Food Aid Research: An Update on Food Aid ICN... · supplements (LNS) for prevention of malnutrition The International Lipid-Based Nutrient Supplements (iLiNS) Project Funded by the

Food Aid Research: An Update on Food Aid

for Preventing & Treating Undernutrition

October 2017

Part II

Please Cite this Presentation as:

• Collins S, de Pee S, Dewey KG, El-Khour T, Michaelsen, K Rogers B. Food aid research: an update on food aid for preventing & treating undernutrition. PowerPoint slides presented at the 21st International Congress of Nutrition, Buenos Aires, Argentina. 2017 Oct 18.

Rationale and evidence regarding small-quantity lipid-based nutrient supplements

for food assistance

Kathryn G. Dewey, PhD

Distinguished Professor

University of California, Davis

Conflict of Interest Disclosure

I have no conflict of interest to report in relation to this presentation.

What are lipid-based nutrient supplements (LNS)?

• A family of products that deliver vitamins and minerals, essential fatty acids, protein and energy in a lipid matrix.

• Low moisture content ensures resistance to spoilage.

• Most LNS formulations include: Soy or canola oil, peanut paste, milk powder, sugar, vitamins and minerals

Types of lipid-based products

Short name/Example product

Quantity Designed for…Typical daily ration size

RUTFPlumpy’Nut®

Large Treatment of severe acute malnutrition (SAM)

~200-300 g/d

RUSFPlumpy’Sup®

Large Treatment of moderate acute malnutrition (MAM)

~100 g/d

Medium-quantity LNSPlumpy’Doz®

Medium Prevention of MAM ~50 g/d

Small-quantity LNS(SQ-LNS)Nutributter®

Small Support healthy growth & development, prevent stunting

~20 g/d

202

615

307

686

548

894

0

200

400

600

800

1000

Breastfed Infants* Non-Breastfed Infants

Ener

gy (k

cal)

6-8 mo

9-11 mo

12-23 mo

20 g LNS

*(Assumes “average” breast milk intake)

Small-quantity LNS compared to energy needs from complementary foods (breastfed) or total energy needs

(non-breastfed)

SQ-LNS in food assistance programs

• Potential advantages– Because quantity is small and ready-to-eat, entire

intended daily ration is easily consumed

• Helps ensure that micronutrient & fatty acid needs of vulnerable target groups are met

• Minimizes risk of displacing breast milk intake

– Small sachets minimize transport & storage costs (shelf life > 18 mo)

– May reduce likelihood of sharing, compared to larger-quantity food assistance products

• Potential disadvantages– If widespread food insecurity, may need to augment with

other foods or cash transfers

Use of LNS in emergency settings: improving the nutrient adequacy of general food distribution rations

for vulnerable sub-groupsChaparro CM & Dewey KG. Matern Child Nutr 2010, 6 (Suppl 1)

• Nutrient gaps in typical GFD rations

• Desired nutritional formulation of LNS for target groups

• Discussion of technical issues:

– Nutrient bioavailability

– Avoiding toxic levels of nutrients

– Stability & shelf-life

– Production, packaging & distribution of LNS

– Cost implications

The iLiNS ProjectDevelopment and evaluation of lipid-based nutrient

supplements (LNS) for prevention of malnutritionwww.iLiNS.org

The International Lipid-Based Nutrient Supplements (iLiNS) Project

Funded by the Bill & Melinda Gates Foundation

• Combined pre- and post-natal SQ-LNS

• iLiNS-DYAD trial in Ghana (n~1300)

• iLiNS-DYAD trial in Malawi (n~1300)

• Postnatal LNS only

• iLiNS-ZINC trial in Burkina Faso (n~3200)

• iLiNS-DOSE trial in Malawi (n~1900)

Nutrient content of LNS in the iLiNS Project[20 g/d; 118 kcal/d]*

LNS-Child:• Includes 22 vitamins & minerals

o ~1 RDA for most micronutrients except Fe (6 mg) & Zn (8 mg)o Macrominerals included (Ca, P, K, Mg)

• Essential fatty acids: 4.5 g linoleic acid; 0.6 g ALA• Protein: 2.6 g

LNS-P&L:• Includes 22 vitamins & minerals; levels based on recent multiple

micronutrient trials during pregnancy• Iron content = 20 mg• Essential fatty acids: 4.6 g linoleic acid; 0.6 g ALA• Protein: 2.6 g

*10 g and 40 g formulations also used in one trial.

