Determinants of compliance with iron supplementation: supplies, side effects, or psychology?

Is it time to replace iron folate supplements in pregnancy with multiple micronutrients?

Anaemia is one of the most resilient global public health problems and affects a staggering 1.62 billion of the world's population, largely concentrated in Asia and Africa. Anaemia contributes to almost 120,000 maternal deaths globally and indirectly to almost a fifth (18%) of the burden of maternal mortality. Given the widespread prevalence of micronutrient deficiencies in developing countries, supplementation with multiple micronutrients rather than iron folate alone, could be of potential benefit to the mother and the fetus. This review evaluates the evidence of the impact of multiple micronutrient supplements during pregnancy, in comparison with standard iron folate supplements, on maternal anaemia. A systematic review of randomised controlled trials was conducted using search engines like PubMed, the Cochrane Library and World Health Organization Regional Databases. Primary outcomes were 'maternal anaemia' and 'haemoglobin level'. We included seven studies for detailed data abstraction. There was no differential benefit of multiple micronutrients as compared with iron folate on maternal anaemia in the third trimester (relative risk = 1.03 [95% confidence interval 0.94, 1.12]). Results were similar for haemoglobin levels. In summary, multiple micronutrients have a similar effect on maternal anaemia compared with iron folate supplementation. These findings have to be interpreted in the context of other benefits of multiple micronutrient supplementation such as promoting better fetal growth and the possible increased risk of neonatal and perinatal mortality that are best resolved through large-scale effectiveness trials.

Temporal trend of anemia among reproductive-aged women in India

BACKGROUND

Anemia is one of the major leading nutritional deficiencies in India, and the most vulnerable groups are preschool and adolescent children and pregnant and lactating women.

AIM

The main objective of the study is to determine the temporal trend of anemia among reproductive-aged women of age 15-49 years.

METHODOLOGY

The study uses data from second and third rounds of the National Family Health Surveys (NFHS-2, 1998-1999, and NFHS-3, 2005-2006), conducted by the International Institute for Population Sciences. The dependent variable was the status of anemia of women. The determining variables were type of residence, age group, religion and castes, educational status, marital status, and household standard of living index.

RESULTS

Anemia was most prevalent in the east zone for both the periods. The changes at the all India level were not much, but the north-east zone improved very well, whereas the south zone deteriorated drastically. The occurrence of severely anemic women in India varied between 1% and 2%. The highest prevalence rates were observed among women who were 15 to 24 years of age, illiterate, from non-Christian scheduled tribes (STs), unmarried, and whose standard of living was low. Rates of anemia have increased over time except in the case of Buddhists, Parsees, Jains, and the STs.

CONCLUSION

From the viewpoint of our study, illiteracy and low standard of living may be the main causes of anemia among women in India. It is also necessary to take appropriate steps to curb anemia in women in their early adulthood.

Increased birth weight associated with regular pre-pregnancy deworming and weekly iron-folic acid supplementation for Vietnamese women

Background

Hookworm infections are significant public health issues in South-East Asia. In women of reproductive age, chronic hookworm infections cause iron deficiency anaemia, which, upon pregnancy, can lead to intrauterine growth restriction and low birth weight. Low birth weight is an important risk factor for neonatal and infant mortality and morbidity.

Methodology

We investigated the association between neonatal birth weight and a 4-monthly deworming and weekly iron-folic acid supplementation program given to women of reproductive age in north-west Vietnam. The program was made available to all women of reproductive age (estimated 51,623) in two districts in Yen Bai Province for 20 months prior to commencement of birth weight data collection. Data were obtained for births at the district hospitals of the two intervention districts as well as from two control districts where women did not have access to the intervention, but had similar maternal and child health indicators and socio-economic backgrounds. The primary outcome was low birth weight.

Principal Findings

The birth weights of 463 infants born in district hospitals in the intervention (168) and control districts (295) were recorded. Twenty-six months after the program was started, the prevalence of low birth weight was 3% in intervention districts compared to 7.4% in control districts (adjusted odds ratio 0.29, 95% confidence interval 0.10 to 0.81, p = 0.017). The mean birth weight was 124 g (CI 68 - 255 g, p<0.001) greater in the intervention districts compared to control districts.

Conclusions/Significance

The findings of this study suggest that providing women with regular deworming and weekly iron-folic acid supplements before pregnancy is associated with a reduced prevalence of low birth weight in rural Vietnam. The impact of this health system-integrated intervention on birth outcomes should be further evaluated through a more extensive randomised-controlled trial.

Low birth weight is an important risk factor for neonatal and infant morbidity and mortality and may impact on growth and development. Maternal iron deficiency anaemia contributes to intrauterine growth restriction and low birth weight. Hookworm infections and an iron-depleted diet may lead to iron deficiency anaemia, and both are common in many developing countries. A pilot program of deworming and weekly iron-folic acid supplementation for non-pregnant women aiming to prevent iron deficiency was implemented in northern Vietnam. We compared the birth weight of babies born to women who had had access to the intervention to babies born in districts where the intervention had not been implemented. The mean birth weight of the intervention districts' babies was 124 g more than the control districts' babies; the prevalence of low birth weight was also reduced. These results suggest that providing women with deworming and weekly iron-folic acid supplements before pregnancy is associated with increased birth weight in rural Vietnam. This intervention was provided as a health system integrated program which could be replicated in other at-risk rural areas. If so it could increase the impact of prenatal and antenatal programs, improving the health of both women and newborns.

Social determinants of iron supplementation among women of reproductive age: a systematic review of qualitative data

Iron supplementation for women of reproductive age is a main part of an interdisciplinary strategy recommended for the control and prevention of iron deficiency and the treatment of mild-to-moderate iron-deficiency anaemia. This systematic review reports the findings from a meta-synthesis of qualitative data concerning the experiences and perceptions of iron supplementation among women of reproductive age and health service providers worldwide. Qualitative systematic review methods were used to conduct a search of published literature, define inclusion and exclusion criteria, appraise quality of studies and extract data on the use of iron supplementation among women of reproductive age. Coding, thematic analysis, reciprocal translation and line of argument synthesis were used to synthesize data. Twelve studies spanning 17 countries met inclusion criteria and were included in the analysis. Seven domains emerged from the review: cultural norms and societal values including explanatory models and medical pluralism; political and socio-economic circumstances; education and communication; social organization and social relationships; health care access and supplement supply; food and nutrition availability; and adherence. In addition, 16 sub-domains are highlighted. Connecting review findings to a conceptual framework of social determinants of health highlights salient issues that policy makers must consider when adapting global iron supplementation recommendations to the local context.

Determinants of adherence to iron/folate supplementation during pregnancy in two provinces in Cambodia

Iron supplementation can effectively control and prevent anemia in pregnancy. However, limited adherence is thought to be a major reason for the low effectiveness of iron supplementation programs.This research describes the factors influencing the adherence to iron/folate supplementation during pregnancy in Siem Reap and Kampong Cham provinces in Cambodia.Triangulation method, combining the quantitative and qualitative data collection methods, was performed for this study. A total of 177 women who gave birth during the year prior to the interview were selected for the quantitative survey. Ten women who gave birth during the year prior to the interview and 10 pregnant women were interviewed in-depth for the qualitative data.The χ2 test and binary logistic regression were used for statistical analysis. The findings showed an adherence rate of 47%. The logistic regression revealed that the number of supplements received, number of prenatal visits, and access to antenatal care were determinants of adherence (P<.05). In conclusion, access to and follow-up of antenatal care were considered elements essential to improve iron/folate supplementation. Community-based interventions, such as nutrition education and distribution of supplements, should be prioritized in the interventions to improve adherence in Cambodia.

Home fortification with micronutrient sprinkles - A new approach for the prevention and treatment of nutritional anemias

Despite global goals set by United Nations' agencies over the past decade for significant reductions in iron deficiency anemia (IDA), it remains a largely unaddressed public health problem affecting more than two billion people, one-third of the world's population. The negative impact of IDA on health and human potential are greatest in the developing world, where it is estimated that 51% of children younger than four years of age are anemic, mainly due to a diet that is inadequate in bioavailable iron. Studies in both developed and developing countries have consistently shown mental and motor impairments that may not be reversible in children younger than two years of age with IDA. From a public health standpoint there are four possible interventions for the prevention of anemia: dietary diversification to include foods rich in absorbable iron; fortification of staple foods including targeted fortification of complementary foods for infants and young children; the provision of iron supplements; and 'home-fortification'. In response to a United Nations Children's Fund (UNICEF) request to develop a new approach to IDA, our research group developed 'Sprinkles' for home-fortification of complementary foods. Sprinkles are single-dose sachets (like small packets of sugar) containing micronutrients in powder form (encapsulated iron, zinc, vitamins A, C and D, and folic acid), which are easily sprinkled onto any home-prepared complementary food. Sprinkles were developed to overcome many of the side effects and disadvantages of iron drops. We have demonstrated that Sprinkles are as effective as iron drops in the treatment and prevention of anemia. Sprinkles are easier to use and are, therefore, better accepted than iron drops, which may improve adherence to iron interventions.

