The role of nutrition in pneumonia disease burden: an update of the evidence on GBD

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The role of nutrition in pneumonia disease
burden an update of the evidence on GBD

• Laura E. Caulfield, PhD
• Professor and Director
• Center for Human Nutrition
• Department of International Health
• The Johns Hopkins Bloomberg School of Public
  Health,
• Baltimore, Maryland USA

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What do we mean by nutrition?

• Overall malnutrition
• Low height for age (stunting)
• Low weight for age (underweight)
• Low weight for height (severe acute malnutrition)
• Low birth weight at term
• Zinc deficiency
• Iron deficiency and anemia
• Vitamin A deficiency
• Iodine deficiency
• Suboptimal breastfeeding

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What do we mean by pneumonia disease burden?

• What are the risks of morbidity and mortality for
  those with the risk factor as compared to those
  without the risk factor (RR or OR)?
• How many have the risk factor (prevalence)?
• Population attributable risk (PAR), fraction of
  morbidity or mortality attributable to the risk
  factor
• Loss of healthy life from premature mortality
  measured as years of life lost YLL
• Loss of healthy life from time lived in states of
  less than perfect health measured as years lived
  with disability YLD
• What is the minimal level of risk? Where are we
  trying to get to?
• DALY YLL YLD

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Undernutrition and the global burden of disease
(GBD) Comparative Risk Assessment (CRA)
(published in 2005)
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Disease Control Priorities in Developing
Countries (2006)

• Reformulated prevalence of underweight,
  deficiencies of iron, vitamin A and zinc for
  World Bank regions
• Re-attributed deaths and DALYS for World Bank
  regions
• Examined program effectiveness, costs and cost
  benefit
• Considered economic costs of malnutrition

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Underweight and ALRI deaths in childhood(Caulfiel
d et al., 2004)
Underweight (lt -1 Z) contributes to 52 of
pneumonia deaths
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Global distribution of disease burden
attributable to 20 selected risk factors
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Lancet Series on Maternal and Child
Undernutrition in 2007

• Maternal and Child Undernutrition
• Global and Regional Exposures and Health
  Consequences
• Writing team
• Black, Allen, Bhutta, Caulfield, de Onis, Ezzati,
  Mathers, Rivera
• Objectives
• Determine risks using the new WHO 2006 growth
  standards
• Consider stunting and wasting vis-a-vis
  cause-specific mortality and morbidity
• Adjust for confounding by socioeconomic factors
• Evaluate risk of neonatal deaths by cause among
  term infants with intra-uterine growth
  restriction
• Estimate disease burden in child deaths and DALYs
• Present new disease burden estimates by UN region

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Data sets to re-estimate RR

• 8 data sets (subset of previous data sets)
• Ghana
• Senegal
• Guinea Bissau
• The Philippines
• India
• Nepal
• Bangladesh
• Pakistan

• Obtained the data sets
• Applied the new WHO reference
• Examined HAZ, WAZ, WHZ and risk of mortality by
  cause by categories (lt -3, -3 to -2, -2 to -1, gt
  -1 (reference)
• Generalized linear models to estimate RR (95 CI)
• Weighted/adjusted for site

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Overall and Cause-Specific Mortality Risk for
Stunting in Children lt5y Old
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Overall and Cause-Specific Mortality Risk for
Wasting in Children lt5y Old
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Prevalence of Stunting Among Children lt5y Old
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Stunting and Severe Wasting in Children lt5 y Old
by World Region
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General conclusions on overlap of stunting and
wasting

• Prevalences of severe wasting are higher at early
  ages and decline and plateau by 24 months
• Among the youngest children, the proportion of
  those severely wasted who are NOT stunted is
  high, 80-100
• Among older children, the proportion of those
  severely wasted who are not stunted is 40-50
• In the analysis of the 36 countries with highest
  prevalences of stunting, prevalence of severe
  wasting ranges from 0.1 to 11.9, which is the
  range across all countries

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What about the newborn baby? What does it mean
to be underweight at birth?
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Causes of neonatal deaths (WHO 1998)

• Transitions at birth
• cardiac function and the circulatory system
• continuous respiration
• thermoregulation
• oral feeding
• independent glucose homeostasis
• Increasingly independent immune function

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Definitions

• Low birth weight (LBW) lt 2500 g
• Small for gestation (SGA) or intrauterine growth
  retardation (IUGR) lt 10th percentile of weight
  for gestation
• Preterm delivery lt 37 completed weeks gestation
• LBW-term LBW gt 37 completed weeks gestation

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Intra-Uterine Growth Restriction by World Region
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Birth weight and log NMR
Note Exclude those born lt 1500 g to exclude
deaths due to prematurity
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Overall and Cause-Specific Neonatal Mortality
Risk for Intra-Uterine Growth Restriction
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National Risk of Zinc Deficiency Based on
Prevalence of Stunting Among Children lt5y Old
and Absorbable Zinc Content of the Food Supply
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Meta-analysis of zinc supplementation and
diarrhea and respiratory infectionsAggarwal,
Sentz and Miller (submitted)

• Zinc supplementation lasting 90 days or more,
  weekly or daily supplements, placebo controlled,
  random allocation, blinding to allocation,
  rigorous case definition
• 12 studies to examine ARI
• 4 studies to examine ALRI
• 4 studies to examine days with ARI
• Standard meta-analysis techniques used

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Meta-analysis of rate ratios of incidence of
respiratory illness episodes in children
receiving zinc supplementation or a placebo
Source Aggarwal, Sentz, Miller (submitted)
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Meta-analysis of rate ratios of incidence of
episodes of lower respiratory tract infection or
pneumonia in children receiving zinc
supplementation or a placebo
Source Aggarwal, Sentz, Miller (submitted)
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Meta-analysis of rate ratios of number of days
with respiratory illness in children receiving
zinc supplementation or a placebo
Source Aggarwal, Sentz, Miller (submitted)
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Percentage of Children by Breastfeeding Pattern,
Age Group and Region
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Overall and Cause-Specific Mortality Risk for
Sub-optimal Breastfeeding in Children 0-23 Mo Old
0-5 mo
6 23 mo
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Global Deaths and Disability-Adjusted Life Years
(DALYs) in Children 0-23 Mo Old Attributed to
Suboptimal Breastfeeding
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Effectiveness of Interventions

• Breastfeeding promotion and support costs
  100-200 per death averted 3-10 per DALY gained
  
• Nutrition education programs cost 250-1200 per
  death averted 8-45 per DALY gained
• Vitamin A capsule distribution costs 160-300 per
  death averted 6-12 per DALY gained
• Iodine fortification costs 1000 per death
  averted 34-36 per DALY gained
• Zinc treatment of diarrhea along with ORS costs
  2100 per death averted 73 per DALY gained
• Iron fortification costs 2000 per death averted
  70 per DALY gained

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Additional Annual Running Costs of Nutritional
Interventions at Universal Coverage

• Promotion of breastfeeding 414 million
• Promotion of complementary feeding 158 million
• Zinc supplementation 301 million
• Total 1 billion (0.28 per capita in developing
  countries) to prevent 2.4 million deaths

From Bryce et al., Lancet 2005
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Top 10 LRI DALY Countries by Risk Factor
NOTE Bolded represent 50 of DALY due to that
risk factor India alone 47 India alone 46