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Hauke Hillebrandt

An Update on Project Healthy Children

An update on the effectiveness of the micronutrient fortification programmes by Project Healthy Children (PHC) (Working Paper)

Hauke Hillebrandt, Ph.D., Mark Engelbert, Ph.D.

Project Healthy Children (PHC) is a charity that we began investigating in recent years, and it has been one of our promising charities for nearly 2 years.

 in the past and also written an introduction on 

 . Our colleagues at Givewell have not officially reviewed PHC, but provide a great overview in form of a 

 with PHC’s Chief operating officer, Laura Rowe. Givewell has also published extensive intervention reviews on Micronutrient fortification as implemented by Project Healthy Children ( 

 ). Finally, they have also written reports on organisations similar to PHC, such as 

 . These programmes are generally considered to be very effective and some of the effectiveness analyses are generalizable to PHC.

In this paper, we give you an update about their efforts that we feel complement Givewell’s intervention reports and our previous report. You can find more general information about PHC on our 

 . In our opinion, PHC continues to be a very promising charity with potentially a very high cost-effectiveness.

Recent Scientific findings that relate to PHC’s effectiveness

Differences between micronutrient supplementation and fortification

To begin, note that there is a difference between micronutrient supplementation and micronutrient fortification. Micronutrient supplementation is here defined as taking capsules or foodstuffs (such as biscuits) that are specifically made to increase micronutrient status of the person eating it, whereas fortification means that commonly eaten staple foods are enriched with micronutrients. Although the aim of this report is to examine the effectiveness of micronutrient fortification, the close relation between supplementation and fortification means that sometimes results from micronutrient supplementation can provide insight into the effectiveness of fortification. Supplementation of all foods is often not as viable or as cost-effective as fortification. Also a recent study suggests that in pregnant adolescents, prenatal supplements cannot fully compensate for preexisting dietary deficiencies 

 ; thus, even if supplementation could be cost-effectively distributed to whole populations, it might still be less effective at improving nutritional outcomes than a continuous diet of enriched food by means of micronutrient fortification. Finally, there is also 

 fortification, which is increasing the micronutrient content of plants directly, which will not be discussed here.

General considerations of micronutrient fortification

A recent systematic review of 201 studies on the impact of micronutrient fortification of food and on woman and child health 

 , concludes that fortification is promising, but because of high burdens of diarrhea and intestinal inflammation, widespread malabsorption may decrease its effectiveness. Further, even though fortification is potentially an effective strategy, evidence from the developing world is scarce and future programs should measure the direct impact of fortification on morbidity and mortality.

While underweight is the number-one contributor to the burden of disease in sub-Saharan Africa 

 , nutritional deficiencies make up a large part of the overall 

 disease and disability burden in developing countries (see 

 . However, nutritional deficiencies are linked to other diseases (see 

, and so over 50% of years lived with disability in children can be traced to these deficiencies 

 Overall “Years Lost due to Disability (YLD)” in developing countries. Nutritional deficiencies are marked in black and make up 7.89% of the total YLDs. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

Institute for Health Metrics and Evaluation

 (Global burden of Disease data 2010, released 3/2013)

Updates from countries in which PHC is currently active

The following updates are quotes from the World Bank’s 2013 ‘Nutrition at a Glance’ country reports of those countries in which PHC is active.

Annually, Rwanda loses nearly US$50 million in GDP to vitamin and mineral deficiencies.

Scaling up core micronutrient interventions would cost US$6 million per year.

52% of children under the age of five are stunted, 16% are underweight, and 5% are wasted. 6% of infants are born with a low birth weight. Rwanda’s progress over the past two decades has not improved to meet MDG 1c (halving 1990 rates of child underweight by 2015) with business as usual.

Rwanda performs worse than countries in its region and income group. Countries with lower per capita incomes, such as Togo and DRC exhibit reduced rates of child stunting.

Rwanda has Higher Rates of Stunting than Lower-Income Peers GNI per capita (US$2008).

 Figure shows risk factors for “Disability adjusted life years” in Rwanda. Micronutritional deficiencies, such as Iron, Zinc, and Vitamin A deficiencies, are substantial risk factors. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

Annually, Malawi loses over US$600 million in GDP to vitamin and mineral deficiencies. Scaling up core micronutrient interventions would cost less than US$9 million per year.

Malawi has the 5th-highest stunting rate in the world. 53% of children under the age of five are stunted, 15% are underweight, and 4% are wasted. 13% of infants are born with a low birth weight. Malawi’s progress over the past two decades has not improved to meet MDG 1c (halving 1990 rates of child underweight by 2015) with business as usual.