Acceptability of lipid-based nutrient supplements (LNS) among Ghanaian infants and pregnant or lactating women

Inadequate micronutrient intake during pregnancy, lactation and infancy is a major problem in many developing countries. Lipid-based nutrient supplements (LNS) can improve micronutrient status, growth and development of infants, and also have potential to improve nutritional status of pregnant and lactating women. The objective of the study was to test the acceptability of LNS designed for infants (LNS-20gM) and pregnant or lactating women (LNS-P&L). Participants were infants (n = 22, mean age = 8 months) and pregnant or lactating women (n = 24) attending routine services at a hospital in Ghana. Infants consumed 45 g of a test meal consisting of one part LNS-20gM and three parts fermented maize porridge, while women consumed 50 g of a similar test meal containing LNS-P&L instead. Participants also used their respective LNS at home for 14 days. Primary outcome was the proportion of the test meal consumed. On average, infants consumed 76.2% of the test meal [95% (confidence interval) CI: 65.7, 86.7], while women consumed 87.1% (95% CI: 82.6, 91.6). During the 14-day period, median daily consumption of LNS-20gM was 19.3 g, very close to the recommended 20 g d(-1), while that of LNS-P&L was one sachet, as recommended. We conclude that LNS-20gM and LNS-P&L were well accepted.

Importância das práticas alimentares no primeiro ano de vida na prevenção da deficiência de ferro

A reconhecida relevância da anemia por deficiência de ferro, em termos de saúde pública, decorre não apenas da magnitude de sua ocorrência, mas, principalmente, dos efeitos deletérios que ocasiona à saúde da criança. Com o objetivo de investigar as práticas alimentares no primeiro ano de vida e sua associação com a deficiência de ferro, realizou-se revisão da literatura científica nacional e internacional sobre a questão, selecionando os artigos mais relevantes. Crianças que nascem atermo e com peso adequado, ao receberem o leite materno de forma exclusiva suprem suas necessidades de ferro, sendo desnecessário qualquer complemento nos primeiros seis meses de vida. Próximo aos seis meses de idade ocorre gradualmente o esgotamento das reservas de ferro e a alimentação complementar passa a ter papel predominante no atendimento às necessidades desse nutriente. O papel do aleitamento materno na ocorrência da deficiência de ferro é ainda controverso e parece depender do país, região e tipo de leite utilizado em substituição ao leite materno. Na impossibilidade da continuidade do aleitamento materno, a substituição deste por leite de vaca aumenta o risco de a criança apresentar deficiência de ferro. Práticas complementares que comprovadamente contribuem com a prevenção da deficiência de ferro são: alimentação complementar com alta biodisponibilidade de ferro, alimentos fortificados e suplemento de ferro em doses profiláticas. Dieta com alta biodisponibilidade de ferro é aquela que contém os alimentos básicos da família, desde que saudáveis, com a presença de carne, vitamina A e vitamina C. A alimentação no primeiro ano de vida tem papel importante na prevenção da anemia por deficiência de ferro e, para sua adequada implementação, é necessário que suas diretrizes sejam adotadas como rotina nas unidades básicas de saúde.

Gold kiwifruit consumed with an iron-fortified breakfast cereal meal improves iron status in women with low iron stores: a 16-week randomised controlled trial

Ascorbic acid, and more recently, the carotenoids lutein and zeaxanthin have been shown to enhance Fe absorption. However, it is not clear whether Fe status improves when foods high in ascorbic acid and carotenoids are consumed with Fe-fortified meals. The present study aimed to investigate whether consuming highv.low ascorbic acid-, lutein- and zeaxanthin-rich fruit (gold kiwifruitv.banana) with Fe-fortified breakfast cereal and milk improved Fe status in women with low Fe stores. Healthy women aged 18–44 years (n89) with low Fe stores (serum ferritin ≤ 25 μg/l and Hb ≥ 115 g/l) were randomly stratified to receive Fe-fortified breakfast cereal (16 mg Fe as ferrous sulfate), milk and either two gold kiwifruit or one banana (164 mgv.not detectable ascorbic acid; 526v.22·90 μg lutein and zeaxanthin, respectively) at breakfast every day for 16 weeks. Biomarkers of Fe status and dietary intake were assessed at baseline and end in the final sample (n69). Median serum ferritin increased significantly in the kiwifruit group (n33) compared with the banana group (n36), with 10·0 (25th, 75th percentiles 3·0, 17·5)v.1·0 (25th, 75th percentiles − 2·8, 6·5) μg/l (P < 0·001). Median soluble transferrin receptor concentrations decreased significantly in the kiwifruit group compared with the banana group, with − 0·5 (25th, 75th percentiles − 0·7, − 0·1)v.0·0 (25th, 75th percentiles − 0·3, 0·4) mg/l (P = 0·001). Consumption of an Fe-fortified breakfast cereal with kiwifruit compared with banana improved Fe status. Addition of an ascorbic acid-, lutein- and zeaxanthin-rich fruit to a breakfast cereal fortified with ferrous sulfate is a feasible approach to improve Fe status in women with low Fe stores.

Determinants of anemia among young children in rural India

OBJECTIVE

More than 75% of Indian toddlers are anemic. Data on factors associated with anemia in India are limited. The objective of this study was to determine biological, nutritional, and socioeconomic risk factors for anemia in this vulnerable age group.

METHODS

We conducted a cross-sectional study of children aged 12 to 23 months in 2 rural districts of Karnataka, India. Children were excluded if they were unwell or had received a blood transfusion. Hemoglobin, ferritin, folate, vitamin B(12), retinol-binding protein, and C-reactive protein (CRP) levels were determined. Children were also tested for hemoglobinopathy, malaria infection, and hookworm infestation. Anthropometric measurements, nutritional intake, family wealth, and food security were recorded. In addition, maternal hemoglobin level was measured.

RESULTS

Anemia (hemoglobin level < 11.0 g/dL) was detected in 75.3% of the 401 children sampled. Anemia was associated with iron deficiency (low ferritin level), maternal anemia, and food insecurity. Children's ferritin levels were directly associated with their iron intake and CRP levels and with maternal hemoglobin level and inversely associated with continued breastfeeding and the child's energy intake. A multivariate model for the child's hemoglobin level revealed associations with log(ferritin level) (coefficient: 1.20; P < .001), folate level (0.05; P < .01), maternal hemoglobin level (0.16; P < .001), family wealth index (0.02; P < .05), child's age (0.05 per month; P < .005), hemoglobinopathy (-1.51; P < .001), CRP level (-0.18; P < .001), and male gender (-0.38; P < .05). Wealth index and food insecurity could be interchanged in this model.

CONCLUSIONS

Hemoglobin level was primarily associated with iron status in these Indian toddlers; however, maternal hemoglobin level, family wealth, and food insecurity were also important factors. Strategies for minimizing childhood anemia must include optimized iron intake but should simultaneously address maternal anemia, poverty, and food insecurity.

Once weekly low-dose iron supplementation effectively improved iron status in adolescent girls

Iron supplementation has been suggested as a strategy for prevention and treatment of iron deficiency (ID) and iron deficiency anemia (IDA) in many countries, but non-compliance of daily regimens and common dosage remain as major challenges. The aim of this study was to investigate the effects of low dose once weekly iron supplementation in adolescent girls. The study was designed as a community-based, randomized, supplementation trial. The initial sample consisted of 200 female high school students, aged 14-16 years old, of whom 193 students concluded the study. They were randomly selected and assigned into either iron-supplemented group (ISG) or iron-unsupplemented group (IUG). The ISG received 150 mg ferrous sulfate once weekly for 16 weeks, whereas the IUG received nothing. Weight, height, and hematological parameters were measured and compared between the two groups before and after the intervention. There was no significant difference between the initial measures of the two groups before the intervention. After 16 weeks of intervention, mean of hemoglobin and serum ferritin improved significantly in ISG compared to IUG. At the beginning of the study, percent of anemia, IDA, and ID in ISG were 12.5%, 8.3%, and 30.2%, whereas these figures for IUG in this period of study were 14.4, 10.3, and 38.2, respectively, which were not significantly different between the two groups. However, percentages of the above items at the end of study in ISG were 2.1%, 0%, and 21.9%, respectively. In contrast to IUG, all cases of IDA were abolished in the ISG. Our study showed that once weekly supplementation of 150 mg ferrous sulfate for 16 weeks significantly improved iron status in female adolescents and effectively treated IDA. There is no need for higher dosage of iron for supplementation that may cause adverse effects and bear higher costs.

Organoleptic properties, ease of use, and perceived health effects are determinants of acceptability of micronutrient supplements among poor Mexican women

We assessed the acceptability of 3 micronutrient supplements for pregnant and lactating women: micronutrient powder (Sprinkles), a fortified food (Nutrivida), and tablets. Pregnant or lactating beneficiaries of the Oportunidades program participating in a cluster randomized supplementation trial in urban Mexico were surveyed about the acceptability of 1 of 3 supplements (n = 268). Semistructured interviews (n = 40) were also conducted with a subset of women in the trial and from adjacent rural areas. Acceptability of the supplements was evaluated based on women's perceptions and experiences with organoleptic qualities, ease of use, and perceived health effects (positive and negative). The median Likert scale ranking of organoleptic and use qualities for all 3 supplements was "I liked it" (2 on a scale of 1-5). However, responses to open-ended survey questions and semistructured interviews indicated decided preferences. Tablets and Sprinkles were strongly preferred over Nutrivida. In interviews, women expressed dislike of the smell, taste, and texture of Nutrivida; they found it cumbersome to store and prepare and reported the most negative effects with it. Between tablets and Sprinkles, tablets were preferred because of the absence of perceptible taste or smell and the simplicity of use. This study provides valuable insights into our currently limited understanding of women's perceptions and preferences among supplements by broadening the concept of acceptability beyond organoleptic properties. Such an analytical approach is useful for identifying both appropriate nutritional supplements within a given sociocultural context as well as the information that should be included in nutrition education to improve adherence.

