By Tekle Tesfalidet
On September 9, 2024, a significant webinar was held focusing on “The Micronutrient Intervention Modeling Tool (MINIMOD) and its Concrete Applications to Nutrition Policy Discussions. This event took place at 5:00 PM Addis Ababa Time, gathering public health professionals and researchers to discuss the critical issue of micronutrient deficiencies. Participants explored how MINIMOD can address specific nutrition challenges and inform policy discussions, ensuring that interventions are both targeted and sustainable. The webinar provided an overview of MINIMOD's key features, emphasizing its ability to model different intervention strategies, assess potential outcomes, and deliver actionable insights.
The event was moderated by Dr. Endale Amare, a Senior Researcher at the Nutrition, Environmental Health, and Non-communicable Disease Research Directorate at EPHI. Dr. Aregash Samuel, the NIPN Ethiopia National Coordinator, introduced the session. The keynote speaker, Dr. Stephen A. Vosti, Adjunct Professor Emeritus at UC Davis, provided a detailed presentation on MINIMOD. Additionally, panelists Dr. Dawd Gashu, Associate Professor at Addis Ababa University, and Dr. Demewoz Woldegebreal from the Institute for Health Metrics and Evaluation (IHME), Seattle, USA, shared their valuable experiences as panelists.
At the beginning, Dr. Aregash Samuel, Senior Researcher at EPHI and NIPN Coordinator, welcomed the speakers and participants and briefly introduced NIPN by saying that in 2018, NIPN was launched in Ethiopia to support evidence-based decision-making within the framework of the National Nutrition Program (NNP) and the National Food and Nutrition Policy (NFNP). The project is based at the Ethiopian Public Health Institute (EPHI). As of June 2022, NIPN receives programmatic and financial support from Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), along with technical assistance from the International Food Policy Research Institute (IFPRI). It regularly organizes seminars, webinars, and other discussion forums, disseminating its outputs through various channels, including the NIPN website, social media, newsletters, and the national English newspaper, the Ethiopian Herald.
Following this, she invited Dr. Endale to moderate the event. He delivered detailed introductions for the speaker, Dr. Stephen A. Vosti, a renowned expert in public health and nutrition with extensive experience in addressing micronutrient deficiencies in developing countries. Dr. Endale also introduced the panelists: Dr. Dawd Gashu, a leading researcher in agricultural interventions and their impact on food security, and Dr. Demewoz Weldegebreal , a specialist in nutrition policy and implementation. After the introductions, Dr. Endale invited Dr. Vosti to begin his presentation.
Dr. Stephen A. Vosti’s presentation highlighted that the prevalence of micronutrient deficiencies remains a significant public health challenge in developing countries. He discussed key strategies to address these deficiencies, including micronutrient supplementation, large-scale fortification, and agricultural interventions like bio-fortification. However, despite these approaches, there is a notable lack of guidance for decision-makers on how to select the most effective, cost-efficient, and sustainable interventions to maximize their impact within existing budget and resource constraints.
According to Dr. Vosti, the MINIMOD tool framework encompasses two key components: the Nutritional Needs and Intervention Program Benefits Model and the Intervention Program Cost Model.
The first model estimates dietary intakes and identifies individuals with low micronutrient intake, using the Lives Saved Tool (LiST) to predict outcomes such as lives saved and anemia averted. The second model assesses the costs associated with implementing various interventions, including planning and operational expenses. Together, these models identify the most cost-effective intervention programs by analyzing their benefits and costs, providing summary measures of nutritional benefits, costs, and cost-effectiveness. Overall, as discussed by Dr. Vosti, MINIMOD facilitates evidence-based decision-making by offering data-driven insights, optimizing resource allocation, enhancing program effectiveness, and supporting policy decisions aimed at combating micronutrient deficiencies.
In his detailed presentation, the speaker pointed out that the MINIMOD tool is an essential resource for stakeholders in micronutrient interventions, enabling researchers and advocacy groups to estimate the impact of new initiatives and enhance health outcomes. Funders benefit by prioritizing interventions for research and funding, ensuring effective resource allocation. For policymakers, MINIMOD provides critical evidence on the impact and cost-effectiveness of various strategies, facilitating comparisons of approaches like fortification versus supplementation. Program implementers, including NGOs, utilize its insights to understand potential impacts and costs, leading to more effective interventions. Ultimately, MINIMOD guides research, funding, policy, and program implementation, significantly contributing to improved public health outcomes.
Dr. Vosti also pointed out the promise of multi-fortified bouillon in West Africa, particularly in Burkina Faso, Nigeria, Senegal, and other countries, which offer equitable reach and the potential to reduce dietary inadequacies, although evidence from randomized control trials (RCTs) is still pending. He acknowledged the technical and commercial challenges that lie ahead, stating that while multi-fortified bouillon is not a comprehensive solution, it can complement existing initiatives. Finally, he mentioned that there is valuable data and analytical capacity available to address critical policy questions, but tackling these issues will require both time and investment.
At the end of the presentation, the moderator, Dr. Endale, expressed his appreciation for Dr. Vosti's detailed and informative talk. He then invited Dr. Dawd Gashu to take the floor to address the following question: Dr. Dawd, as a technical team member of the recently launched National Food Fortification program, what insights have you gained regarding the importance of such models for the program?
Dr. Dawd began his speech by stating, before answering your question, let me define a nutrition model. It can be a computer-assisted optimization tool, such as mapping software, or an Excel-based mathematical model like MINIMOD. These tools help select the most effective interventions for addressing nutrition problems among a range of program options.
In response to the question forwarded by Dr. Endale, Dr. Dawd explained that nutrition models are essential for assessing various deficiencies and excesses within a population. They also help predict the impact of nutrition programs, allowing us to evaluate the financial benefits—such as what percentage of children can be uplifted due to our interventions. Given that we operate in a resource-constrained environment, these models are crucial for prioritizing interventions.