Arimond M, Zeilani M, Jungjohann S, Brown KH, Ashorn P, Allen LH, Dewey KG. Considerations in developing lipid-based

nutrient supplements for prevention of undernutrition: experience from the International Lipid-Based Nutrient Supplements

(iLiNS) Project. Mat Child Nutr epub May 2013.

iLiNS Trials – Summary of growth response

• Effects of LNS-P&L on birth size similar in Ghana & Malawi

– Much larger effect among primiparous mothers in Ghana

• Of the 4 iLiNS trials, increased linear growth by 18 mo in Burkina Faso and Ghana, but not in Malawi

– Stunting reduced by 25% in Burkina Faso (from 39% to 29%) and by 40% in Ghana (from 15% to 9%)

• Lack of response in Malawi likely due to:

– Lower potential for population to benefit, relative to Burkina Faso (very little wasting; more adequate diets)

– Lower potential for population to respond (shorter mothers; more prenatal stunting; high rates of inflammation and maternal infection)

Effectiveness of home-fortification approaches in the first 1000 days for preventing maternal and child undernutrition: the Rang-Din Nutrition Study in Bangladesh

Clusterselectionfrom 11 unions

Randomassignment to

study armsIntervention period

<20wk 36wk Birth 3mo 6mo 12mo 18mo 24mo 36mo 48mo

X 64

X 16

Comprehensive LNS (LNS-LNS)

X 16

Child LNS (IFA-LNS)

X 16

Child MNP (IFA-MNP)

X 16

Control(IFA-Control)

LNS-PLW LNS-child

LNS-child

MNP-child

Timeline of assessments

Iron/Folic acid

Iron/Folic acid

Iron/Folic acid

The Rang-Din Nutrition Study: A cluster-randomized effectiveness trial

Post-Interventionfollow-up

RDNS Supplements

• SQ-LNS for pregnant and lactating women (LNS-PLW): Jononi

• SQ-LNS for children (LNS-child): Sonamoni

• Both versions of SQ-LNS provided 118 kcal/d and 22 micronutrients

• Micronutrient powder (MNP, 15 micronutrients) for children: Pushtikona

© Zigzag Agency, Nutriset

Label for Jononi

Key results of RDNS main trial

• Significant impact of LNS-PL on birth size, including reduced newborn stunting and small head size (Mridha et al. Am J Clin Nutr 2016)

• Significant impact of LNS-PL + LNS-C on child growth at 18-24 months of age (Dewey et al. Am J Clin Nutr 2017)

• Significant impact of LNS and MNP on child development at 18-24 months of age (Matias et al. Am J Clin Nutr 2017)

Stunting at birth by intervention group, by household food insecurity

Pre

vale

nce

of

stu

nti

ng

at b

irth

(%

)

Food insecurity

*

31.4

24.4

21.1 20.420.0

17.7

15.5

20.3

0

5

10

15

20

25

30

35

Severe Moderate Mild None

IFA

LNS

n = 236 75 761 232 356 142 1196 448

p = <0.05*

**

Evidence of impact of SQ-LNS

• Two Cochrane reviews & meta-analyses on LNS, for pregnant women and for children, currently under review. Preliminary findings:

– LNS for pregnant women increases birth weight & reduces SGA and newborn stunting

– LNS for children increases height and may be more effective than fortified blended foods for reducing stunting and wasting

• Heterogeneity in effects both within & across populations

– In some settings, growth response may be constrained by contextual factors such as frequent infections and inflammation

Further evaluation needed

• To assess the effectiveness of SQ-LNS within food assistance programs in different contexts

– Acceptance

– Utilization

– Cost-effectiveness

• To evaluate effectiveness when integrated with other strategies to reduce infections/inflammation and promote child development

Acknowledgments: iLiNS Project Funding

Primary funding of the iLiNSProject was provided by the Bill & Melinda Gates Foundation.

Additional funding provided by the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID), under terms of Cooperative Agreement No. AID-OAA-A-12-00005, through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360.

Acknowledgments

Many thanks to:• iLiNS Steering Committee & Project

ManagerPer Ashorn, Ken Brown, Anna Lartey, Ken Maleta, Jean Bosco Ouedraogo, Steve Vosti, Mamane Zeilani + Mary Arimond, Project Manager

• The research teams• The communities• The participants• The health facilities• The Data Safety and Monitoring

Boards• Collaborators at USDA WHNRC, Cal

Poly San Luis Obispo, Helen Keller International, Project Peanut Butter

• And many, many others

RDNS Acknowledgments• ICDDR,B: Malay Kanti Mridha (ICDDR,B PI), Tahmeed

Ahmed, Fahmida Tofail, Laura Reichenbach, RDNS field site staff

• LAMB CHDP: Stacy L. Saha, Swapan Pahan, Louise Day, Joanne Nout, Peter May, Steve Withington, Altaf Hossain, Mahtab Liton, CHDP staff, community representatives in the RDNS unions