Malawi’s stunting rates are higher than many of its income peers in Africa. While per capita income is very low in Malawi, other countries show that it is possible to reduce stunting with the same or lower GNI.

 Figure shows risk factors for “Disability adjusted life years” in Malawi. Micronutritional deficiencies, such as Iron, Zinc, and Vitamin A deficiencies, are substantial risk factors. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

Annually, Liberia loses over US$11 million in GDP to vitamin and mineral deficiencies. Scaling up core micronutrient nutrition interventions would cost US$2 million per year

39% of children under the age of five are stunted, 19% of children under the age of five are underweight, and 8% are wasted.

Liberia will not meet MDG 1c (halving 1990 rates of child underweight by 2015) with business as usual. 14% of infants are born with a low birth weight.

Liberia’s stunting rates are higher than many countries in the Africa region with similar per capita income.

 Figure shows risk factors for “Disability adjusted life years” in Liberia. Micronutritional deficiencies, such as Iron, Zinc, and Vitamin A deficiencies, are substantial risk factors. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

Annually, Burundi loses US$30 million to vitamin and mineral deficiencies. Scaling up core micronutrient interventions would cost US$4 million per year.

53% of children under the age of five are stunted, 35% are underweight, and 7% are wasted. 11% of infants are born with a low birth weight...the prevalence of stunting is substantially higher in Burundi compared to other countries in the Africa region with similar per capita incomes. It is possible to achieve better nutrition outcomes despite low income.

 Figure shows risk factors for “Disability adjusted life years” in Burundi. Micronutritional deficiencies, such as Iron, Zinc, and Vitamin A deficiencies, are substantial risk factors. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

Annually, Zimbabwe loses nearly US$24 million in GDP to vitamin and mineral deficiencies. Scaling up core micronutrient interventions would cost less than US$8 million per year.

33% of children under the age of five are stunted, 12% are underweight, and 7% are wasted. 11% of infants are born with a low birth weight. Zimbabwe is currently not on track to meet MDG 1c (halving 1990 rates of child underweight by 2015) with business as usual. When overall rates of child stunting are examined, Zimbabwe performs better than countries in its region and income group. However, within the country, there is likely to be variation across geographies and socio-demographic groups.

 Figure shows risk factors for “Disability adjusted life years” in Zimbabwe. Micronutritional deficiencies, such as Iron, Zinc, and Vitamin A deficiencies, are substantial risk factors. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

Annually, Sierra Leone loses over US$28 million in GDP to vitamin and mineral deficiencies. Scaling up core micronutrient interventions would cost less than US$4 million per year.

36% of children under the age of five are stunted, 21% are underweight, and 10% are wasted. Almost 1 in 4 infants are born with a low birth weight. Sierra Leone will not meet MDG 1c (halving 1990 rates of child underweight by 2015) with business as usual.

Sierra Leone exhibits higher rates of child stunting relative to some other countries with similar per capita income. That Zimbabwe, The Gambia, and Togo have much lower stunting rates demonstrates that it is possible to achieve better nutrition outcomes despite low income.

 Figure shows risk factors for “Disability adjusted life years” in Sierra Leone. Micronutritional deficiencies, such as Iron, Zinc, and Vitamin A deficiencies, are substantial risk factors. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

Cost-effectiveness of different micronutrient fortification interventions

Even though there are some uncertainties with regard to estimating the cost-effectiveness of micronutrient fortification programmes and there is variation in cost-effectiveness across programmes 

 , fortification is generally considered to be a very cost-effective intervention. Early estimates suggested that fortification with iron, vitamin A and zinc were well below $100 per DALY averted (see 

 Comparison of cost effectiveness of fortification in East Africa. Figure adapted from 

A 2006 report from the Disease Control Priorities Project suggests that overall cost-effectiveness is US$66 to US$70 per DALY averted for iron fortification programs and US$34 to US$36 per DALY averted for iodine fortification programs 

There is now a vast literature on the cost effectiveness of micronutrient fortification. A recent review article 

 on the economics of nutrition summarizes the evidence of cost-effectiveness for different micronutrient programmes (see Table 2 of this review for a summary of research papers on the topic 

 ). Two studies from this paper provide $ per DALY averted estimates of fortification programmes:

Folic acid fortification in Chile: costs per neural tube defect case and infant death averted were I$1,200 

 and I$11,000, respectively; cost per DALY averted was I$89; net cost savings of fortification were I$2.3 million

Vitamin A fortification of edible oils and sugar in Uganda: Cost per DALY averted is US $82 for sugar fortification and $18 for oil fortification

