Jörg Spieldenner

Dietary strategies for improving iron status: balancing safety and efficacy

In light of evidence that high-dose iron supplements lead to a range of adverse events in low-income settings, the safety and efficacy of lower doses of iron provided through biological or industrial fortification of foodstuffs is reviewed. First, strategies for point-of-manufacture chemical fortification are compared with biofortification achieved through plant breeding. Recent insights into the mechanisms of human iron absorption and regulation, the mechanisms by which iron can promote malaria and bacterial infections, and the role of iron in modifying the gut microbiota are summarized. There is strong evidence that supplemental iron given in nonphysiological amounts can increase the risk of bacterial and protozoal infections (especially malaria), but the use of lower quantities of iron provided within a food matrix, ie, fortified food, should be safer in most cases and represents a more logical strategy for a sustained reduction of the risk of deficiency by providing the best balance of risk and benefits. Further research into iron compounds that would minimize the availability of unabsorbed iron to the gut microbiota is warranted.

Meta-analysis of a partially hydrolysed 100%-whey infant formula vs. extensively hydrolysed infant formulas in the prevention of atopic dermatitis.

Abstract Objectives: This study presents previously unpublished point and cumulative incidence rates and relative risks (RRs) for comparing a partially hydrolysed 100% whey-based infant formula, NAN-HA* (PHF-W) to extensively hydrolysed whey- (EHF-Whey) or casein-based (EHF-Casein) infant formulas in the prevention of atopic dermatitis (AD) in infants who cannot be breastfed exclusively. It also outlines methods to convert the above-mentioned data as well as data comparing PHF-W to cows’ milk formula (SF) into inputs to be applied to a pharmacoeconomic model. * NAN-HA is a registered trade name of Nestlé SA, Switzerland. Methods: The incidence rates and RRs were obtained from a meta-analysis which analysed efficacy for PHF-W vs. EHF but did not present those. It took into consideration any relevant randomized controlled trial which compared the use of PHF-W with SF or EHF for the prevention of allergies. The primary outcomes of interest were the incidence, cumulative incidence and period prevalence of allergic manifestations and of AD in particular. Fifteen studies had been included for analysis of which six studies explored PHF-W vs. EHF. These results and PHF-W vs. SF data were adapted for inputs into a pharmacoeconomic model which used a spreadsheet decision-analytic economic model based on 3-month cycles to explore the cost-effectiveness of PHF-W vs. SF and EHF. Weights were applied to the incidence rates and RRs for each reported time period which were then adapted into 3-month indicators. Results: This meta-analysis for PHF-W (557 patients) vs. EHF-Whey (559 patients) yielded RR of 0.75 (0.54, 1.05) and 0.80 (0.63, 1.02) at 0–12 months and at 0–36 months, respectively. Corresponding RRs for PHF-W vs. EHF-Casein (580 patients) were 1.06 (0.74, 1.53) at 0–12 months and 1.13 (0.87, 1.47) at 0–36 months. Conclusion: It appears that the efficacy of PHF-W falls within the range of that of both EHF formulas (whey and casein) and allows the application of these results in a pharmacoeconomic model.

Economic evaluation of a 100% whey-based, partially hydrolysed formula in the prevention of atopic dermatitis among French children

Abstract Objective: A pharmacoeconomic analysis was performed to determine costs, consequences and cost effectiveness of a partially hydrolysed 100% whey-based infant formula, NAN HA, manufactured by Nestlé S.A, Switzerland (PHF-W) and branded under Nidal Excel HA in France, in the prevention of atopic dermatitis (AD) in ‘at risk’ children when compared to standard cows’ milk formula (SF) in France. Methods: A decision-analytic economic model depicting AD treatment pathways, as well as resource utilisation and costs associated with the treatment of AD in healthy yet ‘at risk’ French newborns who cannot be exclusively breastfed was constructed for a 12-month time horizon, including an initial 6 months of intervention with formula consumption. Model inputs were based on the literature, official formularies and expert opinion. The modelled treatment pathways included a dietary management approach (formula change), a medical treatment approach and a combination thereof. The final outcome was the expected cost per avoided case of AD, yielding an incremental cost per avoided case (ICER) of AD when comparing subjects who used PHF-W versus SF. Outcomes were presented from three perspectives: the French Ministry of Health (MOH), the subjects’ family and society as a whole. A secondary analysis also compared PHF-W to extensively hydrolysed formula (EHF) in prevention. Results: The number of avoided AD cases by selecting PHF-W over SF was 13 356 cases in a birth cohort of 185 298 ‘at risk’ infants. The base case analysis, at 65% reimbursement, yielded expected ICERs of €1343, € –624 (savings) and €719 from the MOH, family and societal perspectives, respectively. From all three perspectives, the highest cost was attributable to formula. In case of a 35% reimbursement rate for PHF-W, the ICER was €615 from the MOH perspective, while the use of PHF-W was cost neutral at 10% reimbursement. PHF-W was cost-saving against EHF (€98–€116 million savings depending on type of EHF), when this latter was used in prevention. One-way and probabilistic sensitivity analyses confirmed the robustness of the model. Conclusion: Under a certain range of assumptions, this analysis based on predictive modelling has established the cost effectiveness of PHF-W in the prevention of AD in infants.

Cost-effectiveness of partially-hydrolyzed formula for prevention of atopic dermatitis in Australia.