• UC Davis: Susana L. Matias, Joseph Cummins, Kassandra Harding, Christine Stewart, Janet Peerson, Charles Arnold, Rebecca Young, Stephen A. Vosti

• FANTA: Camila M. Chaparro, Zeina Maalouf-Manasseh, Megan Deitchler

• The mothers and babies in the Rang-Din Nutrition Study• Funded by USAID/GH

This presentation is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID) under terms of Cooperative Agreement No. AID-OAA-A-12-00005, through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360. The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.

Scaling-up the use of Special Nutritious Foods, going beyond food assistance

Saskia de PeeWorld Food Programme

Tufts University & Wageningen University

26

Do we have the minimal conditions favoring local production in place to justify further analysis?

Demand level(Market demand analysis)

Manufacturing level(Local capacity &

environment analysis)

Do market conditions (commercial, aid,

governmental) generate sustained and sizeable demand favoring the

development of businesses?

Is the local business environment fertile for a

business in the SNFs market?

There is minimal scale for a market

Business is feasible locally

Ma

in q

ues

tio

n

1 2

Here, we consider infant cereals and LNS type SNFs

Increasing local supply of special nutritious foods for different consumer groups

27

• For WFP, the increase in quantity of suppliers, reduction of order sizes and varied quality standards pose complexity challenges in managing contracts, logistics, supply chain, food quality & safety, etc.

• Existing capacity is currently 5 times bigger than WFP demand, leading to a scenario of sub-utilization of plants if production continues to expand, with serious repercussions for businesses

Demand of SNFs for WFP is already largely addressed by current production

Increase in number and geographic footprint of suppliers adds complexity

Rather than a question of supplies or costs, which often disfavor local production, the initiative is geared towards development, benefiting

beneficiaries, consumers and the local economy

1 2

Local production is more complex to manage, it should be employed from a development, long term perspective

Central Gonja -rural

Bolgatanta - urban

LoFAIN pilot

Example from Ghana, increasing the availability and ‘market’ for special foods for children aged 6-23 months, starting with creating demand

• Demand: public sector (WFP) - 3,000 children aged 6-23

months

• Supply: LNS-SQ (GrowNut from PPB)

• Distribution using e-vouchers using the WFP SCOPE platform

• Distribution channels:

• Retail capacity for storing not (yet) adequate

• Distribution through pharmacies & reach-out by health

volunteers

• Using mobile points of sale devices

• Challenges with the e-vouchers & redemption

Local Food-based Approaches for Improved Nutrition (LoFAIN)

Central Gonja (also LoFAIN)

Yendi

Gushiegu

Sagnerigu

Zabzugu

East Mamprusi

Chereponi

ENVAC

Example from Ghana, increasing the availability and ‘market’ for special foods for children aged 6-23 months, starting with creating demand

• Support to manufacturers to ensure capacity to produce good quality special nutritious foods

• 20,000 children 6-23 mo, different SNFs:• LNS-SQ (in 2017-2018)• Supercereal Plus (SC+, by Yedent & Premium Foods) & possibly other

products

• 20,000 Pregnant and Lactating Women, different SNFs:• Tom Vita (developed & commercialised by Yedent – Obaasima seal)• Maizoya (to be produced by Premium Foods using SC specs)

• Retailers handle the products

• Distribution at health facilities to ensure beneficiaries access the relevant health services (antenatal, postnatal, child welfare clinics)

Enhanced Nutrition & Value Chains (ENVAC)

• Local manufacturing needs to be according to high standards, requires

investment and Technical Assistance

• Demand is required to ensure supply :

• Combine public sector & consumer demand

• Local manufacturers to have a portfolio of products for a range of

consumer groups (6-23 mo, women)

• Challenges:

• Consumer liking & affordability are key considerations for product

design, may require a compromise on ingredients and nutrient

content

• Institutional demand may be for very specific composition (LNS-SQ as

per researched formulation) whereas commercial product may be

different

• Outcome: increased nutrient intake or specific biological impact?

Lessons

Cost effectiveness of specialized food aid products – what do we know?

