title: Analysing the nutrition-disease nexus: the case of malaria.
abstract: BACKGROUND
  Motivated by the observation that children suffering from undernutrition are more likely to experience disease and are more likely to die if they do contract a disease, mathematical modelling is used to explore the ramifications of targeting preventive disease measures to undernutritioned children.
  
  
  METHODS
  A malaria model is constructed with superinfection and heterogeneous susceptibility, where a portion of this susceptibility is due to undernutrition (as measured by weight-for-age z scores); so as to isolate the impact of supplementary food on malaria from the influence of confounding factors, the portion of the total susceptibility that is due to undernutrition is estimated from a large randomized trial of supplementary feeding. Logistic regression is used to estimate mortality given malaria infection as a function of weight-for-age z scores. The clinical malaria morbidity and malaria mortality are analytically computed for a variety of policies involving supplementary food and insecticide-treated bed nets.
  
  
  RESULTS
  The portion of heterogeneity in susceptibility that is due to undernutrition is estimated to be 90.3 %. Targeting insecticide-treated bed nets to undernutritioned children leads to fewer malaria deaths than the random distribution of bed nets in the hypoendemic and mesoendemic settings. When baseline bed net coverage for children is 20 %, supplementary food given to underweight children is estimated to reduce malaria mortality by 7.2-22.9 % as the entomological inoculation rate ranges from 500 to 1.0. In the hyperendemic setting, supplementary food has a bigger impact than bed nets, particularly when baseline bed net coverage is high.
  
  
  CONCLUSIONS
  Although the results are speculative (e.g., they are based on parameter estimates that do not possess the traditional statistical significance level), the biological plausibility of the modelling assumptions and the high price-sensitivity of demand for bed nets suggest that free bed net distribution targeted to undernutritioned children in areas suffering from both undernutrition and malaria (e.g., sub-Saharan Africa) should be the subject of a randomized trial in a hypoendemic or mesoendemic setting.
authors.affiliation: Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, 94305, USA. milindal@stanford.edu.
authors.forename: Milinda
authors.initials: M
authors.lastname: Lakkam
authors.affiliation: Graduate School of Business, Stanford University, Stanford, CA, 94305, USA. lwein@stanford.edu.
authors.forename: Lawrence M
authors.initials: LM
authors.lastname: Wein
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D000818:Animals; D002675:Child, Preschool; D004198:Disease Susceptibility; D006801:Humans; D007223:Infant; D008288:Malaria / Q000453:epidemiology* / Q000401:mortality*; D015233:Models, Statistical; D009752:Nutritional Status