Malnutrition and Child Mortality: How Micronutrients Can Help and Policy Options for Delivering Them
Hunger in childhood is especially devastating as it can lead to malnutrition, stunted growth and development, and even death. In sub-Saharan Africa today, 57 million children under the age of 5 suffer stunting due to severe malnutrition, according to the United Nations. And malnutrition contributes to about 45% of deaths in children under the age of 5 worldwide, according to the World Health Organization. While progress has been made in some regions, childhood hunger remains a major global concern, driven in large part by extreme poverty, conflict and climate change.
In 2015, all 193 U.N. member states adopted 17 goals known as the Sustainable Development Goals (SDGs) in “a universal call to action to end poverty, protect the planet, and improve the lives and prospects of everyone, everywhere” by 2030. Key SDGs include improving nutrition and reducing child mortality, with vulnerable populations in sub-Saharan Africa and South Asia being prime targets for action. Success in achieving these goals will require a collaborative effort by the international community, including national and local governments, donors, nongovernmental organizations (NGOs), industries, nutritionists, and economists.
One collaboration between nutritionists and economists is the subject of the 2023 paper “Impacts of Micronutrient Intervention Programs on Effective Coverage and Lives Saved: Modeled Evidence From Cameroon,” published in Annals of the New York Academy of Sciences. Karen Ortiz-Becerra, PhD, an assistant professor of economics at the University of San Diego Knauss School of Business, is among the researchers who modeled the effectiveness, costs, and cost-effectiveness of alternative micronutrient intervention programs (MIPs) for improving nutritional adequacy among children under the age of five and women of reproductive age and reducing child mortality in Cameroon.
Using this data on MIP effectiveness and costs, the study applied an economic optimization model to identify the most cost-effective MIPs for two different policy objectives over a 10-year horizon: improving dietary adequacy of critical micronutrients and saving children’s lives. “There are several MIPs that can improve dietary adequacy and save child lives to various degrees. We wanted to identify those that are most cost-effective since resources are limited,” Ortiz-Becerra says.
Key Insights
- Because money is tight and needs are great, modeling-informed micronutrient intervention programs (MIPs) prioritization is critical for policymakers working in Cameroon and other low- and middle-income countries to improve nutritional adequacy and reduce child mortality
- The MIPs currently underway in Cameroon were found by researchers to be largely cost-effective in achieving dietary adequacy of critical micronutrients
- However, in order to have a larger impact on reducing child mortality, researchers found it would be more cost-effective to shift some resources away from vitamin A supplementation to provide more zinc to young children and more folic acid to women of reproductive age
The Critical Role of Micronutrients in Health
Micronutrients are vitamins and minerals that, while required by the body in very small amounts, have a significant impact on child health and development. A deficiency in some of them can cause severe and even life-threatening conditions. Globally, low- and middle-income countries (LMICs) like Cameroon are overrepresented when it comes to micronutrient deficiencies. The study compared interventions that use various food/condiment vehicles to deliver different concentrations of the following micronutrients:
- Vitamin A, important for vision, immune system health, and child growth and development
- Zinc, required during pregnancy, infancy, childhood and adolescence for proper growth and development
- Folic acid, a B vitamin that’s especially important for pregnant women and fundamental to reducing neural tube defects
“We selected these three micronutrients because of their potential to save lives,” Ortiz-Becerra says. Major MIPs for addressing micronutrient deficiencies include supplementation and large-scale food fortification. The vehicles analyzed in this study include the fortification of wheat flour and bouillon cubes with zinc and/or folic acid and/or vitamin A, and the supplementation of young children with vitamin A through two different health service platforms.
Measuring the Benefits and Costs of Micronutrient Intervention Programs in Cameroon
Cameroon is noted for its geographic and climatic diversity and the availability of data on intake levels for critical micronutrients. A lower-middle-income country with a population of more than 28.6 million, Cameroon is located just north of the equator on the coast of West Africa. The country has four distinct topographical regions, including rainforest in the south and savannah in the north.
The paper modeled the national and subregional effectiveness of different MIPs using 24-hour dietary intake data from a 2009 survey of consumption and micronutrient status in Cameroon. Using a suite of modeling tools developed at the University of California, Davis that are collectively known as the Micronutrient Intervention Modeling (MINIMOD) Project, the research simulated the effective coverage and number of child lives saved for alternative sets of MIPs aiming at reducing inadequate intake of vitamin A and zinc for children, and of folic acid for women in reproductive age, some of which include the interventions that have been implemented in Cameroon in the past two decades (i.e., the business-as-usual scenario).