Use of lipid-based nutrient supplements (LNS) to improve the nutrient adequacy of general food distribution rations for vulnerable sub-groups in emergency settings

The term 'lipid-based nutrient supplements' (LNS) refers generically to a range of fortified, lipid-based products, including products like Ready-to-Use Therapeutic Foods (RUTF) (a large daily ration with relatively low micronutrient concentration) as well as highly concentrated supplements (1-4 teaspoons/day, providing <100 kcal/day) to be used for 'point-of-use' fortification. RUTF have been successfully used for the management of severe acute malnutrition (SAM) among children in emergency settings. Recent research on smaller doses of LNS for prevention of malnutrition has created interest in their potential use in emergency settings to ensure a more nutritionally adequate ration for the most vulnerable groups [e.g. infants and children between 6 and 24 months of age, and pregnant and lactating women (PLW)]. Currently, the main food and nutrition interventions in emergency settings include general food distribution (GFD) rations, which are provided to the affected population as a whole, and selective (or supplementary) feeding programs (SFP), which are to be provided to nutritionally vulnerable or malnourished individuals. In addition to logistical and operational challenges that may limit the intended effect of these programs, the nutritional quality of the food commodities provided may be insufficient to meet the needs of infants and young children and PLW. Because these subgroups have particularly high nutrient needs for growth and development, meeting these needs is challenging in settings where the ration is limited to a few food commodities, with little access to a diverse diet and bioavailable sources of micronutrients. In recent years, there has been increased attention to adding micronutrient interventions, on top of the other food-based interventions (such as GFDs and SFPs), to fill micronutrient gaps in diets in emergency settings. The focus of this document is the potential role of LNS in meeting the nutritional needs of these vulnerable subgroups, with the goal of preventing malnutrition in emergency-affected populations. The document addresses the desired nutritional formulation of LNS for these target groups, taking into account the expected bioavailability of relevant nutrients and toxicity concerns. It also discusses the recommended chemical forms of the fortificants in LNS; stability and shelf-life considerations; production, packaging and distribution of LNS in the context of emergencies; and cost implications of the addition of LNS to current GFD rations for vulnerable groups. To develop the desired nutritional formulation of LNS for these purposes, we calculated the current nutrient content of commonly provided GFD rations and determined the nutritional 'gaps' (of both micro- and macronutrients) of these rations for each of the target groups (i.e. children 6-35 months of age and PLW). For fat and protein, both quantity and quality were evaluated. Through an iterative process, we determined the formulation of a small dose of LNS that would best meet the recommended nutrient intakes for each group in combination with other foods in the GFD ration [composed of a grain, pulse, oil, sugar and salt, but excluding a fortified blended food (FBF)], as well as breast milk for children 6-24 months of age, while avoiding excess levels of any one nutrient to the extent possible. The composition of the LNS used for these calculations is based on an existing LNS product (Nutributter, Malaunay, France, Nutriset), but with less sugar and more oil. Two different approaches were used: (1) developing two different formulations of LNS, one to be used for infants and children 6-35 months of age and a separate one for PLW; and (2) developing a single formulation that could be used for all of these subgroups. We used commodity cost data to estimate the cost of adding an LNS product to the GFD ration. The results indicate that the typical GFD ration currently provided in emergency settings--based on cereals, pulse, an FBF such as corn-soy blend (CSB), oil, salt and sugar-does not meet the nutritional needs of infants and young children and PLW. The hypothetical intake from a ration composed of food aid commodities (based on the current USAID/USDA specifications for exported food aid commodities used in emergency settings), and including breast milk for children 6-24 months of age, provided less than 75% of the recommended intake for several micronutrients for certain age/physiologic groups, including calcium, iron, zinc, B vitamins such as riboflavin, B6 and B12, and fat-soluble vitamins such as D, E and K. It also generally contained lower than recommended levels of fat and essential fatty acids. The initial LNS formulation for each target group was designed to provide 100% of the recommended amount (RDA or RNI) for most micronutrients per daily dose (20 g, approximately 118 kcal) of LNS. This would ensure consumption of the recommended levels of each nutrient even if the 'base' diet changed. However, because such a formulation could provide excess amounts of certain nutrients when consumed in combination with the 'base' diet (especially when the 'base' diet contains fortified foods), we made adjustments in the LNS formulation when there was a risk of greatly exceeding the Upper Level for certain subgroups and there were relevant concerns about adverse effects from chronic consumption of such amounts. For most nutrients, consumption of toxic amounts is highly unlikely with the proposed LNS formulations. The 'one-size' LNS formulation was designed so that one 'dose' (20 g) would be provided to infants and young children and two 'doses' (i.e. 40 g/day) would be provided to PLW. This 'one-size' formulation was based on the LNS formulation developed for children 6-35 months of age. Although the resulting formulation is not a perfect match for the unique nutritional needs of each subgroup, there are several practical advantages to using such an approach. As anticipated, addition of LNS to the GFD ration, even after eliminating the FBF (e.g. CSB), increases the cost. The 'revised' ration without CSB but with LNS would cost 34-52% more (food only) than the 'typical' GFD diet for a hypothetical mother-infant pair, depending on how many LNS 'doses' were provided to the mother. However, depending on the contribution of food costs to overall program costs, the overall increase in costs may be significantly less. Although cost is an important consideration, options to improve the nutritional quality of foods provided in emergency settings should also be assessed with regard to effectiveness in maintaining and improving nutritional outcomes. Another consideration is whether a specialized product like LNS is more easily targeted to the individuals for whom it is intended, thus reducing inter- and intra-household sharing, a common concern with other fortified products such as CSB. This could have substantial cost implications because programs usually compensate for sharing by inflating the amount of FBF provided. This document is intended to be a starting point for considering the incorporation of LNS in the food packages provided in emergency settings. Our goal was to examine the potential nutritional benefits but also the challenges of adopting such a strategy. There are many different options for emergency nutrition programs, and there are also many considerations governing which option to choose. This document is intended to encourage further evaluation of all of these options.

Multiple Micronutrient Supplementation during Pregnancy in Developing-Country Settings: Policy and Program Implications of the Results of a Meta-Analysis

Background

An independent Systematic Review Team performed a meta-analysis of 12 randomized, controlled trials comparing multiple micronutrients with daily iron–folic acid supplementation during pregnancy.

Objective

To provide an independent interpretation of the policy and program implications of the results of the meta-analysis.

Methods

A group of policy and program experts performed an independent review of the meta-analysis results, analyzing internal and external validity and drawing conclusions on the program implications.

Results

Although iron content was often lower in the multiple micronutrient supplement than in the iron–folic acid supplement, both supplements were equally effective in tackling anemia. Community-based supplementation ensured high adherence, but some mothers still remained anemic, indicating the need to concomitantly treat infections. The small, significant increase in mean birthweight among infants of mothers receiving multiple micronutrients compared with infants of mothers receiving iron-folic acid is of similar magnitude to that produced by food supplementation during pregnancy. Larger micronutrient doses seem to produce greater impact. Meaningful improvements have also been observed in height and cognitive development of the children by 2 years of age. There were no significant differences in the rates of stillbirth, early neonatal death, or neonatal death between the supplemented groups. The nonsignificant trend toward increased early neonatal mortality observed in the groups receiving multiple micronutrients may be related to differences across trials in the rate of adolescent pregnancies, continuing iron deficiency, and/or adequacy of postpartum health care and merits further investigation.

Conclusions

Replacing iron–folic acid supplements with multiple micronutrient supplements in the package of health and nutrition interventions delivered to mothers during pregnancy will improve the impact of supplementation on birthweight and on child growth and development.

Effects and safety of preventive oral iron or iron+folic acid supplementation for women during pregnancy

BACKGROUND

Intake of supplements containing iron or a combination of iron and folic acid by pregnant women may improve maternal health and pregnancy outcomes. Recently, intermittent supplementation regimens have been proposed as alternatives to daily regimens.

OBJECTIVES

To assess the effectiveness and safety of daily and intermittent use of iron or iron+folic acid supplements by pregnant women.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2009) and contacted relevant organisations for the identification of ongoing and unpublished studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating the effect of supplementation with iron or iron+folic acid during pregnancy.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using the standard Cochrane criteria. Two authors independently assessed which trials to include in the review and one author extracted data.

MAIN RESULTS

We included 49 trials, involving 23,200 pregnant women. Overall, the results showed significant heterogeneity across most prespecified outcomes and were analysed assuming random-effects. The trials provided limited information related to clinical maternal and infant outcomes.Overall, daily iron supplementation was associated with increased haemoglobin levels in maternal blood both before and after birth and reduced risk of anaemia at term. These effects did not differ significantly between women receiving intermittent or daily iron or iron+folic acid supplementation. Women who received daily prenatal iron supplementation with or without folic acid were less likely to have iron deficiency at term as defined by current cut-off values than those who received no treatment or placebo. Side effects and haemoconcentration (a haemoglobin level greater than 130 g/L) were more common among women who received daily iron or iron+folic acid supplementation than among those who received no treatment or placebo. The risk of haemoconcentration during the second and third trimester was higher among those on a daily regimen of iron supplementation. The clinical significance of haemoconcentration remains uncertain.

