1.
Preventive Nutrition
Interventions
Reina Engle-Stone, Christine P Stewart, Hanqi Luo,
Stephen A Vosti, Katie Adams
University of California, Davis
Haiti Priorise conference, April 28-May 3, 2017

2.
Inadequate micronutrient nutrition
affects health and development
• Women of reproductive age and young children are most
vulnerable
• Anemia in pregnancy (53.9% in Haiti) is associated with increased
risk of infant mortality, and preterm birth and low birth weight
(which have long term consequences for infant)
• Calcium supplementation to pregnant women reduces the risk of
pre-eclampsia, which increases risk of maternal mortality.
• Sufficient folic acid at the time of conception reduces the risk of
neural tube defects (500+ cases/year in Haiti), which are usually
either fatal or result in severe disability.
• Fortification delivers folic acid early enough to reduce NTDs
• Consistent reductions in NTDs observed following folic acid
fortification in other countries

3.
Inadequate micronutrient nutrition
affects health and development
• Anemia prevalence in Haiti
• 45.3% (rural) to 53.9% (urban) among women of
reproductive age
• 64.5% (rural) to 66.0% (urban) among preschool children
• 50% of anemia assumed to be caused by iron
deficiency
• Programs to increase iron intake (food fortification,
supplements) reduce the risk of iron deficiency
anemia
Summary: high burden of death and disability from micronutrient deficiencies

4.
Multiple micronutrient and
calcium supplements
delivered to pregnant
women

5.
Micronutrient malnutrition in pregnancy:
There are interventions that work
• Iron folic acid supplements (vs. placebo) during
pregnancy reduce the risk of anemia by 64% and low
birth weight by 16%
• Multiple micronutrient supplements (vs. IFA) during
pregnancy reduce the risk of stillbirth by 8% and low
birth weight by 12%
• Calcium supplements (vs. placebo) during pregnancy
reduce the risk of maternal mortality by 20%,
preeclampsia by 55%, and preterm birth by 24%

6.
Maternal supplementation with multiple
micronutrients and calcium during pregnancy
• Provision of multiple micronutrient supplements
and calcium supplements to pregnant women
• Daily supplements for 8 months; supplement
bottles provided every 2 months
• Delivered through antenatal care system.
Current ANC coverage (DHS 2012)
Any coverage
(≥1 visit)
WHO recommended
coverage (≥4 visits)
Urban 93% 74%
Rural 90% 60%

7.
Costs of supplement distribution
• Startup costs
• Training all existing ANC staff
• Hiring additional staff to cover added workload for supplement
delivery (estimated at ~10 min per pregnant woman per 2 mo)
• Development of social marketing campaign for use in ANC facilities
to promote MN supplements
0%
20%
40%
60%
80%
100%
2017 2022 2027
Year
Coverage
(% of optimal visits achieved)
• Recurring costs
• Tablet costs, storage, and transport
• Refresher trainings, new trainings
due to staff turnover
• Rural area outreach to catch
women missed by the ANC system
• Supervision

8.
Benefits of supplementation during
pregnancy
• DALYs averted
• Deaths avoided
• Maternal deaths due to pre-eclampsia (168 in Y1  235 in Y12)
• Stillbirths (287 in Y1  403 in Y12)
• Preterm birth (567 in Y1  796 in Y12)
• Disability avoided
• Maternal anemia cases (85,000 in Y1  119,000 in Y12)
• Low birth weight (13,000 in Y1  19,000 in Y12)
• Preterm birth (8,000 in Y1  11,000 in Y12)
• Productivity losses avoided due to low birthweight
reduction

9.
Total benefits, total costs, and
cost-benefit ratios
Valuation of
DALYs
Discount Rate
Benefit
(in Gourdes)
Cost
(in Gourdes)
BCR
3 X GDP 5% 79,844,981,881 7,637,956,645 10
Sensitivity analyses showed that greater coverage
associated with greater BCR