Dr. Dawd emphasized the importance of identifying which groups will benefit from specific interventions, noting that costs can be shared among government, development partners, and consumers. He outlined two types of cost estimation: startup costs and recurring costs. He encouraged anyone interested to utilize his impact and cost-effectiveness model, which has been formalized for end users. This model can be applied for both research purposes and policy-making.
Additionally, Dr. Dawd highlighted that one must be cautious about the type of data used in nutrition modeling. This data could include biomarker data or dietary data, both of which are critical for accurate assessments.
The third speaker, Dr. Demewoz Woldegebreal, discussed the MINIMOD tool, highlighting its significance in estimating the impact of micronutrient interventions on mortality and the reduction of anemia and neural tube defects (NTDs). He noted that the tool has been effectively used to model the impact of such interventions in several African countries, including Cameroon, Ethiopia, Nigeria, Senegal, and Burkina Faso.
Dr. Demewoz emphasized that the outputs generated by the MINIMOD tool have been instrumental in facilitating policy discussions surrounding micronutrient interventions. However, he cautioned that the tool has a steep learning curve and requires expert input at each stage of the modeling process. He outlined key components of the process, including usual intake estimation, effect size estimation, and the simulation of interventions, such as various levels of food fortification.
In his presentation, Dr. Demewoz expressed his vision for the future of the MINIMOD tool. He noted that the tool tends to underestimate the total benefits of interventions, as it primarily focuses on specific functional outcomes such as mortality. Dr. Haile suggested that incorporating Disability Adjusted Life Years (DALYs), which measure both years of life lost due to premature death and years lived with disability, could serve as a more comprehensive metric for assessing the impact of micronutrient interventions.
Furthermore, he advocated for the development of interactive visualization maps that would illustrate the need, impact, and cost-effectiveness of micronutrient intervention programs based on MINIMOD. These enhancements, he argued, could significantly improve the tool's utility and effectiveness in guiding public health decisions.
After thanking and acknowledging the contributions of the three speakers, Dr. Endale invited the audience to participate in a question-and-answer session, fostering a dynamic exchange of ideas and insights. Accordingly, two questions were asked:
1. Dr. Meron Girma from EPHI/NIPN, who asked: Dr. Vosti, thank you for an interesting presentation. Drawing from your experience working on fortification, in countries where a single vehicle is not widely used, Ethiopia is an example, what alternative modalities can be used to reduce micronutrient deficiencies.
2. Esayas from EIAR and GFFP who asked: Enhancing intake of micronutrients is primarily by fortification. 1. How can we select the best vehicle to carry the targeted nutrient? 2. In which case is fortification more effective, in nutrient rich food products or the nutrient poor one? 3. How can we be sure the metabolism of the product is effective?
The following responses were given by Dr. Vosti and Dr. Dawd:
Dr. Stephen began by discussing the concept of dual fortification of salt, noting that India is currently experimenting with this approach to address micronutrient deficiencies. While technically challenging due to the need for careful blending, it is a feasible solution.
He also mentioned the potential for fortifying water, although this method poses challenges, particularly because water is not commercially packaged in many regions. Additionally, he touched on bio-fortification, acknowledging its’ potential but highlighting that it often takes a long time to implement effectively.
Dr. Stephen pointed out that while supplementation programs can be beneficial, they are often expensive and not foolproof. He suggested that a multifaceted approach could be effective, including multiple forms of supplementation alongside salt fortification to enhance overall micronutrient intake.
Dr. Dawd, reflecting on the challenges of large-scale fortification, emphasized key issues such as the lack of coordination among stakeholders, which hinders effective implementation. He noted that funding is often inadequate, primarily relying on development partners rather than government support. The high cost of interventions, especially supplementation programs, limits accessibility, and many initiatives only reach urban areas, restricting their overall impact. In contrast, he highlighted agronomic bio-fortification as a promising alternative that can effectively serve rural populations. In discussing alternative modalities for reducing micronutrient deficiencies, Dr. Dawd stressed the importance of addressing these challenges to create more inclusive and sustainable solutions.
Furthermore, Dr. Dawd addressed the challenges of large-scale fortification, highlighting several key issues. First, he pointed out the lack of coordination among stakeholders, which is crucial for effective collaboration. He noted that funding primarily comes from development partners rather than government sources, limiting resources. Additionally, the high cost of interventions, such as supplementation programs, poses a significant barrier. Many initiatives also tend to favor urban areas, making strategies like agronomic bio-fortification more advantageous for broader coverage.
Talking about selecting the best vehicle for micronutrient fortification, Dr. Dawd emphasized that the choice should depend on its accessibility and acceptance by the target population. He also mentioned that fortification is most effective in nutrient-poor food products, as these can greatly enhance nutritional status. Lastly, he highlighted the importance of understanding how the body metabolizes fortified nutrients to ensure effectiveness.
Finally, the webinar concluded with remarks from Dr. Endale, who expressed gratitude to the speaker, the panelists, and the participants for their valuable insights and engagement with the Micronutrient Intervention Modeling Tool (MINIMOD).
The NIPN webinar on the Micronutrient Intervention Modeling Tool (MINIMOD) featured insightful presentations and discussions led by expert panelists, who emphasized the tool's critical role in developing evidence-based nutrition policies. The panelists shared practical applications of MINIMOD, illustrating its effectiveness in addressing micronutrient deficiencies and improving public health outcomes. They highlighted real-world case studies and engaged participants in discussions that showcased the importance of integrating data-driven approaches into policy-making. Overall, the session reinforced the value of MINIMOD as a vital resource for shaping robust nutrition strategies globally.
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