Comment

what happens when teriparatide is stopped (the licence

only supports use for a maximum of 24 months). Finally,
the reduction in fracture risk needs to be quantied so
that cost-eectiveness can be assessed.

*Richard Eastell, Jennifer S Walsh

Academic Unit of Bone Metabolism, Metabolic Bone Centre,
Northern General Hospital, Sheeld S5 7AU, UK (RE, JSW); and
Mellanby Centre for Bone Research, University of Sheeld,
Sheeld, UK (RE, JSW)
r.eastell@sheeld.ac.uk

RE has acted as a consultant for and received resarch funding from Amgen,
GlaxoSmithKline, Lilly, Merck, and Novartis. JSW declares that she has no conicts
of interest.

Tsai JN, Uihlein AV, Lee H, et al. Teriparatide and denosumab, alone or
combined, in women with postmenopausal osteoporosis: the DATA study
randomised trial. Lancet 2013; published online May 15. http://dx.doi.
org/10.1016/S0140-6736(13)60856-9.
Neer RM, Arnaud CD, Zanchetta JR, et al. Eect of parathyroid hormone
(134) on fractures and bone mineral density in postmenopausal women
with osteoporosis. N Engl J Med 2001; 344: 143441.
Obermayer-Pietsch BM, Marin F, McCloskey EV, et al. Eects of two years of
daily teriparatide treatment on BMD in postmenopausal women with
severe osteoporosis with and without prior antiresorptive treatment.
J Bone Miner Res 2008; 23: 1591600.

10

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12

Finkelstein JS, Wyland JJ, Lee H, Neer RM. Eects of teriparatide,

alendronate, or both in women with postmenopausal
osteoporosis. J Clin Endocrinol Metab 2010; 95: 183845.
Finkelstein JS, Leder BZ, Burnett SM, et al. Eects of teriparatide,
alendronate, or both on bone turnover in osteoporotic
men. J Clin Endocrinol Metab 2006; 91: 288287.
Black DM, Greenspan SL, Ensrud KE, et al. The eects of parathyroid
hormone and alendronate alone or in combination in postmenopausal
osteoporosis. N Engl J Med 2003; 349: 120715.
Martin TJ, Quinn JM, Gillespie MT, Ng KW, Karsdal MA, Sims NA.
Mechanisms involved in skeletal anabolic therapies. Ann N Y Acad Sci 2006;
1068: 45870.
Saag K, Lindsay R, Kriegman A, Beamer E, Zhou W. A single zoledronic acid
infusion reduces bone resorption markers more rapidly than weekly oral
alendronate in postmenopausal women with low bone mineral density.
Bone 2007; 40: 123843.
Cosman F, Eriksen EF, Recknor C, et al. Eects of intravenous zoledronic
acid plus subcutaneous teriparatide [(134)rhPTH] in postmenopausal
osteoporosis. J Bone Miner Res 2011; 26: 50311.
Eastell R, Christiansen C, Grauer A, et al. Eects of denosumab on bone
turnover markers in postmenopausal osteoporosis. J Bone Miner Res 2011;
26: 53037.
Delmas P, Munoz F, Black D, et al. Eects of yearly zoledronic acid 5 mg on
bone turnover markers and relation of PINP with fracture reduction in
postmenopausal women with osteoporosis. J Bone Miner Res 2009;
24: 154451.
Pierroz DD, Bonnet N, Baldock PA, et al. Are osteoclasts needed for the
bone anabolic response to parathyroid hormone? A study of intermittent
parathyroid hormone with denosumab or alendronate in knock-in mice
expressing humanized RANKL. J Biol Chem 2010; 285: 2816473.

Promise, and risks, of conditional cash transfer programmes

What do we know about how to help poor children in
low-income and middle-income countries? Various
approaches have workedimproved nutrition, reduced
exposure to infection, and introduction of parenting or
preschool programmesbut there is still a long way to
go.1,2 Conditional cash transfer programmes try to go
deeper than these other approaches and get at the root
causes of poverty. These programmes use cash to help
households deal with their most pressing nancial needs
and also as an incentive to promote certain behaviours.
The conditions (or conditionalities) that are required for
receipt of cash are most often related to preventive health
care, participation in nutrition education, and school
attendance. Conditional cash transfer programmes with
these goals and conditions have been in place since the
1990s, are mainly focused on improvement of health
and wellbeing of children, and are in place in dozens of
countries around the world. Cash transfer schemes are
now also being used to promote other behaviours such as
practising of safer sex, and are being enhanced with novel
approaches to increase compliance (eg, text messaging).
In The Lancet, Davide Rasella and colleagues3 report the
eects of Brazils conditional cash transfer programme,
www.thelancet.com Vol 382 July 6, 2013