Effective coverage was calculated as the increase in adequate consumption of a given micronutrient thanks to one or more MIPs relative to the baseline intake, while the number of child lives saved was estimated using the Lives Saved Tool— a mathematical model that allows users to estimate the impacts of changes in coverage for one or more micronutrients on child mortality in LMICs.
Meanwhile, the cost estimates were obtained based on budgetary data from existing programs and expert knowledge from collaborators in the field. These costs were calculated for a time horizon of ten years, including a two-year scale-up period.
Cost-Effectiveness Modeling Method
Based on these benefits and cost data, the researchers apply an economic optimization model to identify the most cost-efficient MIPs to achieve two goals that are important for policymakers: saving child lives and attaining dietary adequacy of critical micronutrients. By comparing all the sets of possible MIPs over time and space, the model selects the interventions that are most cost-effective at each goal, subject to doing at least as well as the business-as-usual scenario.
To assess the robustness of the findings obtained with this economic model, the study uses a Monte Carlo process and calculates the likelihood of a change in the chosen set of economically optimal MIPs, when uncertainty in benefits and costs is taken into consideration. The economic optimization was conducted using a Python-based tool that Ortiz-Becerra jointly developed with the MINIMOD team, minimod-opt.
Key Study Findings
While the results of this study appear to confirm that the MIPs currently underway in Cameroon are largely cost-effective, room for improvement was found for achieving the goal of saving child lives. Specifically, after running all the various scenarios, the model found that it would be more cost-effective to shift some resources from vitamin A supplementation to providing more zinc to young children and more folic acid to women of reproductive age. Both vitamin A and zinc are instrumental in reducing diarrhea mortality, and they usually complement each other in doing so.
Currently, in what Ortiz-Becerra and her colleagues’ paper refers to as the business-as-usual scenario, there are two MIPs underway in Cameroon to deliver vitamin A — via cooking oil fortified with vitamin A and vitamin A supplements administered during child health days — and one intervention to deliver zinc via fortified wheat flour.
However, as the researchers document, it’s expensive to provide vitamin A via child health days nationwide. “Our findings suggest that it would be more cost-effective to regionally target the delivery of vitamin A supplementation and use the freed-up resources to add more zinc to children’s diets and more folic acid to women’s diets,” Ortiz-Becerra says. “By doing so, it would be possible to both save a larger number of children’s lives and at half the cost of the business-as-usual scenario.”
For policymakers and government and health officials in Cameroon, the key takeaways from this part of the MINIMOD Project regarding child lives saved is to focus on vitamin A supplementation in the north region (where needs are greatest and cost per child reached is lowest) and to increase the amounts of zinc and folic acid contained in wheat flour.
Next Steps in Micronutrient Research
The goal of the paper and, more broadly, the MINIMOD Project is to demonstrate how modeling can help predict the effects of ongoing, alternative, and different combinations of micronutrient intervention programs on the number of lives saved and the adequacy of dietary intake over a 10-year planning time horizon. Ortiz-Becerra joined the MINIMOD Project as a graduate student at UC Davis, where she earned her PhD in Agricultural and Resource Economics in 2022.
Ortiz-Becerra says the MINIMOD suite of modeling tools can help policymakers and health officials identify which critical micronutrients to deliver, in what concentrations, and via what delivery mechanisms to improve dietary intake and save child lives in the most cost-effective way. “By providing modeled evidence on the set of most cost-effective MIPs, these tools can help health officials choose from a broad set of possible programs,” she says.
Because money is tight and needs are great, modeling-informed MIP prioritization is critical for policymakers working in Cameroon and other LMICs, where women and children are at risk of inadequate dietary intake of key micronutrients. Currently, work is underway in Senegal, Burkina Faso, and Nigeria to address the same sets of issues using MINIMOD tools.
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Sources
CountryReports, Cameroon Geography
Food Insight, “A Brief History of Food Fortification in the U.S.”
Oxfam International, “Over 20 Million More People Hungry in Africa’s ‘Year of Nutrition’”
United Nations, Sustainable Development Goals
United Nations, The Sustainable Development Goals Report 2023
University of California, Davis, Micronutrient Intervention Modeling Project
The World Bank, The World Bank in Cameroon
World Health Organization, Child Health
World Health Organization, Micronutrients
World Population Review, Cameroon Population 2023 (Live)
Karen Ortiz-Becerra is an assistant professor of economics at the Knauss School of Business at the University of San Diego. Dr. Ortiz’s research examines the impacts of policies and technological innovations on local economies, with a special focus on employment, structural transformation, and welfare.