AUTHORS' CONCLUSIONS

Universal prenatal supplementation with iron or iron+folic acid provided either daily or weekly is effective to prevent anaemia and iron deficiency at term. We found no evidence, however, of the significant reduction in substantive maternal and neonatal adverse clinical outcomes (low birthweight, delayed development, preterm birth, infection, postpartum haemorrhage). Associated side effects and particularly haemoconcentration during pregnancy may suggest the need for revising iron doses and schemes of supplementation during pregnancy and adjust preventive iron supplementation recommendations.

Nutritional deficiencies during normal growth

Nutritional deficiencies have always been a major consideration in pediatrics. Although the classic forms of many of the well-documented nutritional deficiencies are memorized during training as a physician, nutritional deficiencies that can occur in otherwise asymptomatic normally growing children are often overlooked. The two most common deficiencies seen in children who are growing normally are iron and vitamin D deficiencies. These deficiencies are surprisingly common and can have a significant impact on the overall health of a child. This article reviews these nutritional deficiencies and other less commonly seen deficiencies in children who are otherwise growing normally.

Effect of education and pill count on hemoglobin status during prenatal care in Nepalese women: a randomized controlled trial

AIM

To determine the effect of an education program and/or pill count on the change in hemoglobin levels and the prevalence of anemia in pregnant women.

METHODS

A randomized, factorial design controlled trial was conducted at the Tribhuvan University Teaching Hospital, Nepal. A total of 320 eligible pregnant women receiving prenatal care were randomized into four groups (control, education, pill count and education with pill count) by block randomization with allocation concealment. All recruited women received conventional routine prenatal care with a daily dose of 60 mg iron supplementation. In addition, the education group received an education program. Pill counting was done for the pill count group at their routine prenatal visits. The education with pill count group received both the education program plus pill counting. Baseline hemoglobin at the recruitment phase and follow-up hemoglobin after three months of recruitment were measured. Changes in hemoglobin levels and anemia prevalence were analyzed and compared between groups.

RESULTS

The education only and education with pill count groups had significantly higher hemoglobin changes (0.23 and 0.26 g/dL, respectively) than the control group (P < 0.01). Anemia was reduced by 59% in the education group and by 65% in the education with pill count group, compared to the control group (P < 0.05). Pill count alone significantly improved neither the hemoglobin level nor anemia prevalence compared to the control group.

CONCLUSION

An education program along with routine iron supplementation can improve hemoglobin levels and reduce anemia prevalence in pregnant women. Pill count as a measure of compliance has no additional effect on improving hemoglobin status.

Relative bioavailability of iron and folic acid from a new powdered supplement compared to a traditional tablet in pregnant women

BACKGROUND

Deficiencies of iron and folic acid during pregnancy can lead to adverse outcomes for the fetus, thus supplements are recommended. Adherence to current tablet-based supplements is documented to be poor. Recently a powdered form of micronutrients has been developed which may decrease side-effects and thus improve adherence. However, before testing the efficacy of the supplement as an alternate choice for supplementation during pregnancy, the bioavailability of the iron needs to be determined. Our objective was to measure the relative bioavailability of iron and folic acid from a powdered supplement that can be sprinkled on semi-solid foods or beverages versus a traditional tablet supplement in pregnant women.

METHODS

Eighteen healthy pregnant women (24 - 32 weeks gestation) were randomized to receive the supplements in a crossover design. Following ingestion of each supplement, the changes (over baseline) in serum iron and folate over 8 hours were determined. The powdered supplement contained 30 mg of iron as micronized dispersible ferric pyrophosphate with an emulsifier coating and 600 mug folic acid; the tablet contained 27 mg iron from ferrous fumarate and 1000 mug folic acid.

RESULTS

Overall absorption of iron from the powdered supplement was significantly lower than the tablet (p = 0.003). There was no difference in the overall absorption of folic acid between supplements. Based on the differences in the area under the curve and doses, the relative bioavailability of iron from powdered supplement was lower than from the tablet (0.22).

CONCLUSION

The unexpected lower bioavailability of iron from the powdered supplement is contrary to previously published reports. However, since pills and capsules are known to be poorly accepted by some women during pregnancy, it is reasonable to continue to explore alternative micronutrient delivery systems and forms of iron for this purpose.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00789490.

Effectiveness of a redesigned iron supplementation delivery system for pregnant women in Negros Occidental, Philippines

Objective

To determine the effectiveness of a redesigned Fe supplementation delivery system (ISDS) in improving Hb concentrations and compliance among pregnant women.

Design

A controlled before and after study design was used. Interviews and Hb measurements of randomly selected pregnant women in both treatment areas were conducted at baseline and after 6 months. The redesigned ISDS, reached by consensus based on the surveys and focus group discussions, involved the health workers in spot mapping and clustering; Fe tablets’ distribution, monitoring and promotion; and counselling of pregnant women.

Setting

Negros Occidental and Negros Oriental, Philippines.

Subjects

In total, 1180 pregnant women given Fe/folic acid tablets daily through the redesigned ISDS in the experimental areas and the existing ISDS in the control areas.

Results

There were significantly more anaemic pregnant women in the experimental than in the control area at baseline (50·7 v. 37·3 %; P = 0·001). However, at endline, the anaemia prevalence rate in the experimental area was comparable to that of the control (35·6 v. 33·1 %; P = 0·530). Also, the mean Hb concentration increased significantly in the experimental area by 0·5 g/dl (P = 0·002). An increase in the actual number of prenatal visits/trimester in the experimental area was observed (from 0·99 to 1·66; P < 0·0001). Pregnant women in the experimental area were four times more likely to take Fe tablets (OR = 3·79; P < 0·001) and sixteen times more likely to being monitored for Fe intake (OR = 16·86; P < 0·001) compared to the control.

Conclusions

The redesigned ISDS was effective in improving the Hb concentration and health-related behaviour of pregnant women.

Impact of a Positive Deviance Approach to Improve the Effectiveness of an Iron-Supplementation Program to Control Nutritional Anemia among Rural Senegalese Pregnant Women

Background

Iron supplementation through prenatal care remains the most widespread strategy to control anemia during pregnancy, but its effectiveness is only partial, showing the need to address other approaches.

Objective

This study was conducted to measure the impact of a positive deviance approach to improve an iron-supplementation program among pregnant women in a rural Senegalese area.

Methods

A positive deviance approach (PD Micah) was compared with an ongoing integrated nutrition and health program intervention (Micah) in a rural Senegalese area. A pre-post evaluation was conducted using independent cross-sectional samples with a total of 371 pregnant women. A sociodemographic questionnaire was administered, and biologic and anthropometric measurements were performed.

Results

After 9 months of activities, the mean hemoglobin level rose from 93.9 to 100.7 g/L in the PD Micah group. Distribution of iron supplements through community volunteers and implementation of healthy pregnancy promotion sessions on a monthly basis improved the accessibility to 23.3% in the PD Micah group. No significant change was observed in the Micah group. Logistic regression analysis showed a significantly reduced risk of anemia in the PD Micah area (adjusted odds ratio, 0.25; 95% confidence interval, 0.12 to 0.53).

Conclusions

This intervention shows that a community-based strategy, such as the positive deviance approach, can contribute to improving the effectiveness of iron supplementation during pregnancy.

Acceptability and use of iron and iron-alloy cooking pots: implications for anaemia control programmes

OBJECTIVE

To evaluate the acceptability of iron and iron-alloy cooking pots prior to an intervention trial and to investigate factors affecting retention and use.

DESIGN

Pre-trial research was conducted on five types of iron and iron-alloy pots using focus group discussions and a laboratory evaluation of Fe transfer during cooking was undertaken. Usage and retention during the subsequent intervention trial were investigated using focus group discussions and market monitoring.

SETTING

Three refugee camps in western Tanzania.

SUBJECTS

Refugee health workers were selected for pre-trial research. Mothers of children aged 6-59 months participated in the investigation of retention and use.

RESULTS

Pre-trial research indicated that the stainless steel pot would be the only acceptable type for use in this population due to excessive rusting and/or the high weight of other types. Cooking three typical refugee dishes in stainless steel pots led to an increase in Fe content of 3.2 to 17.1 mg/100 g food (P < 0.001). During the trial, the acceptability of the stainless steel pots was lower than expected owing to difficulties with using, cleaning and their utility for other purposes. Households also continued to use their pre-existing pots, and stainless steel pots were sold to increase household income.

CONCLUSIONS

Pre-trial research led to the selection of a stainless steel pot that met basic acceptability criteria. The relatively low usage reported during the trial highlights the limitations of using high-value iron-alloy cooking pots as an intervention in populations where poverty and the availability of other pots may lead to selling.

Determinants of compliance to antenatal micronutrient supplementation and women's perceptions of supplement use in rural Nepal

OBJECTIVE

We examined factors affecting compliance to antenatal micronutrient supplementation and women's perceptions of supplement use.

DESIGN

Randomized controlled supplementation trial of four alternative combinations of micronutrients given during pregnancy through to 3 months postpartum. Women were visited twice weekly to monitor compliance and to replenish tablets by female study workers. At 6 weeks postpartum women with live births (n 4096) were interviewed regarding their perceptions of the supplement. Median compliance calculated as percentage of total eligible doses received by women was high (84 %).