Abstract Objective: To perform an economic evaluation of a specific brand of partially hydrolyzed infant formula (PHF-W) in the prevention of atopic dermatitis (AD) among Australian infants. Methods: A cost-effectiveness analysis was undertaken from the perspectives of the Department of Health and Aging (DHA), of the family of the affected subject and of society as a whole in Australia, based on a decision-analytic model following a hypothetical representative cohort of Australian newborns who are not exclusively breastfed and who have a familial history of allergic disease (i.e., are deemed ‘at risk’). Costs, consequences, and incremental cost-effectiveness ratios (ICER) were calculated for PHF-W vs standard cow’s milk based infant formula (SF), and, in a secondary analysis, vs extensively hydrolyzed infant formula (EHF-Whey), when the latter was used for the prevention of AD. Results: From a representative starting cohort of 87,724 ‘at risk’ newborns in Australia in 2009, the expected ICERs for PHF-W vs SF were AU

Partially Hydrolysed 100% Whey-Based Infant Formula and the Prevention of Atopic Dermatitis: Comparative Pharmacoeconomic Analyses

496 from the perspective of the DHA and savings of AUD1739 and AU

Nutrient profiling for product reformulation: public health impact and benefits for the consumer

1243 from the family and societal perspectives, respectively. When compared to EHF-Whey, PHF-W was associated with savings for the cohort of AU

Maternal nutrition: opportunities in the prevention of gestational diabetes

5,183,474 and AU

Industry Approach to Nutrition-Based Product Development and Reformulation in Asia

6,736,513 from the DHA and societal perspectives. Limitations: The generalizability and transferability of results to other settings, populations, or brands of infant formula should be made with caution. Whenever possible, a conservative approach directing bias against PHF-W rather than its comparators was applied in the base case analysis. Assumptions were verified in one-way and probabilistic sensitivity analyses, which confirmed the robustness of the model. Conclusions: PHF-W appears to be cost-effective when compared to SF from the DHA perspective, dominant over SF from the other perspectives, and dominant over EHF-Whey from all perspectives, in the prevention of AD in ‘at risk’ infants not exclusively breastfed, in Australia.

Health Economic Perspectives of Pediatric Malnutrition: Determinants of Innovative Progress

Clinical trials have demonstrated that the risk of developing atopic dermatitis is reduced when using hydrolysed formulas to feed infants with a documented risk of atopy (i.e. an affected parent and/or sibling)when breastfeeding is not practised. However, little is known about the cost-effectiveness of using hydrolysed formulas. Consequently, economic analyses in 5 European countries (Denmark, France, Germany, Spain and Switzerland) have evaluated the costs and cost-effectiveness of a specific brand of 100% whey-based partially hydrolysed infant formula, NAN-HA® (PHF-W) compared with a cow’s milk standard formula (SF) in the prevention of atopic dermatitis in at-risk children. This review synthesises the findings of these studies. Cost-effectiveness analyses (CEA) used a decision-analytic model to determine treatment pathways, resource utilisation and costs associated with the management of atopic dermatitis in healthy at-risk newborns who were not exclusively breastfed. The model had a 12-month horizon and applied reimbursement rates of 60–100% depending on the country. Outcomes were considered from the perspective of the public healthcare system (e.g. the Ministry of Health; MOH), family and society. The final outcome was the incremental cost-effectiveness ratio per avoided case of atopic dermatitis (ICER) for PHF-W versus SF. A cost-minimisation analysis was also performed to compare PHF-W with extensively hydrolysed formulas (EHF). The base-case CEA produced ICERs per avoided case for PHF-W versus SF of EUR 982–1,343 (MOH perspective), EUR –2,202 to –624 (family perspective) indicating savings, and EUR –1,220 to 719 from the societal perspective. The main costs related to formula (MOH and society) and time loss (family). In the cost-minimisation analysis, PHF-W yielded savings of between EUR 4.3 and 120 million compared with EHF-whey when the latter was used in prevention. In conclusion, PHF-W was cost-effective versus SF in the prevention of atopic dermatitis and cost saving compared with EHF when used in prevention.

The Food Industry as a Partner for Public Health

The food industry holds great potential for driving consumers to adopt healthy food choices as (re)formulation of foods can improve the nutritional quality of these foods. Reformulation has been identified as a cost-effective intervention in addressing non-communicable diseases as it does not require significant alterations of consumer behaviour and dietary habits. Nutrient profiling (NP), the science of categorizing foods based on their nutrient composition, has emerged as an essential tool and is implemented through many different profiling systems to guide reformulation and other nutrition policies. NP systems should be adapted to their specific purposes as it is not possible to design one system that can equally address all policies and purposes, e.g. reformulation and labelling. The present paper discusses some of the key principles and specificities that underlie a NP system designed for reformulation with the example of the Nestlé nutritional profiling system. Furthermore, the impact of reformulation at the level of the food product, dietary intakes and public health are reviewed. Several studies showed that food and beverage reformulation, guided by a NP system, may be effective in improving population nutritional intakes and thereby its health status. In order to achieve its maximum potential and modify the food environment in a beneficial manner, reformulation should be implemented by the entire food sector. Multi-stakeholder partnerships including governments, food industry, retailers and consumer associations that will state concrete time-bound objectives accompanied by an independent monitoring system are the potential solution.