

COST PER SELECTED HEALTH OUTCOMES

Cases Prevented Cost/Case Prevented* Health Outcome n º Total Anencephaly 60 $4,591 Encephalocele 13 $22,036 Spina Bífida 103 $2,687 NTD live births 110 $2,515

* Obtained

Obtained f from dividing the

• m dividing the t

tota

• tal co

l cost of st of th the pr e prog

• gram

am by by the the numb number of er of cas cases es pr preven ented ted.

COST SAVINGS PER SPINA BIFIDA CASE PREVENTED

Surgical and rehabilitation cost extended to 20 years of life per child with spina bifida was: $ US 100,209 $ US 74,763 ( 3% discount rate) Extrapolating this cost to the 110 infants with Spina Bifida that were averted by the program, the average year- saving for the health system was: $US 10,973,308 $US 8,187,596

The result of the cost-effectiveness analysis supports the implementation of this intervention despite the low incidence of NTD. Cost-saving per spina bifida case averted corresponds to the yearly expenditure by the public health system for approximately 400 people in Chile. Further analyses will include determination of cost of

• ther measures of effectiveness such as QUALYs and

DALYs

Health Economic Model for Assessing the Impact of High Birth Weight on Public Health

Ir Irene ene Lenoir Lenoir-Wijnk ijnkoop

• op1,

, Mar Mark Nuijten k Nuijten2, , Eline Eline M.

• M. van

van der der Beek Beek3 & Ricar & Ricardo Uauy do Uauy4

MONDAY NOV 18TH 2013

1DEPARTEMENT OF PHARMACEUTICAL SCIENCES, UNIVERSITY OF UTRECHT, THE

NETHERLANDS;

2ACCESSUS MEDICA, THE NETHERLANDS; 3NUTRICIA RESEARCH, SINGAPORE; 4INSTITUTE OF NUTRITION INTA UNIVERSITY OF CHILE, CHILE

THIS STUDY WAS SUPPORTED BY A GRANT FROM THE DANONE INSTITUTE INTERNATIONAL, FRANCE

Prevalence of macrosomia, macrosomia delivered by pre-labor caesarean delivery and LGA births from 1994 – 2005 USA data

MACROSOMIC BIRTH & SHORT TERM COMPLICATIONS FOR MOTHER & CHILD Macrosomia increases neonatal risks

Birth Weight Grade Risks 4000 – 4499 g I Mother+ newborn (induction of labour, caesarean delivery, and birth injuries) 4500 – 4999 g II Neonatal morbidity (5-min Apgar <3, meconium aspiration, and greater risk of lung immaturity) > 5000 g III Birth trauma and death

Boulet et al. Am J Obstet Gynecol 2003 Stotland et al. Int J Gynecol Obstet 2004

Birth weight is associated with maternal complications

$7.990 $11.794 $13.047 $7.990 $11.794 $13.684 $0 $3.799 $5.243 $0 $4.646 $5.699

$7.990 $15.593 $18.290 $7.990 $16.440 $19.383

$0 $5.000 $10.000 $15.000 $20.000 $25.000

Normal GDM Overweight Normal GDM Overweight Pregnancy and Delivery Short term costs mother & child (<6yrs)

Total Child Mother

A budget impact analysis (BIA) of GDM for the USA was calculated based on an assumption of

GDM incidence at 5.5%3. This leads to an annual number of cases

• f GDM of 236,139 in the USA.

BIA based on 5.5% GDM = $2,544,632,345 USD

Irene Lenoir-Wijnkoop1, Mark Nuijten2, Eline M. van der Beek3 & Ricardo Uauy4

Why should we use Measures of Disease Burden DALYs Assessing performance. country-specific (or regional) measure of the burden of disease provides an outcome indicator that can be used over time to judge progress and performance across countries or regions Forum for informed debate of values and priorities. Disease burden in practice, requires participation of a broad range of specialists. Debating appropriate values, for disability weights or for years of life lost Identifying national disease control priorities. Many countries now identify a relatively short list of interventions, implementation becomes a clear priority for national political and administrative attention. Allocating training time for clinical and public health practitioners. Allocating research and development resources. Effort proportional to the size of the problem being addressed, comparison across diseases in terms cost per daly prevented.

Interventions identified in Scaling Up Nutrition (SUN)

Vit A supplementation for children 6-59 m of age Therapeutic zinc supplements as diarrhea Rx in children 6-59 m In-home fortification of complementary food for children 6-23 m Deworming medication for pre-school aged children Iron-folic acid supplementation for pregnant women Iron fortification of staple foods Salt iodization for the general population Every effort was made to obtain estimates on current coverage rates for each of the interventions. The “uncovered” target population was approximated and the additional cost of providing the interventions was calculated. The goal coverage rate was assumed to be 100% of the target population for each intervention

Direct Interventions to Prevent/Treat Undernutrition Promoting good nutritional practices ($2.9 billion):

❑ breastfeeding

❑ complementary feeding for infants after the age of six months ❑ improved hygiene practices including handwashing ❑ Increasing intake vitamins/minerals ($1.5 billion) young children/mothers: ❑ periodic Vitamin A supplements ❑ therapeutic zinc supplements for diarrhoea management ❑ multiple micronutrient powders ❑ de-worming drugs for children (to reduce losses of nutrients) ❑ iron-folic acid supplements for women to prevent and treat anaemia ❑ iodized oil capsules where iodized salt is unavailable Provision of micronutrients through food fortification for all: ❑ salt iodization ❑ iron fortification of staple foods Therapeutic feeding for malnourished children ($6.2 billion):

❑ prevention or treatment for moderate undernutrition ❑ treatment of severe undernutrition (“severe acute malnutrition”) with ready-to-use therapeutic foods (RUTF).

How Much Health Will a Million Dollars Buy?

How Much Health Will a Million Dollars Buy?

How Much Health Will a Million Dollars Buy?