SETTING

Rural southern Nepal.

SUBJECTS

Pregnant women.

RESULTS

Women with high compliance (above the median of 84 %) were likely to be older, less educated, poorer, undernourished, belong to lower caste and of Pahadi (hill) ethnicity compared with women with low compliance (at or below the median of 84 %). Smoking and drinking alcohol in the past week during pregnancy were strongly associated with low compliance. The major reason for irregular intake was forgetting to take supplements. A higher proportion of the high compliers liked taking the supplements but only half of them were willing to purchase them in the future. A large proportion of women (91 %) perceived a benefit from taking the supplement such as improved strength and health, whereas only about 10 % perceived any side-effects which were not a major barrier to compliance.

CONCLUSIONS

The present analysis highlights that poor, undernourished, uneducated women can have high compliance to antenatal supplementation if they are supplied with the tablets and reminded to take them regularly, and counselled about side-effects.

Role of oxidative stress while controlling iron deficiency anemia during pregnancy - Indian scenario

Iron Deficiency anemia ranks 9(th) among 26 diseases with highest burden. Asia bears 71% of this global burden. Adverse maternal and birth outcome associated with hemoglobin status renders the issue worth attention. Indian scenario has worsened over the period despite continuous international and national efforts. This indicates some lacunae in the approach and strategies applied. Various reports state that even with maximum effort to increase outreach and monitoring for adherence to Iron schedule, consumer's compliance remains abysmally low. Recent studies has pointed out biological basis of side effects (gastrointestinal complains and systemic events) as raised oxidative stress for which iron is the key catalyst. Up till now the only target of research has been to raise hemoglobin of pregnant women above 11gm/dl. With the reports of pregnancy specific morbidities i.e. hemorrhage and septicemia with low hemoglobin, eclampsia, small for gestation age, gestational diabetes with higher ranges of hemoglobin, alarm is raised to define optimum range. Use of oxidative stress as biochemical marker with different doses and schedules has been defined because India lack information for its own population upon oxidative stress status when iron is supplemented as per current guidelines. Studies done in India and abroad have defined that too much and too less, both may raise oxidative stress and studies of this sort may provide biochemical scale for optimization. This review therefore has evaluated currently available Indian research and reports to understand the need of future research area. Important findings from other countries have been incorporated for comparison.

Motivators and barriers to prenatal supplement use among minority women in the United States

Minority women in the United States are at a higher risk of iron deficiency and less likely to report use of prenatal supplements compared with non-Hispanic white women. Little information exists on the perceived benefits and barriers to prenatal supplement use. We analyzed the results of 12 focus groups conducted with African-American and Hispanic women (n=104). Groups were equally divided into consistent (five to seven times per week for 3 or more months) and inconsistent (zero to four times per week for 0 to 2 months) users and by race/ethnicity. We examined motivators and barriers to prenatal supplement use and identified common themes; we also compared responses between consistent and inconsistent users, and between African American and Hispanic women. For all groups, positive effects, convenient supply, affordability, and reinforcement by health care providers enhanced adherence. Common barriers were prenatal supplement qualities, adverse effects, and poor communication from health care providers about the benefits of use. Common motivators among consistent users included social network reinforcement of daily intake and fear of adverse effects to the fetus if prenatal supplements were not taken. Common barriers among inconsistent users included skepticism toward the efficacy and necessity of prenatal supplements and the health care provider assenting to nonadherence. Prenatal supplement use was influenced by multiple factors in women's daily lives. Adherence will likely be enhanced by reducing barriers related to prenatal supplement qualities and adverse effects, improving social network support, and improving health care provider interactions.

Treatment response to standard of care for severe anemia in pregnant women and effect of multivitamins and enhanced anthelminthics

BACKGROUND

Severe anemia (hemoglobin < 70 g/L) in pregnancy may increase the risk of maternal and perinatal mortality.

OBJECTIVES

We assessed response to standard treatment with high-dose iron-folic acid for 90 d and single-dose (500 mg) mebendazole among severely anemic pregnant women in periurban Karachi, Pakistan. In addition, we evaluated the efficacy of 2 enhanced treatment regimens.

DESIGN

We screened pregnant women (n = 6288) for severe anemia and provided them all with the standard treatment. To test the efficacy of 2 additional treatments, women were randomly assigned to standard treatment alone (control) or with 100 mg mebendazole twice daily for 3 d or 90 d of daily multivitamins or both using a 2 x 2 factorial design.

RESULTS

Prevalence of severe anemia was high (10.5%) during pregnancy. Prevalence of geohelminths and malaria was low. Treatment response was defined as hemoglobin > 100 g/L at the 90-d or > or = 25 g/L at the 60-d follow-up visit. The standard-of-care treatment resulted in a response rate of 49% at follow-up, although an adherence of > or = 85% elicited a higher response (67%). The effect of the additional treatments was weak. Although response was higher in the enhanced groups than for the standard treatment at the final assessment, the differences were not statistically significant. However, hemoglobin concentration increased significantly in all groups and was higher in the enhanced mebendazole group compared with the standard group (P < 0.05).

CONCLUSIONS

Iron deficiency was high in this population, and the standard-of-care treatment resulted in a treatment response of 50%, although better treatment adherence showed a higher response. Multivitamins and the enhanced mebendazole regimen had a modest benefit over and above the standard treatment.

The potential role of private pharmacies in maternal iron supplementation in rural Tanzania

BACKGROUND

The reduction of maternal anemia is an agreed public health goal but one that has been very difficult to achieve. On Pemba Island, Tanzania, more than 90% of pregnant women are anemic, despite government efforts to identify and treat anemia during antenatal clinic visits.

OBJECTIVE

To investigate the potential of private pharmacies to be accessed for iron supplements for maternal anemia.

METHODS

We compared and contrasted the care given at private pharmacies and public clinics in terms of six characteristics: accuracy, affordability, availability, geographic accessibility, accommodation, and acceptability. We used data from in-depth interviews, surrogate customer encounters, governmental medicine record reviews, and participant observation.

RESULTS

The accuracy of health care workers' advice about the treatment of anemia at private pharmacies and government clinics was similar. Supplements purchased at pharmacies were sometimes cheaper than the free supplements from the government, when the costs of transportation and time spent at the clinic were considered. Supplements at private pharmacies were always available, whereas the supply at government clinics was erratic. Private pharmacies were physically closer, socially less distant, and more accommodating than government clinics. Both clinics and private pharmacies were socially acceptable to pregnant women, although government clinics were typically not attended until later in pregnancy.

CONCLUSIONS

The private sector probably has untapped potential for the reduction of maternal anemia in settings in which public health services fall short. Private pharmacies can contribute to the reduction of maternal anemia on Pemba Island and beyond.

Providing iron/folic acid tablets free of charge improves compliance in pregnant women in Senegal

Iron (Fe) deficiency and anemia during pregnancy remain highly prevalent in Senegal because of low compliance with Fe supplementation. Improving women's access to supplements may increase compliance. Six prenatal centers in Dakar were randomly assigned to either a control group in which women received routine prenatal visits, including prescriptions to purchase iron/folic acid tablets (IFA) according to the guidelines of the current Senegalese supplementation program (n=112), or to an intervention group in which women received free IFA (n=109) in addition to routine prenatal care. Compliance was assessed 20 weeks after enrollment by pill count and interviews. Hemoglobin, erythrocyte protoporphyrin and serum ferritin were measured at baseline and follow-up. Compliance was 48% and 86% in the control and intervention groups, respectively (P<0.001). After adjustment for confounding, prevalence of anemia was 62% in the control group versus 31% in the intervention group (P<0.001); prevalence of Fe deficiency was 49% and 21% in the control and intervention groups, respectively (P<0.001). Improving access to IFA for pregnant women visiting health centers could dramatically increase their compliance, improve Fe status and decrease the incidence of anemia.

Multilevel modelling of sociodemographic predictors of various levels of anaemia among women in Mali

OBJECTIVE

Anaemia currently affects 40-80% of women in Africa. While risk factors for anaemia have been intensively studied, research has rarely compared risk factors between mild anaemia and moderate/severe anaemia. Also, the contribution of neighbourhood to the prevalence of anaemia has been rarely studied. The aim of the present study was to identify and compare individual and contextual factors associated with various levels of anaemia among women.

DESIGN

A multilevel analysis of data from the 2001 Mali Demographic and Health Survey (n 3763) was carried out. Outcomes variables were mild anaemia, moderate-to-severe anaemia and any anaemia. Multilevel regression analyses were performed for each outcome.

SETTING

Mali, West Africa.

SUBJECTS

Women (n 3763) aged 15 to 49 years, including 512 pregnant women.

RESULTS

Among the eleven potential risk factors included in the models, two factors were associated with mild anaemia (BMI and education), three with any anaemia (pregnancy, BMI and education) and six with moderate-to-severe anaemia (pregnancy, BMI, education, wealth, childhood residency and region of residence). Clustering of anaemia within communities was 20% for moderate-to-severe anaemia and 13% for mild anaemia. Despite significant differences in the prevalence of anaemia across regions in Mali, no difference between regions in the risk of mild anaemia was found and only the region of Gao showed a significantly higher risk of moderate-to-severe anaemia.