A 2009 review by John Fiedler and Barbara MacDonald 

 provides cost-per-DALY-averted estimates for micronutrient fortification programmes in many countries. Although these were not programmes implemented by PHC, they were adopted in many of the same countries where PHC operates. Thus, these data provide some indication of likely cost effectiveness levels that can be expected for similar programmes implemented by PHC in these same countries. 

 are adapted from Fiedler and MacDonald’s review to show only countries in which Project Healthy Children is currently operating. These estimates suggest high cost-effectiveness at around $100 per DALY averted, similar to previous high cost-effectiveness estimates of fortification programmes in other countries (see 

 summarizes key statistics for micronutrient programmes in a number of countries in which PHC operates, along with each programme’s ranking among worldwide programmes in terms of cost effectiveness. For instance, wheat fortification in Malawi was the 16th most cost-effective food fortification programme in the world. Taken together, these data indicate that PHC operates in countries where micronutrient fortification programmes have proved to be cost-effective. It should be noted, however, that this table is from 2009, and it is possible that many of the most cost-effective programmes (i.e., the ‘low hanging fruit’) have in the meantime been executed.

 Total incremental 10-year cost and cost per DALY averted arrayed alphabetically by countries in which PHC operates in. Figure adapted from 

 The ranking of the countries PHC is active in from a table of the 60 countries’ micronutrient interventions arrayed by cost per DALY averted. Table adapted from 

In sum, even though these cost-effectiveness estimates are subject to limitations (i.e., up-to-date cost-effectiveness estimates of the exact fortification programmes that PHC conducts are unavailable, and cost-effectiveness estimates are sometimes uncertain and difficult to compare), overall we believe that that the available evidence suggests PHC’s cost-effectiveness is roughly similar to the reported estimates—in other words, that PHC’s programmes are highly cost-effective.

Nutritional deficiencies have been shown to have negative economic consequences. Out summary of these effects draws from several recent studies, including the Global Nutrition Report 2014 

 . Note that micronutrient deficiencies only account for 

 of the economic losses from nutritional deficiencies—macronutrient deficiencies (i.e., hunger) also contribute to these losses.

A study from Guatemala suggests that preventing undernutrition in childhood increases productivity in several ways. Specifically, preventing undernutrition increases hourly earnings by 20% and wage rates by 48%. Moreover, children treated for undernutrition are 33% more likely to escape poverty, while treated girls are 10% more likely to own a business as adults 

 . Stunted growth or stunting, is a reduced growth rate in human development due to nutritional deficiencies, is highly prevalent in developing countries (see 

 ) and a significant contributor to lost productivity. Analyses suggest that growth failure in early life has profound adverse consequences over the life course on human, social, and economic capital 

 . One study in particular showed that one extra centimeter of adult height corresponds to a 4.5% increase in wage rates 

 . Low birth weight is also associated with increased risk of hypertension and kidney disease in later life; however, micronutrient supplementation during pregnancy reduces the risk of low birth weight and prematurity 

 Stunting among children under 5: latest national prevalence estimates. Figure taken from 

Economic analyses suggest that undernutrition within a country lowers the overall economic productivity of that country. Specifically, undernutrition has been suggested to lower GDP for Egypt by 1.9%; Ethiopia, 16.5%; Swaziland, 3.1%; and Uganda, 5.6% 

 . Asia and Africa lose 11% of GNP every year owing to poor nutrition 

 . One recent study suggests that, in Cambodia, malnutrition costs more than US $400 million annually, corresponding to -2.5% of the country’s GDP. In Pakistan, protein malnutrition, iodine deficiency and iron deficiency collectively accounted for about 3–4% of gross domestic product (GDP) loss annually 

 . A study of 10 developing countries suggest that iron-deficiency anaemia causes an average loss of 4.5% of GDP 

A recent World Bank study estimated that investing in nutrition can increase a country’s GDP by at least 3 percent annually 

 . The same study concluded that global benefit-to-cost ratio of micronutrient powders for children is 37 to 1; of deworming it is 6 to 1; of iron fortification of staples it is 8 to 1; and of salt iodization is 30 to 1 

We have calculated the average benefit-to-cost ratio of fortification programmes in the countries where PHC is active. Using the World Bank’s estimates of the economic on GDP loss annually to vitamin and mineral deficiencies alone 

 that the average benefit-to-cost ratio in these countries is about 23:1. In other words, the cost of scale-up for fortification programmes is 23 times smaller than the economic benefits. Other researchers have found similarly high estimates of cost-effectiveness: a recent paper 

 looked at the value of stunting-reducing nutrition investments, such as micronutrient fortification, in 17 high-burden countries. The benefit-to-cost ratios ranged from 3.6 (Democratic Republic of Congo) to 48 (Indonesia) with a median value of 18 (Bangladesh). Another recent paper 

 finds similarly impressive benefit-cost ratios for iodizing salt (80), iron supplements for mothers and small children (24), vitamin A supplementation (13), and zinc supplementation for children (3). Thus, these estimates in the literature are broadly comparable to our calculations.