Beatrice Lorge Rogers

Friedman School of Nutrition Science and Policy

Tufts University



• Costing data needed for budgeting and program planning

• Breaking down cost by component identifies opportunities to

improve efficiency, reduce cost overall

• Beneficiary cost of participation can explain coverage, barriers

• Cost-effectiveness data needed to choose among alternative

designs

– Commodity selection

– Distribution modality

• Cost effectiveness requires identifying the desired impact

– But programs have multiple impacts; these need to be

considered18/10/2017 IUNS 21st International Congress of Nutrition 35

WHY DO WE NEED COST-EFFECTIVENESS

ANALYSIS?

• ”Cost” studies mention the cost of a given

program or intervention

• “Effectiveness” studies examine the impact of a

program or intervention on outcomes of interest

• “Cost-effectiveness” studies examine the cost per

outcome

11/15/2017 FOOTER GOES HERE 36

COST, EFFECTIVENESS, AND COST-

EFFECTIVENESS

• Cost of a program can’t be assessed without reference to effectiveness: a cheap, ineffective program is not cheap at all!

• But cost-effectiveness is one input into program design: it is one tool

• Other factors affect choice of program

–Who incurs the cost

–Political factors

–Administrative, logistic, budgetary considerations


COST, EFFECTIVENESS, AND COST-

EFFECTIVENESS

• Shadow pricing of donated inputs – labor, storage, transportation… why (and how) to include

• Beneficiary cost of participation – cost not incurred by the program

• Price volatility – commodities, storage, transportation

• Start-up vs. ongoing

• Effect on cost per beneficiary of scaling up

• Need for sensitivity and robustness analysis: test alternative assumptions

– Direct costs

– Size of program

18/10/2017 IUNS 21st International Congress of Nutrition 38

INCORPORATING COST-EFFECTIVENESS

INFORMATION INTO DECISION MAKING


PUBLISHED LITERATURESource: REFINEnutrition.org

11

132

30

20

40

60

80

100

120

140

Cost Effectiveness Cost-Effectiveness


ONGOING CLINICAL TRIALSSource: REFINEnutrition.org

0

39

6

0

5

10

15

20

25

30

35

40

45

Cost Effectiveness Cost-Effectiveness

Cost-effectiveness of CMAM vs. standard inpatient treatment

Findings:

• CMAM cost US $26/DALY averted

• Inpatient treatment: US $1344/DALY averted

• Cost to CMAM participants 1/6 of inpatient treatment cost (for the same effect)

Puett, C., Sadler, K., Alderman, H., Coates, J., Fiedler, J. L., & Myatt, M. (2012). Cost-effectiveness of the community-based management of severe acute malnutrition by community health workers in southern Bangladesh. Health Policy and Planning, 28(4), 386-399. doi:10.1093/heapol/czs070


COST-EFFECTIVENESS FOR ADVOCACY

– Cost-effectiveness of program changes to achieve target oil:CSB ratio in prepared porridge.


COST-EFFECTIVENESS FOR PROGRAM DESIGN

Intervention Cost per caregiver

reaching target ratio

Group 1 1 L Oil + 8kg bulk CSB + SBCC $391

Group 2 2.6 L Oil + 8kg bulk CSB + SBCC $527

Group 3 2.6 L Oil + 4 2kg packages CSB + SBCC $1,666

Rogers, B. L., Wilner, L. B., Maganga, G., Walton, S. M., Suri, D. J., Langlois, B. K., . . . Webb, P.

(2017). Program changes are effective and cost-effective in increasing the

amount of oil used in preparing corn soy blend porridge for treatment of

moderate acute malnutrition in Malawi. Maternal & Child Nutrition, 13(4).

doi:10.1111/mcn.12393

Cost Components for Cost-Effectiveness Analysis

Cost per

case

averted

Cost Components - Explanation

• These are variable costs of an ongoing program

• Need to add: fixed costs, start-up costs

• Cost per beneficiary falls as program scales up – in proportion to fixed costs

• Research is embedded into programming to capture on-the-ground realities

• Outputs of research provide tools for more cost-effective programming

“Rogers Law”

The effort to obtain cost data is inversely related to its contribution to total cost!