CONCLUSIONS

The findings indicate that sociodemographic risk factors as well as clustering of anaemia varies with the severity of anaemia. Specific studies are needed to identify risk factors of mild anaemia as well as its consequences, as mild anaemia accounts for 20-40% of total prevalence of anaemia in Africa.

Nutrition intervention strategies to combat zinc deficiency in developing countries

Widespread zinc deficiency is likely to exist in developing countries where staple diets are predominantly plant based and intakes of animal tissues are low. The severe negative consequences of zinc deficiency on human health in developing countries, however, have only recently been recognized. An integrated approach employing targeted supplementation, fortification and dietary strategies must be used to maximize the likelihood of eliminating zinc deficiency at a national level in developing countries. Supplementation is appropriate only for populations whose zinc status must be improved over a relatively short time period, and when requirements cannot be met from habitual dietary sources. As well, the health system must be capable of providing consistent supply, distribution, delivery and consumption of the zinc supplement to the targeted groups. Uncertainties still exist about the type, frequency, and level of supplemental zinc required for prevention and treatment of zinc deficiency. Salts that are readily absorbed and at levels that will not induce antagonistic nutrient interactions must be used. At a national level, fortification with multiple micronutrients could be a cost effective method for improving micronutrient status, including zinc, provided that a suitable food vehicle which is centrally processed is available. Alternatively, fortification could be targeted for certain high risk groups (e.g. complementary foods for infants). Efforts should be made to develop protected fortificants for zinc, so that potent inhibitors of zinc absorption (e.g. phytate) present either in the food vehicle and/or indigenous meals do not compromise zinc absorption. Fortification does not require any changes in the existing food beliefs and practices for the consumer and, unlike supplementation, does not impose a burden on the health sector. A quality assurance programme is required, however, to ensure the quality of the fortified food product from production to consumption. In the future, dietary modification/diversification, although long term, may be the preferred strategy because it is more sustainable, economically feasible, culturally acceptable, and equitable, and can be used to alleviate several micronutrient deficiencies simultaneously, without danger of inducing antagonistic micronutrient interactions. Appropriate dietary strategies include consumption of zinc-dense foods and those known to enhance zinc absorption, reducing the phytic acid content of plant based staplesviaenzymic hydrolysis induced by germination/fermentation or nonenzymic hydrolysis by soaking or thermal processing. All the strategies outlined above should be integrated with ongoing national food, nutrition and health education programmes, to enhance their effectiveness and sustainability, and implemented using nutrition education and social marketing techniques. Ultimately the success of any approach for combating zinc deficiency depends on strong advocacy, top level commitment, a stable infrastructure, long term financial support and the capacity to control quality and monitor and enforce compliance at the national or regional level. To be cost effective, costs for these strategies must be shared by industry, government, donors and consumers.

Improved adherence and anaemia cure rates with flexible administration of micronutrient Sprinkles: a new public health approach to anaemia control

BACKGROUND/OBJECTIVES

Despite repeated public commitments and availability of various forms of iron supplements, rates of anaemia in developing countries remain high. A major reason for this lack of success has been poor adherence. The objective of this study was to compare the effectiveness of daily and flexible administration of micronutrient Sprinkles on adherence, acceptability and haematological status among young children in rural Bangladesh.

SUBJECTS/METHODS

A sample of 362 children (haemoglobin (Hb)>or=70 g l(-1)) aged 6-24 months were cluster-randomized to receive 60 sachets of Sprinkles either (i) daily over 2 months; (ii) flexibly over 3 months; or (iii) flexibly over 4 months. With a flexible regimen, mothers/caregivers decided how frequently to use Sprinkles without exceeding one sachet per day. Adherence was assessed monthly by counting the number of sachets used and acceptability was evaluated through focus group discussions. Haemoglobin was measured at baseline, at the end of each intervention period and 6 months post-intervention.

RESULTS

Mean percent adherence was significantly higher in the flexible-4-month group (98%) compared to the flexible-3-month (93%) and daily-2-month (88%) groups (P<0.01). Most mothers found flexible administration to be more acceptable than daily due to perceived benefits of use. Hb at the end of intervention was significantly higher in the flexible-4-month group compared to the daily group (P=0.03). Anaemia prevalence decreased by 65% in the flexible-4-month group compared to 54% in the flexible-3-month and 51% in the daily-2-month groups. Percent of cured children who maintained a non-anaemic status 6 months post-intervention was significantly higher in the flexible-4-month (82%) and flexible-3-month (80%) groups than the daily-2-month (53%) group (P<0.05).

CONCLUSIONS

The adherence, acceptability and haematological response to flexible administration over 4 months were found preferable to daily.

Determinants of compliance with iron supplementation among pregnant women in Senegal

BACKGROUND

Community iron supplementation programmes for pregnant women have lacked effectiveness, partly because of low compliance.

OBJECTIVE

To determine factors that influence compliance among pregnant women in Senegal.

DESIGN

Two hundred and twenty-one pregnant women, recruited from six health centres in Dakar during their first prenatal visit, were randomly assigned to receive either a prescription to purchase iron/folic acid tablets (control, n = 112) to be taken daily, according to official policy, or to receive free tablets (treatment, n = 109). Compliance was assessed 20 weeks after enrollment through interviews and pill count. Women with low or high compliance (<70% or >or=70%) were asked to explain what influenced their adherence to supplementation.

RESULTS

Overall compliance was 69%; it was significantly higher in the treatment than in the control group (86% vs. 48%; P < 0.0001). Women with high compliance (58%) were motivated by: (1) the perception of improved health upon taking the tablets (treatment = 24%, control = 10%); (2) the insistence by midwives that they take the tablets; and (3) the mention that the tablets would improve health. Women with low compliance (42%) reported: (1) the experience of side-effects that they associated with the tablets (treatment = 13%, control = 14%); (2) misunderstanding that they needed to continue taking the tablets throughout pregnancy (treatment = 0%, control = 18%); and (3) forgetfulness.

CONCLUSION

Compliance with iron/folic acid supplementation in Senegal can be increased by providing women with clear instructions about tablet intake and educating them on the health benefits of the tablets.

Factors that affect the adoption and maintenance of weekly vitamin A supplementation among women in Ghana

Objective

To identify regimen, individual, community and cultural factors that affect adoption and adherence to weekly vitamin A supplementation in Ghana.

Design

Fifty semi-structured interviews were conducted with women who would be eligible for vitamin A supplementation, 30 with husbands, and 13 with drug sellers, birth attendants and health workers. Six focus group discussions were also conducted with women. These interviews were followed by a 4-month capsule trial with 60 women. Data from a previously conducted communication channel survey of 332 women were also reviewed.

Setting

The study was conducted in Kintampo District in central Ghana.

Subjects

Participants for the semi-structured interviews and focus groups were selected from four villages and the district capital, and women in the capsule trial were selected at random from two villages.

Results

Knowledge of vitamins was low and taking ‘medicines’ for long periods and when healthy is a new concept. In spite of this, long-term supplementation will be accepted if motives are explained, specific questions answered and clear instructions are given. Potential barriers included the idea of ‘doctor’ medicines as curative, false expectations of the supplement, forgetting to take the supplement, losing the supplement, travelling, lack of motivation, perceived side-effects, concerns that the supplement is really family planning or will make delivery difficult, and concerns about taking the supplement with other ‘doctor’ or herbal medicine, or when pregnant or breast-feeding, or if childless.

Conclusion

Successful supplementation programmes require appropriately designed information, education and communication strategies. Designing such strategies requires pre-programme formative research to uncover barriers and facilitators for supplementation.

Prenatal iron supplementation in rural Vietnam

OBJECTIVE

To assess the potential impact of a national iron supplementation programme in rural Vietnam.

METHODS

The study included questionnaires, focus group discussions of pregnant women and key informant interviews, together with measurements of haemoglobin (Hb) and a stool examination for soil-transmitted helminths.

RESULTS

Iron supplementation significantly increased Hb concentration among participants in the second and third trimesters by 0.4 and 0.7 g/dl, respectively (P=0.017 and P<0.001). The risk of anaemia (Hb <10.0 g/dl) was increased significantly by hookworm infestation (P=0.041) and in summer season (P=0.001) and was decreased significantly by taking iron tablets (P=0.041).

CONCLUSIONS

The results of this study show that an iron supplementation programme is beneficial as a part of a comprehensive anaemia programme for pregnant women in these communities. These results will be useful for developing improved iron-deficiency anaemia control programs for pregnant women.

Iron supplementation compliance among pregnant women in Bicol, Philippines

OBJECTIVE

To quantify factors influencing iron supplementation compliance and haemoglobin (Hb) concentrations among pregnant women participating in an iron supplementation programme under routine field conditions.

DESIGN

Cross-sectional interviews and Hb measurements.

SETTINGS

Albay and Sorsogon provinces, Bicol, Philippines.

SUBJECTS

Three hundred and forty-six pregnant women receiving iron supplements via the Philippine iron supplementation programme.

RESULTS

Women had a mean Hb concentration of 10.75 +/- 1.43 g dl-1, and 56.4% were anaemic (Hb < 11.0 g dl-1). On average, the first prenatal visit occurred at nearly 4 months (3.80 +/- 1.56). The ratio of visits to number of months pregnant was 0.51 +/- 0.24. Self-reported consumption of pills received was 85% (0.85 +/- 0.23), although pill counts suggested that consumption was 70% (0.70 +/- 0.35). Using multiple regression, an earlier first prenatal visit and greater self-reported compliance were positively associated with Hb concentrations. Additionally, perceived health benefits from taking the supplements and higher health programme knowledge were positively associated with pill consumption, while experiencing side-effects and disliking the taste of the supplements were associated with lower pill consumption. A greater number of living children was negatively associated with the frequency of prenatal visits. The number of children was also directly negatively associated with Hb concentrations.