Effects of micronutrients for mental development

A review and meta-analysis of 21 interventions examined the effects of multiple micronutrients on mental development, and yielded a very small but significant overall effect size of d = 0.09 

 . However, even small effect sizes can translate to very high cost-effectiveness, so long as the effects are robust and the interventions are very cheap to implement. However, it is very difficult to estimate the exact cost-effectiveness.

 Forest plot for effect sizes (standard mean difference represented as a red square and 95% confidence interval represented as red lines) of nutrition on the mental development of children. Overall effect size was 0.086 (95% CI 0.034, 0.137).

Moreover, another recent study showed that across several countries improving linear growth in children under two years of age by 1 standard deviation adds about half a grade-level to school attainment 

Micronutrient supplementation for children with HIV infection

A recent systematic Cochrane review summarized the available evidence on micronutrient supplementation for children with HIV infection 

 . The authors conclude that both Vitamin A and zinc supplementation are safe and carry benefits for children with HIV infection (in particular, zinc appears to have similar benefits in terms of reducing death due to diarrhea in children with HIV as in children without HIV infection. Finally, Cochrane suggests that multiple micronutrient supplements have some clinical benefit in poorly nourished, HIV-infected children.

Recent research on fortification with specific micronutrients

Iodine deficiency disorders are prevalent in many African countries (see 

 ), where they make up a substantial part of the overall disease burden (see 

 Iodine nutrition based on the median urinary iodine concentration, by country 

 . Disability-adjusted life years (DALYs) (thousands) lost due to iodine deficiency in children younger than 5 years of age, by region 

 Overall “Years Lost due to Disability (YLD)” in developing countries. Iodine deficiency are marked in black and make up 0.56% of the total YLDs. Figure adapted with ‘Global Burden of Disease Compare tool’- see 

An Update on Project Healthy Children — Part II

This post continues our update on Project Healthy Children.

Vitamin A deficiency is the leading cause of preventable blindness in children and increases the risk of disease and death from severe infections 

 . In the recent Lancet series on maternal and child undernutrition, deficiencies of vitamin A were estimated to be responsible for 600,000 deaths per year, and together with zinc deficiency, a combined 9.8% of global childhood Disability-Adjusted Life Years (DALYs) (most deaths were due to diarrhea and measles: see 

 . Given that PHC’s work in Burundi has led to the start of vegetable oil fortification with vitamin A 

 , below we review the evidence for the cost-effectiveness of vitamin A fortification programmes.

Vitamin A fortification has been shown to be very cost-effective. A recent study from Uganda showed that the cost-per-DALY-averted for vitamin A fortification is only US $82 for sugar fortification and $18 for oil fortification 

 . A recent study suggested that even during prolonged deep frying with cooking oil, 45% of the fortified vitamin A remains intact, which is sufficient to meet daily requirements 

 . In line with this, a recent correlational study finds that it is strongly plausible that oil fortified with vitamin A increases vitamin A status in Indonesian women and children 

Givewell has extensively reviewed Vitamin supplementation interventions 

 that found no reduction of mortality. This trial has led some researchers to suggest that Vitamin A policies should be revised, and that there should be more of an emphasis on vitamin A 

 . Other researchers have pointed to some severe limitations of the large trial and suggest that abandonment of vitamin A supplementation programmes is not prudent 

 . Moreover, an accompanying meta-analysis 

 suggested that taking into account all available evidence—including the large trial—simply yields a smaller estimate of 11% mortality reduction (rather than 25% as previously assumed). Benefits of vitamin A fortification are well established in western countries 

 and a Cochrane review to examine the effects of staple food fortification with vitamin A for preventing vitamin A deficiency is currently being conducted 

Figure 16: Overall “Disability Adjusted Life Years (DALYs)” lost in developing countries. Vitamin A deficiency direct impact is marked in black and make up 0.038% of the total DALYs. Risk factor attributions of Vitamin A deficiency for other diseases are in red. For instance, Vitamin A deficiency accounts for 10% of the risk factor of DALYs lost to do Diarrhea and 15% of DALYs lost due to Measles. Figure adapted with ‘Global Burden of Disease Compare tool’- see

(Global burden of Disease data 2010, released 3/2013)

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