Cost-Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso: A Geographically Randomized Trial

Ilana R Cliffer, Laetitia Nikiema, Breanne K Langlois, Augustin N Zeba, Ye Shen, Hermann B Lanou, Devika J Suri, Franck Garanet, Kenneth Chui, Stephen Vosti, Shelley Walton, Irwin Rosenberg, Patrick Webb, Beatrice L Rogers, Ilana R Cliffer, Laetitia Nikiema, Breanne K Langlois, Augustin N Zeba, Ye Shen, Hermann B Lanou, Devika J Suri, Franck Garanet, Kenneth Chui, Stephen Vosti, Shelley Walton, Irwin Rosenberg, Patrick Webb, Beatrice L Rogers

Abstract

Background: There is a variety of specialized nutritious foods available for use in programs targeting undernutrition, but evidence supporting the choice of product is limited.

Objectives: We compared the cost-effectiveness of 4 specialized nutritious foods to prevent stunting and wasting in children aged 6-23 mo in Burkina Faso.

Methods: Four geographic regions were randomly assigned to 1 of 4 intervention arms: Corn-Soy Blend Plus (CSB+) programmed with separate fortified vegetable oil (the reference food), Corn-Soy-Whey Blend (CSWB; a new formulation) with oil, SuperCereal Plus (SC+), and ready-to-use supplementary food (RUSF). We compared the effects of each intervention arm on growth (length-for-age z score (LAZ), weight-for-length z score (WLZ), end-line stunting (LAZ < -2), and total monthly measurements of wasting (WLZ < -2). Rations were ∼500 kcal/d, distributed monthly. Children were enrolled in the blanket supplementary feeding program at age ∼6 mo and measured monthly for ∼18 mo. Average costs per child reached were linked with effectiveness to compare the cost-effectiveness of each arm with CSB+ with oil.

Results: In our sample of 6112 children (CSB+, n = 1519; CSWB, n = 1503; SC+, n = 1564; RUSF, n = 1526), none of the foods prevented declines in growth. Children in the SC+ and RUSF arms were not significantly different than those in the CSB+ with oil arm. Children in the CSWB with oil arm experienced higher end-line (measurement at age 22.9-23.9 mo) stunting (OR: 2.07; 95% CI: 1.46, 2.94) and more months of wasting (incidence rate ratio: 1.29; 95% CI: 1.09, 1.51). CSB+ with oil was the least-expensive ration in all costing scenarios ($113-131 2018 US dollars/enrolled child) and similar in effectiveness to SC+ and RUSF, and thus the most cost-effective product for the defined purposes.

Conclusions: CSB+ with oil was the most cost-effective ration in the prevention of wasting and stunting in this trial. This trial was registered at clinicaltrials.gov as NCT02071563.

Keywords: children; complementary feeding; corn-soy blend; cost-effectiveness; food aid; lipid-based nutrient supplements; low-income countries; stunting; supplementary feeding; wasting.

Copyright © The Author(s) 2020.

Figures

FIGURE 1
FIGURE 1
Map of food distribution sites and surrounding villages for the Food Aid Quality Review study in Sanmatenga Province, Burkina Faso, 2014–2016. CSB+, Corn-Soy Blend Plus; CSWB, Corn-Soy-Whey Blend; RUSF, ready-to-use supplementary food; SC+, SuperCereal Plus.
FIGURE 2
FIGURE 2
Cost calculations in study comparing the cost-effectiveness of 4 supplementary foods in the prevention of stunting and wasting. Dotted borders are where adjustments for losses incurred were made. CSB, Corn-Soy Blend; MT, Metric Ton.
FIGURE 3
FIGURE 3
Directed acyclic graph showing relations among intervention arms, outcomes, mediating factors, and potential confounders. BF, breastfeeding; CF, complementary feeding; CSB+, Corn-Soy Blend Plus; CSWB, Corn-Soy-Whey Blend; FDP, food distribution point; HH, household; RUSF, ready-to-use supplementary food; SBCC, social behavior change communication; SC+, SuperCereal Plus; SES, socioeconomic status.
FIGURE 4
FIGURE 4
Enrollment flow chart, children aged 6–23 mon, Sanmatenga Province, Burkina Faso. Values for distributions received are means ± SDs. Outcomes are stunting at endline (measurement between 22.9 and 23.9 mo) and monthly measurements of wasting throughout the study period. *Lost-to-follow-up only applicable for stunting models and defined as no endline measurement between 22.9 and 23.9 mo. CSB+, Corn-Soy Blend Plus; CSWB, Corn-Soy-Whey Blend; RUSF, ready-to-use supplementary food; SC+, SuperCereal Plus.
FIGURE 5
FIGURE 5
Adjusted marginal predictions from linear mixed-effects regression model for length-for-age z scores over time in children aged 6–27 mo in Sanmatenga Province, Burkina Faso, 2014–2016. Error bars are 95% CIs. CSB+, Corn-Soy Blend Plus; CSWB, Corn-Soy-Whey Blend; RUSF, ready-to-use supplementary food; SC+, SuperCereal Plus.
FIGURE 6
FIGURE 6
Adjusted marginal predictions from linear mixed effects regression model for weight-for-length z scores over time in children aged 6–27 mo in Sanmatenga Province, Burkina Faso, 2014–2016. Error bars are 95% CIs. CSB+, Corn-Soy Blend Plus; CSWB, Corn-Soy-Whey Blend; RUSF, ready-to-use supplementary food; SC+, SuperCereal Plus.
FIGURE 7
FIGURE 7
Incremental cost-effectiveness plane for stunting prevention among children participating in the supplementary feeding program “Victoire sur la Malnutrition” (ViM) in Sanmatenga Province, Burkina Faso, showing the program perspective and realistic procurement costs, 2014–2016. Both axes were constructed comparing each of the SC+, RUSF, and CSWB w/oil arms with the reference arm, CSB+ w/oil. Vertical uncertainty ranges for incremental costs from the program perspective were constructed based on 1 SD above and below the mean realistic product costs. Horizontal uncertainty ranges for adjusted incremental effectiveness were constructed based on 95% CIs around the adjusted marginal means estimated from the stunting statistical model that excluded lost to follow-up. *P < 0.001. Data label: (point estimate on incremental adjusted stunting prevalence, point estimate on incremental cost per enrolled child). CSB+, Corn-Soy Blend Plus; CSWB, Corn-Soy-Whey Blend; Ref., reference; RUSF, ready-to-use supplementary food; SC+, SuperCereal Plus; USD, US dollars.
FIGURE 8
FIGURE 8
Incremental cost-effectiveness plane for wasting prevention among children participating in the supplementary feeding program “Victoire sur la Malnutrition” (ViM) in Sanmatenga Province, Burkina Faso, showing the program perspective and realistic procurement costs, 2014–2016. Both axes were both constructed comparing each of the SC+, RUSF, and CSWB w/oil arms with the reference arm, CSB+ w/oil. Vertical uncertainty ranges for incremental costs from the program perspective were constructed based on 1 SD above and below the mean realistic product costs. Horizontal uncertainty ranges for adjusted incremental effectiveness were constructed based on 95% CIs around the adjusted marginal means estimated from the wasting statistical model that included lost to follow-up. *P  = 0.02. Data label: (point estimate on incremental adjusted months of wasting, point estimate on incremental cost per enrolled child). CSB+, Corn-Soy Blend Plus; CSWB, Corn-Soy-Whey Blend; Ref., reference; RUSF, ready-to-use supplementary food; SC+, SuperCereal Plus; USD, US dollars.

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