CONCLUSIONS

Compliance was positively related to Hb concentrations. Several factors associated with greater compliance were identified, including marital status, number of children, health programme knowledge, side-effects, perceived health benefits, and dislike of taste. Some of these factors may serve as avenues for interventions to increase compliance, and ultimately Hb concentrations.

Priorities in nutritional rehabilitation

This review examines nutritional rehabilitation and stresses nutrition prophylaxis or prevention because for school-age children, health promotion and disease prevention are the keys to a healthy childhood.

Linking traditional treatments of maternal anaemia to iron supplement use: an ethnographic case study from Pemba Island, Zanzibar

Iron deficiency anaemia is the most common form of malnutrition in the world. Pregnant women are particularly at risk for anaemia. Insufficient attention has been paid to the reasons underlying the only moderate success of iron supplementation. In this article an additional factor that can affect the use of iron supplements is proposed: their relevance to 'traditional' or nonbiomedical treatments of anaemia. This paper represents what is to our knowledge the first ethnographic description of nonbiomedical treatments for maternal anaemia. The research was conducted over several months on Pemba, one of the islands of the Zanzibar archipelago. Data were collected using a variety of qualitative methods, including in-depth interviews, focus group discussions and participant observation. Informants included 25 mothers and 27 traditional and biomedical health care workers. The resulting ethnography elucidates Pembans' beliefs about the relationship of food, traditional medicine, spirits and biomedical medicine in relation to anaemia. In the analysis of the ethnography, both anthropology and public health perspectives are incorporated to suggest how the understanding of these beliefs is useful for increasing iron supplement use.

Weekly iron as a safe alternative to daily supplementation for nonanemic pregnant women

BACKGROUND

We undertook this study to compare the effectiveness and safety of antenatal daily and weekly supplementation with iron, folic acid, and vitamin B(12) in healthy, pregnant women who were not anemic at gestational week 20.

METHODS

Women with singleton pregnancies and blood hemoglobin (Hb) >115 g/L at gestational week 20 (equivalent to 105 g/L at sea level) were randomly assigned to two groups, one consuming one tablet containing 60 mg iron, 200 mug folic acid and 1 mug vitamin B(12) daily (DS, n = 56); the other consuming two tablets once weekly (WS, n = 60). Blood Hb and serum ferritin concentrations were measured every 4 weeks from weeks 20 to 36, and pregnancy outcomes were evaluated.

RESULTS

Mild anemia and hypoferritinemia throughout pregnancy occurred less frequently in DS than WS. None of the 116 women had Hb concentrations <103 g/L at any evaluation point. In contrast, hemoconcentration (Hb >145 g/L) from gestational week 28 onwards occurred in 11% in DS and 2% in WS. We observed ex post facto that hemoconcentration at gestational week 28 was associated with a significantly higher relative risk of low birth weight (RR 6.23, 95% CI 1.46-26.57) and premature delivery (RR 7.78, 95% CI 1.45-24.74).

CONCLUSIONS

In women who were nonanemic at gestational week 20, both schemes (DS and WS) prevented the occurrence of Hb levels <100 g/L. DS women had a higher incidence of hemoconcentration. Hemoconcentration was associated with increased risk of low birth weight and premature delivery.

Effects of routine oral iron supplementation with or without folic acid for women during pregnancy

BACKGROUND

It has been suggested that routine intake of supplements containing iron or combination of iron and folic acid during pregnancy improves maternal health and pregnancy outcomes.

OBJECTIVES

To assess the efficacy, effectiveness and safety of routine antenatal daily or intermittent iron supplementation with or without folic acid during pregnancy on the health of mothers and newborns.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2005). Additionally, we contacted relevant organizations for the identification of ongoing and unpublished studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating the effect of routine supplementation with iron or combination of iron and folic acid during pregnancy.

DATA COLLECTION AND ANALYSIS

We assessed trials for methodological quality using the standard Cochrane criteria. Two authors independently assessed the trials for inclusion and one author extracted data. We collected information on randomisation method, allocation concealment, blinding and loss to follow up. The primary outcomes included maternal and infant clinical and laboratory outcomes.

MAIN RESULTS

Forty trials, involving 12706 women, were included in the review. Overall, the results showed significant heterogeneity across most prespecified outcomes. Heterogeneity could not be explained by standard sensitivity analyses including quality assessment; therefore, all results were analysed assuming random-effects. Very limited information related to clinical maternal and infant outcomes was available in the included trials. The data suggest that daily antenatal iron supplementation increases haemoglobin levels in maternal blood both antenatally and postnatally. It is difficult to quantify this increase due to significant heterogeneity between the studies. Women who receive daily antenatal iron supplementation are less likely to have iron deficiency and iron-deficiency anaemia at term as defined by current cut-off values. Side-effects and haemoconcentration are more common in women who receive daily iron supplementation. No differences were evident between daily and weekly supplementation with regards to gestational anaemia; haemoconcentration during pregnancy appears less frequent with the weekly regimen. The clinical significance of hemoconcentration defined as haemoglobin greater than 130 g/L remains uncertain.

AUTHORS' CONCLUSIONS

Further studies are needed to assess the effects of routine antenatal supplementation with iron or a combination of iron and folic acid on clinically important maternal and infant outcomes.

Differing perspectives of inner-city parents and pediatric clinicians impact management of iron-deficiency anemia

OBJECTIVE

To ascertain the beliefs and experiences of inner-city pediatric clinicians and parents regarding anemia in young children.

DESIGN

Focus groups and in-depth interviews.

SETTING

Pediatric clinics and community agencies in Hartford, Connecticut.

PARTICIPANTS

Convenience sample of 41 pediatric clinicians (93% white, 73% female) and 85 parents (100% minority, 88% female, 47% < 12 years education).

PHENOMENON OF INTEREST

Identification, understanding, and management of anemia.

ANALYSIS

Researcher pairs coded complete transcriptions. Recurrent themes were identified, which were then contrasted and compared between clinicians and parents.

RESULTS

Both clinicians and parents were familiar with, but frustrated by the persistence of anemia. They noted time constraints and poor communication during office visits as contributing to the problem. Parents felt alarmed upon initial diagnosis; linked anemia with heredity, food patterns, and activity; reported culturally linked management strategies; but were uncertain of the seriousness. Health clinicians saw physiological processes as outside the parents' understanding and emphasized prevention through feeding recommendations.

CONCLUSIONS AND IMPLICATIONS

In order to address childhood anemia effectively, differing socio-cultural perspectives of clinicians and parents need to be incorporated into a unified health care plan. Nutritionists are well suited to collaborate on the health care team to effectively address this issue.

Pill count adherence to prenatal multivitamin/mineral supplement use among low-income women

In the United States, the prevalence of third trimester anemia among low-income pregnant women is 29% and has not improved since the 1980s. Although low adherence has been linked to the ineffectiveness of iron supplementation programs, data regarding adherence to supplementation in low-income women are currently lacking. Hence this study was conducted to better understand the factors associated with adherence to the use of iron-containing prenatal multivitamin/mineral supplements among low-income pregnant women. Adherence to supplement use was assessed by pill counts among 244 pregnant women of 867 women who were initially randomized to receive 1 of 3 prenatal supplements. All women received care at a public prenatal clinic. Maternal characteristics associated with adherence were identified using predictive modeling. Women took 74% of supplements as prescribed. Adherence was higher among non-Hispanic white women than among non-Hispanic black women (79% vs. 72%, P </= 0.01). Interactions of ethnicity with age group, smoking status, and prior supplement use were significant. Multivariate regression analysis stratified by ethnicity revealed that among the white women education beyond high school, unmarried status, nulligravidity, and smoking were positively associated with adherence. In contrast, among the black women, supplement use 3 mo prior to current pregnancy and no loss of appetite were positively associated with adherence. Further research investigating the influence of cultural factors is necessary to better understand adherence to supplement use and the differences in adherence among ethnic groups.

Iron bioavailability in prenatal multivitamin supplements with separated and combined iron and calcium

OBJECTIVE

To compare iron absorption of a prenatal multivitamin supplement containing both iron and calcium (HICA) to that of another multivitamin containing a lower iron dose and no calcium (LI).

METHODS

In a crossover study, serum iron was measured in 12 healthy women administered HICA and LI separately on 2 different occasions. Blood samples were taken at 0, 1, 2, 3, 4, 6, and 8 hours after administration of each supplement.

RESULTS

The values of the area under the concentration-time curve (AUC) were not significantly different between LI (79.1 +/- 36.0 micro M*h) and HICA (91.4 +/- 50.4 micro M*h) (P =.37). After standardizing the AUC for dose, the relative absorption over the 8-hour time period was significantly higher for LI (2.3 +/-.0 micro M*h/mg) than for HICA (1.5 +/- 0.8 micro M*h/mg) (P =.021).

CONCLUSION

The absorption of iron from a low-iron-containing supplement was similar to that from a supplement with almost twice the amount of iron, due possibly to the exclusion of calcium in the LI product. Thus, while offering similar amounts of iron, the LI supplement may be better tolerated by women who are sensitive to iron-induced adverse effects.