11/15/2017 44

• Repackaging

• Unloading (volunteer labor)

• Transporting food ‘the last mile’ (beneficiary cost)

45

Cost Components

Example from Burkina Faso Four Foods Study:

Cost per Treated Child by Component

$118 $123 $133 $118

$36 $34 $36

$39

$11 $11 $1

$2 $16

$28 $41

$85 $47

$98

$186

$190

$-

$50

$100

$150

$200

$250

$300

$350

$400

$450

CSB+ w/oil CSWB w/ oil RUSF SC+

Commodity Cost

International Freight and

ITSH Cost (loss-adjusted)

Repackaging and

Recoditioning cost (loss-

adjusted)

Distribution and

Programmatic Costs

(staff, administrative, and

opportunity cost)

Beneficiary Opportunity

Cost (transportation and

distribution time)

$227

$294

$396

$434

Cost Components: Beneficiary Opportunity Cost could be

substantial – Example from Burkina Faso Four Foods Study

Total Cost/Treated Child to Program and Beneficiaries: $227

Total Cost/Treated Child to

Program: $110

CSB+ 0% $0

CSWB -3% $67

SC+ 0% $153

RUSF -2% $207

-$100

-$50

$0

$50

$100

$150

$200

$250

-5% -4% -3% -2% -1% 0% 1% 2% 3%

Marg

inal P

rogra

m&

Beneficia

ry C

ost/

Child

Marginal Model-Adjusted Percent of Children Not Stunted at 24mo

Marginal Program Cost per Marginal Child

Not Stunted at 24mos. (Ref: CSB+) –Burkina Faso Four Foods Study

Less Effective More Effective

Less Cost

More Cost

CSB+ 0% $0

CSWB -7% $60

SC+ -2% $153

RUSF -2% $206

-$300

-$200

-$100

$0

$100

$200

$300

-15% -10% -5% 0% 5% 10%

Ma

rgin

al P

rog

ram

Co

st/

Ch

ild

Model-Adjusted Marginal Percent of Children Never Wasted

CSB+

CSWB

SC+

RUSF

Marginal Program Cost per Marginal Child

Never Wasted (Ref: CSB+) - Burkina Faso Four Foods Study

Less Effective More Effective

Less Cost

More Cost

This work was made possible through support provided by the Office of Food For Peace, Bureau for

Democracy, Conflict, and Humanitarian Assistance, U.S. Agency for International Development, under the

terms of Contract No. AID-OAA-C-16-00020. The opinions expressed herein are those of the author(s) and

do not necessarily reflect the views of the U.S. Agency for International Development.

50

Acknowledgement

Malawi and Burkina Faso Studies

• Cost-effectiveness analysis is critical for program design and

evaluation

–Achieving maximum effect for a given investment

–Selecting among alternative program components and delivery

modes

– Improving efficiency

–Advocating for the most cost-effective interventions

• But it is a tool, not “the answer”!


CONCLUSION

52

Thank you

Cost-effectiveness: how can we use what we know?

Tatyana El-Kour, MS, RDN, FAND Independent Practice



• Objective: review implications of findings from cost-effectiveness studies in food aid research for impactful nutrition practice:

– Practical considerations

– Key lessons learned


COST-EFFECTIVESS: HOW CAN WE USE WHAT

WE KNOW?

• Why consider cost-effectiveness now?

• Not enough progress achieved

• Challenge of doing more with less

• Need to address immediate effects as well as long-term goals



WE KNOW?

• What can cost-effectiveness achieve:

• Influence resource allocation decisions

• Support advocacy efforts

• Improve policy design

• Highlight partner and community contributions

• Inform programmatic evaluation and learning

• Improve the quality and efficiency of delivering nutrition care

• Estimate future nutrition care expenses



WE KNOW?

• Can cost-effectiveness findings be put in place in all countries?

– Affordability; i.e. is it really cheaper?

– Operational reality; i.e. how much, who to, and how?

• What do we need to do differently?

– Not all institutional contexts are the same

18/10/2017 58

COST-EFFECTIVESS: HOW CAN WE USE WHAT WE KNOW?

COST-EFFECTIVESS: HOW CAN WE USE WHAT WE KNOW?

• Implementation challenges

• Determining cost of items, characteristics of beneficiaries, food system environment

• Food aid mechanism and amount

• Approaches to handling cost and addressing administrative, operational, and contextual

complexity

• Country leadership and ownership

18/10/2017 59

• Key Considerations

– Underlying determinants of food and

nutrition

– Strategic and operational context

– Cross-cultural adaptation

– Gender-responsiveness.

• Future needs

– Advances in cost-effectiveness methodology

– Expanding use of technology for data

collection and utilization, and partnership

coordination

– Addressing socioeconomic, cultural, and

institutional factors

– Greater systematic integration of cost-

effectiveness approaches into mainstream

programming to affect nutrition and

population health response.



WE KNOW?

Are the right questions being addressed?

Are they being addressed in the right ways?

What else should be prioritized in this research domain?

Who else should be involved in such research?


For our deliberation

Documents

Food Aid Research: An Update on Food Aid ICN... · supplements (LNS) for prevention of malnutrition The International Lipid-Based Nutrient Supplements (iLiNS) Project Funded by the