the Bolsa Familia Programme (BFP), on morbidity

and mortality in children younger than 5 years. This
study has great political implications because of the
vastness of BFPs coverage: as Rasella and colleagues
describe, the BFP provides 13 million families with
annual benets in all municipalities of Brazil and has
an annual budget of more than US$11 billion. Partly
because of the governments concerted investment in
safety net policies in Brazil, there have been substantial
improvements in maternal and child health outcomes
during the past decade.4 Rasella and colleagues provide
evidence that the BFP might be part of the reason that
outcomes are improving for millions of vulnerable
individuals in Brazil.
The primary outcome measures used in the study
were mortality rates per municipality. The investigators
also examined the reported causes of death (eg,
diarrhoeal disease or malnutrition) in the target
population (ie, households with an income of up to
$70 per person per month). The primary independent
variable was the percentage of the target population
in any particular municipality receiving benets from
the BFP (classied as low [00171%], intermediate

Published Online
May 15, 2013
http://dx.doi.org/10.1016/
S0140-6736(13)61035-1
See Articles page 57

Werner Rudhardt/dpa/Corbis

Comment

[172320%], high [>320%], or consolidated [>320%

and target population coverage 100% for at least
4 years]). The key nding was that municipalities with
the greatest proportion of the population covered
by the BFP were the ones with the lowest mortality
rates for children younger than 5 years (rate ratio 094
[95% CI 092096] for intermediate coverage, 088
[085091] for high coverage, and 083 [079088]
for consolidated coverage). This nding was interpreted
to be a consequence of having higher vaccination
coverage, fewer admissions to hospital in children
younger than 5 years because of improved nutritional
status, and an increase in the number of women
receiving prenatal care. The investigators also speculate
that the monetary benets from the BFP allowed
families to purchase food and health-related goods and
services. A particularly interesting and policy-relevant
result was that the eect of programme participation
was highest when full coverage of the target population
was maintained for 4 or more years.
These positive results build on a growing scientic
literature documenting the benecial eects of conditional cash transfers.5 There are good reasons to be
somewhat sceptical about the promise of these programmes, however. Conditional cash transfers have been
criticised because provision of incentives for individuals
to change behaviour might not work without supply side
investments.6 In Brazil, for example, part of the reason
that the BFP had positive eects was because of the
availability of primary health care services through the
countrys Family Health Programme. Conditional cash
8

transfer programmes in countries without nationalised

health care might not be as eective. Another very real
risk of conditional cash transfer programmes is that they
might provide resources necessary for individuals to
consume extra calories in a context without intentional
policies or programmes designed to prevent obesity
and non-communicable diseases (NCDs). Brazil is a
middle-income country in the midst of a demographic
and nutritional transition;7 in adults, 524% of men and
510% of women are already overweight,8 and in children
the prevalence of obesity is 221%.9 In a recent Series
in The Lancet about NCDs, there was a call to embed
NCD prevention within a larger human development
agenda.10 We have shown previously that receiving a
greater amount of cash in Mexicos conditional cash
transfer programme (Oportunidades) was associated with
increased risk for obesity and hypertension in adults.11
Participation in the BFP has already been shown to be
associated with increased consumption of sugar and
sugar-sweetened beverages,12 which could contribute to a
higher prevalence of obesity and NCDs.13 It is certainly not
reasonable to expect conditional cash transfers to solve
all problems for low-income or middle-income countries.
But it will be very important for these programmes to
balance the simultaneous demands of eradication of
extreme poverty and improvement of child health with
the increasingly important prevention of chronic disease.
Lia C H Fernald
School of Public Health, University of California, Berkeley,
CA 94720, USA
fernald@berkeley.edu
I declare that I have no conicts of interest.
1

2
3

Engle PE, Fernald LCH, Alderman H, et al. Strategies for reducing

inequalities and improving developmental outcomes for young children in
low and middle income countries. Lancet 2011; 378: 133953.
Bhutta ZA, Ahmed T, Black RE, et al. What works? Interventions for
maternal and child undernutrition and survival. Lancet 2008; 371: 41740.
Rasella D, Aquino R, Santos CAT, Paes-Sousa R, Barreto ML. Eect of a
conditional cash transfer programme on childhood mortality: a nationwide
analysis of Brazilian municipalities. Lancet 2013; published online May 13.
http://dx.doi.org/10.1016/S0140-6736(13)60715-1.
Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC,
Szwarcwald CL. Maternal and child health in Brazil: progress and
challenges. Lancet 2011; 377: 186376.
Fernald LCH, Gertler PJ, Hidrobo M. Conditional cash transfer programs:
eects on growth, health and development in young children. In King R,
Maholmes V, eds. The Oxford handbook of poverty and child development.
Oxford: Oxford University Press, 2012: 569600.
Forde I, Bell R, Marmot MG. Using conditionality as a solution to the
problem of low uptake of essential services among disadvantaged
communities: a social determinants view. Am J Public Health 2011;
101: 136569.
Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic
of obesity in developing countries. Nutr Rev 2012; 70: 321.