10.
Wheat flour fortification
with iron and folic acid

11.
Addition of iron and folic acid to
industrially produced wheat flour
• Flour fortification programs being scaled up globally  growing
experience in implementation in LMICs
• Wheat is imported and milled in Haiti (centralized/few millers; small %
imported as wheat flour)
• Concentrated micronutrient premix mixed into flour
• Reaches all consumers of wheat flour (41% urban, 34% rural)
• Reach estimated from ECVMAS household survey data (defined as
households purchasing bread 3-4 times in past week)
0%
50%
100%
2017 2022 2027
% of flour adequately fortified
 % of flour adequately fortified
is assumed to scale up gradually
to 95% beginning in year 6

12.
Costs of wheat flour fortification
• Startup costs
• 47,214,375 Gourdes in Y1
• Equipment
• Micronutrient survey
• Revisiting norms
• Recurring costs
• 42,417,810 Gourdes in Y12)
• Micronutrient premix (90+% of annual costs in Year 12)
• Monitoring and evaluation
• Additional periodic costs included to replace
equipment and conduct evaluation surveys
0
20,000,000
40,000,000
60,000,000
80,000,000
2017 2022 2027
Program cost, Gourdes per year

13.
Benefits: DALYs averted
• Decrease in deaths due to neural tube defects by folic acid
• Decrease in iron deficiency anemia
• Women of reproductive age (15-49 y)
• School age children (5-14 y)
• Preschool children (6mo-4 y)
After scaling up to 95% fortified:
• 140+ cases of neural tube defects
averted annually (assume 100%
mortality)
• Number of cases of anemia averted
annually (1 year duration)
• 92,000+ women
• 100,000+ school-age children
• 61,000+ preschool children
0
5000
10000
15000
20000
25000
30000
35000
Anemia,
women
Anemia,
school age
children
Anemia,
preschool
children
Deaths,
neural
tube
defects
Total DALYs over 12 y, 3% discount

14.
Total benefits, total costs, and
cost-benefit ratios
Valuation of
DALYs
Discount Rate
Benefit
(in Gourdes)
Cost
(in Gourdes)
BCR
3 X GDP 5% 7,938,064,315 331,312,834 24
Sensitivity analyses showed favorable BCRs even if reductions in
iron deficiency anemia among children are not included
(e.g., if young children eat less wheat flour than assumed)

15.
Micronutrient powder
distribution to children
6-23 months of age

16.
Micronutrient powders (MNP)
• Micronutrient powder sachets =
“home fortification”
• WHO guideline recommends delivery
to children 6-23 months for reduction of anemia
• 2 doses per year; 1 dose=2 months of daily sachets
• We assumed “passive” distribution at health clinics
and rally posts
• Relies on caregiver to visit clinic to receive sachets
• Use vaccination rates as proxy for % of children who
would receive MNP
More intensive distribution would have
greater costs and greater benefits.

17.
Costs of distribution of MNP
though health centers
• Startup
• Train all health workers
• Recurring
• Additional health workers needed: Assumes 2 visits per
year and 15 min/visit to provide instructions on MNP use
• Periodic retraining of health workers
• Supervision
• MNP procurement
(product, transportation, storage)
0%
10%
20%
30%
40%
50%
60%
2017 2022 2027
year
Coverage
% receiving all 8
vaccines
% receiving MNP
• Main cost after
startup is MNP itself
• ~75+% of total cost,
assuming
$0.017/sachet, and 2
courses of 60 sachets
each 
~$2/child/year

18.
DALYs averted by anemia
reduction in children 6-23 months
• MNP include multiple micronutrients (iron, zinc, vitamin A),
but impact on anemia thought to be due mainly to reduction
in iron deficiency anemia
• 44% reduction in anemia observed in study in Haiti (cluster
randomized pre-post intervention design: Menon et al., 2007)
• [For comparison: 31% reduction in anemia estimated by meta-
analysis of 6 trials (WHO, 2011)]
• Assuming program reaches full scale up by year 8 (all children
who receive vaccines also get MNP),
• 58,000+ cases of anemia averted annually beginning Year 8

19.
Total benefits, total costs, and
cost-benefit ratios
Valuation of
DALYs
Discount Rate
Benefit
(in Gourdes)
Cost
(in Gourdes)
BCR
3 X GDP 5% 1,200,675,600 157,324,005 8
Benefits are sensitive to cost of MNP product;
less sensitive to achieved coverage