Micronutrient sprinkles to control childhood anaemia

Over 750 million children have iron-deficiency anemia. A simple powdered sachet may be the key to addressing this global problem

Controlling iron deficiency anemia through the use of home-fortified complementary foods

Iron deficiency anemia (IDA) is more common in South Asian countries including India, Bangladesh and Pakistan than anywhere else in the world. During infancy and early childhood, IDA is associated with impaired psycho-motor development and cognitive function that may be irreversible. As a consequence, there is a growing awareness that IDA is one of many factors impeding socio-economic prosperity of developing nations. The combination of unacceptably high prevalence rates and inadequate preventative programs highlights the need for new effective sustainable strategies to control IDA. The burden of iron deficiency can be reduced by taking a more holistic approach that would include promotion of healthy weaning practices and use of appropriate complementary foods, together with improving the nutritional value of such foods. There is an increasing body of peer-reviewed literature to support the contention that "micronutrient Sprinkles" is an effective strategy to improve the nutritional value of home-prepared complementary foods and thus to reduce the burden of iron deficiency among children. By combining data from recently conducted randomised control trials, Sprinkles were shown to be as efficacious as iron drops for treating childhood anemia. The iron in Sprinkles is well absorbed, and Sprinkles are easy to use and well accepted by young children and their caregivers. Integrated into existing public health programs, Sprinkles has the potential to improve the effectiveness of such programs.

Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world

Iron deficiency is the most common and widespread nutritional disorder in the world, affecting millions of people in both nonindustrialized and industrialized countries. We estimated the costs, effects, and cost-effectiveness of iron supplementation and iron fortification interventions in 4 regions of the world. The effects on population health were arrived at by using a population model designed to estimate the lifelong impact of iron supplementation or iron fortification on individuals benefiting from such interventions. The population model took into consideration effectiveness, patient adherence, and geographic coverage. Costs were based on primary data collection and on a review of the literature. At 95% geographic coverage, iron supplementation has a larger impact on population health than iron fortification. Iron supplementation would avert <12,500 disability adjusted life years (DALY) annually in the European subregion, with very low rates of adult and child mortality, to almost 2.5 million DALYs in the African and Southeast Asian subregions, with high rates of adult and child mortality. On the other hand, fortification is less costly than supplementation and appears to be more cost effective than iron supplementation, regardless of the geographic coverage of fortification. We conclude that iron fortification is economically more attractive than iron supplementation. However, spending the extra resources to implement iron supplementation is still a cost-effective option. The results should be interpreted with caution, because evidence of intervention effectiveness predominantly relates to small-scale efficacy trials, which may not reflect the actual effect under expected conditions.

Daily iron supplementation is more efficacious than twice weekly iron supplementation for the treatment of childhood anemia in western Kenya

A recent meta-analysis of 14 clinical trials indicated that daily compared with intermittent iron supplementation resulted in significantly greater hematological improvement in pregnant women. No such definitive beneficial effect was demonstrated in preschool children. We compared the efficacy of daily and twice weekly iron supplementation for 6 wk under supervised and unsupervised conditions in the treatment of mild and moderate anemia [hemoglobin (Hb) 50-109 g/L] in children aged 2-59 mo living in a malaria-endemic area of western Kenya. The study was a cluster-randomized trial using a factorial design; participants were aware of the treatment assigned. All children (n = 1049) were administered a single dose of sulfadoxine-pyrimethamine at enrollment followed by 6 wk of daily supervised iron supplementation [3-6 mg/(kg.d)], twice weekly supervised iron supplementation [6-12 mg/(kg.wk)], daily unsupervised iron supplementation, or twice weekly unsupervised iron supplementation. In the supervised groups, Hb concentrations at 6 and 12 wk (6 wk postsupplementation) were significantly higher in children given iron daily rather than twice weekly [mean (95% CI) difference at 6-wk: 4.2 g/L (2.1, 6.4); 12-wk: 4.4 g/L (1.8, 7.0)]. Among the unsupervised groups, Hb concentrations were not different at 6 wk [mean (95% CI) difference: 0.86 g/L (-1.4, 3.1)], but significantly higher at 12 wk for those assigned daily iron [mean (95% CI) difference: 3.4 g/L (0.79, 6.0), P = 0.02]. In this malarious area and after initial antimalarial treatment, 6 wk of daily iron supplementation results in better hematological responses than twice weekly iron supplementation in the treatment of anemia in preschool children, regardless of whether adherence can be ensured.

Valeur diagnostique de la pâleur des téguments dans l'anémie chez les femmes enceintes au Bénin

Anemia in pregnant women is a common and severe public health problem encountered in developing countries. Its detection is most often based upon clinical examination and observation of conjunctive pallor; however, little is known or documented on the performance indicators of this clinical method in Africa. This work aims assess the value of performance indicators in detecting moderate and severe anemia by means of tegument pallor examination in a maternity ward in rural Benin. To this end, 480 pregnant women were recruited at random during their prenatal visits to a rural maternity clinic. Two independent observers had noted conjunctive or other forms of teguments in all of the women selected, and a concentration of hemoglobin was confirmed by a blood test. An analysis of the results indicated that 67.4% of pregnant women were biologically anemic (Hb < 11.0 g/dl) while only 49% among them were clinically anemic. The sensitivity of the clinical observation method for conjunctive pallor is 87.5% for severe anemia and 74% for moderate anemia. Its positive predictive value is 62.5% for moderate anemia and very weak for light cases of anemia, at only 3%. The accuracy of this clinical method varies from 51-71%, when the likelihood is determined as 1.8 to 2.3. Its reproducibility appears equally weak and clinical observer variability seems to be poor to fair agreement at k = 0.34 (p = 0.00). For practical reasons, the authors suggest the strengthening of the teaching of this method to obstetrics' care providers and medical students in training in order to improve its more effective use and practice in rural maternity units without laboratories.

Inflammatory bowel disease in early childhood and adolescence: special considerations

Several aspects of IBD overlap between pediatric and adult population. Those include nutritional issues, bone density, and medical and surgical therapies. Some aspects like natural course of the disease, and epidemiology and genetics are more easily examined and researched in the pediatric population. Others like pubertal and growth delay, and transition of health care are unique to pediatric patients. This article examines some of the similarities, as well as differences of IBD in these two populations.

Food prepared in iron cooking pots as an intervention for reducing iron deficiency anaemia in developing countries: a systematic review

OBJECTIVE

To complete a systematic review of the effect of preparing food cooked in iron pots on haemoglobin concentrations and to assess compliance with pot use. DESIGN AND SEARCH STRATEGY: We searched The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, The Cochrane Controlled trials Register, The Cochrane Methodology Register, Health Technology Assessment Database and NHS Economic Evaluation Database (Cochrane Library, Issue 3, 2002). Medline (1966 to May 2002) and EMBASE (1988 to May 2002). Reference lists of published trials were examined for other potentially relevant trials and authors of selected trials were contacted to obtain information about ongoing or unpublished trials. Selection criteria included randomized trials which compared the effect of food cooked in cast iron pots with food cooked in noncast iron pots on participants of a minimum age of 4 months. One reviewer applied inclusion criteria to potentially relevant trials. Two reviewers assessed trial quality and extracted data.

RESULTS

Three trials were eligible for inclusion in the review. There is some evidence from these studies that eating food prepared in iron pots increases the haemoglobin concentration of anaemic/iron deficient individuals. This effect seems to be modified by compliance, users age, and the presence of malaria and hookworm. Compliance with pot use varies considerably between countries depending on several factors, including: size of the cooking pot, targeted user group, whether the pot is used as an extra or replacement pot, and familiarity with cast iron pots.

CONCLUSION

The introduction of iron pots or improving their use in communities in developing countries for the preparation of food maybe a promising innovative intervention for reducing iron deficiency and iron deficiency anaemia. Further research is required to monitor the use and effectiveness of this intervention.

Iron supplementation during pregnancy in Sweden: to what extent is the national recommendation followed?

BACKGROUND

While there has been a worldwide trend to reduce the recommended amount of iron in prenatal supplements, this has still not been implemented in Sweden. It is likely that the current national recommendation of 100 mg of iron/day to all pregnant women provides a larger amount of iron than warranted and results in increased occurrence of side-effects and reduced compliance. This may also reduce midwives' motivation to implement the recommendation. The aim of this study was to assess adherence to the current recommendation and to describe factors associated with prescription and use of iron supplements.

METHODS

A questionnaire capturing determinants for and use of prenatal iron supplementation was distributed to newly delivered women and midwives in five regions of Sweden. In addition, an inquiry about implementation of the recommendation was sent to all senior obstetricians in charge of antenatal care.

RESULTS

Most (79%) of the senior obstetricians indicated adherence to the national recommendation. A lower percentage of midwives (41%) and a further lower proportion of pregnant women (28%) did so. Despite limited compliance to the recommendation, the majority of pregnant women had used some type of iron-containing supplement. Side-effects of supplements, perceived need and advice from midwives influenced their use. Many midwives preferred and practiced a selective supplementation strategy.

CONCLUSIONS

The current recommendation is not practiced. Side-effects and perceptions that the amount of iron is larger than necessary contribute to its limited use. A revision is needed to address the amount of iron required and strategies to ensure good adherence.