www.thelancet.com Vol 382 July 6, 2013

Comment

8
9
10
11

WHO. NCD country proles: Brazil, 2011. http://www.who.int/nmh/

countries/bra_en.pdf (accessed May 6, 2012).
Gupta N, Goel K, Shah P, Misra A. Childhood obesity in developing countries:
epidemiology, determinants, and prevention. Endocr Rev 2012; 33: 4870.
Alleyne G, Binagwaho A, Haines A, et al. Embedding non-communicable
diseases in the post-2015 development agenda. Lancet 2013; 381: 56674.
Fernald LC, Gertler PJ, Hou X. Cash component of conditional cash transfer
program is associated with higher body mass index and blood pressure in
adults. J Nutr 2008; 138: 225057.

12

13

de Bem Lignani J, Sichieri R, Burlandy L, Salles-Costa R. Changes in food

consumption among the Programa Bolsa Familia participant families in
Brazil. Public Health Nutr 2011; 14: 78592.
Malik VS, Popkin BM, Bray GA, Despres JP, Hu FB. Sugar-sweetened
beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk.
Circulation 2010; 121: 135664.

GBD 2.0: a continuously updated global resource

The Global Burden of Disease Study 2010 (GBD 2010)
provides a comprehensive and coherent assessment
of the state of the worlds health from 1990 to 2010.17
With consistent denitions, standardised approaches
to data quality, and consistent modelling strategies,
GBD 2010 assesses mortality, premature mortality, and
disability caused by a detailed list of diseases, injuries,
and risk factors. The analysis is undertaken in great
detail, covering 187 countries, two decades, both sexes,
and 20 age groups. The ndings point to rapid changes
in patterns of health outside sub-Saharan Africa, with
large shifts in many regions towards non-communicable
diseases, chronic disability, and risk factors related to
behaviours. In sub-Saharan Africa, mortality of children
younger than 5 years decreased substantially and maternal mortality also fell; since 2005, major progress has
been made for HIV, and for malaria since 2004. Despite
this progress, GBD 2010 also shines a spotlight on the
challenges that many of the poorest countries continue
to face, where several infectious diseases, such as diarrhoea, pneumonia, and neonatal conditions, continue
to dominate as major causes of premature child death.
Substantial investments by developing countries and
US$281 billion in 2012 in development assistance for
health, focusing on the Millennium Development Goals,
are contributing to accelerated transitions.8 Countries
are experiencing a complex set of changes in health
problems and their underlying causes, which need more
and more contextualised policy responses.
For several reasons, national, regional, and global actors
need to have access to the best available evidence for
patterns of health and how they are changing. Although it
is an enormous resource, GBD 2010 needs to be regularly
and systematically revised and improved to reect
new evidence and new methods as they accumulate
for at least ve reasons. First, new data sources for a
countryeg, a Demographic and Health Survey, a census,
www.thelancet.com Vol 382 July 6, 2013

a local survey, or national vital registration datacan

substantially change understanding of health trends.
Demographic and Health Surveys in several sub-Saharan
African countries have shown accelerated decreases in
child mortality in the past decade.7,9 Trends in mortality
can change abruptly: from 2008 to 2010, adult male
mortality in Ukraine dropped about 22%; and scale-up of
antiretroviral therapy (ART) has radically reduced adult
mortality since 2005 in several countries (eg, Botswana).
Second, multicentre studies, such as the Global Enterics
Multi-Center Study10 or Pneumonia Etiology Research
for Child Health Study,11 will provide much-needed highquality information about the aetiology of diarrhoea and
pneumonia. Additionally, proposed studies of the risks
of death associated with malaria parasitaemia in adults
would potentially change understanding of malaria
mortality when completed. Multicentre investigations
will probably change detailed understanding of disease
patterns. Burden estimates should be quickly revised
to reect this type of new knowledge. New studies will
also aect understanding of the hazards associated with
dierent risk factors.
Third, expanded use of the GBD 2010 results will
probably lead local analysts to identify data sources that
have not been used and could strengthen the analysis
for a specic country. For example, collaborative work
with the University of Zambia and the Ministry of Health
of Zambia on district-level health outcomes was able to
make use of many data sources not used in international
assessments of child health.12
Fourth, careful reection on the GBD 2010 results
and future iterations of GBD will probably suggest
alternative interpretations of the biases and necessary
corrections in many data sources. This type of assessment
is iterative and benets from repeated assessments. The
development of the UNAIDS estimation methods and
datasets for HIV prevalence over more than 15 years is

Published Online
May 17, 2013
http://dx.doi.org/10.1016/
S0140-6736(13)60225-1