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

The Effect of Iron-Fortified Lentils on Blood and Cognitive Status among Adolescent Girls in Bangladesh

BACKGROUND

Iron deficiency is highly prevalent in South Asia, especially among women and children in Bangladesh. Declines in cognitive performance are among the many functional consequences of iron deficiency.

OBJECTIVE

We tested the hypothesis that, over the course of a 4-month iron fortification trial, cognitive performance would improve, and that improvement would be related to improvements in iron status.

METHODS

Participants included 359 adolescent girls attending Bangladesh Rural Advancement Committee (BRAC) clubs as a subsample of a larger double-blind, cluster-randomized community trial in which participants were assigned to one of three conditions: a condition in which no lentils were supplied (NL, n = 118, but which had the usual intake of lentils), a control (non-fortified) lentil condition (CL, n = 124), and an iron-fortified lentil condition (FL, n = 117). In the FL and CL conditions, approximately 200 g of cooked lentils were served five days per week for a total of 85 feeding days. In addition to biomarkers of iron status, five cognitive tasks were measured at baseline (BL) and endline (EL): simple reaction time task (SRT), go/no-go task (GNG), attentional network task (ANT), the Sternberg memory search Task (SMS), and a cued recognition task (CRT).

RESULTS

Cognitive performance at EL was significantly better for those in the FL relative to the CL and NL conditions, with this being true for at least one variable in each task, except for the GNG. In addition, there were consistent improvements in cognitive performance for those participants whose iron status improved. Although there were overall declines in iron status from BL to EL, the declines were smallest for those in the FL condition, and iron status was significantly better for those in FL condition at EL, relative to those in the CL and NL conditions.

CONCLUSIONS

the provision of iron-fortified lentils provided a protective effect on iron status in the context of declines in iron status and supported higher levels of cognitive performance for adolescent girls at-risk of developing iron deficiency.

Effect of iron fortification on anaemia and risk of malaria among Ghanaian pre-school children with haemoglobinopathies and different ABO blood groups

BACKGROUND

Haemoglobinopathies such as sickle cell disorder and glucose-6-phosphate dehydrogenase (G6PD) deficiency as well as differences in ABO blood groups have been shown to influence the risk of malaria and/or anaemia in malaria-endemic areas. This study assessed the effect of adding MNP containing iron to home-made weaning meals on anaemia and the risk of malaria in Ghanaian pre-school children with haemoglobinopathies and different ABO blood groups.

METHODS

This study was a double-blind, randomly clustered trial conducted within six months among infants and young children aged 6 to 35 months in rural Ghana (775 clusters, n = 860). Participants were randomly selected into clusters to receive daily semiliquid home-prepared meals mixed with either micronutrient powder without iron (noniron group) or with iron (iron group; 12.5 mg of iron daily) for 5 months. Malaria infection was detected by microscopy, blood haemoglobin (Hb) levels were measured with a HemoCue Hb analyzer, the reversed ABO blood grouping microtube assay was performed, and genotyping was performed by PCR-RFLP analysis.

RESULTS

The prevalence of G6PD deficiency among the study participants was 11.2%. However, the prevalence of G6PD deficiency in hemizygous males (8.5%) was significantly higher than that in homozygous females (2.7%) (p = 0.005). The prevalence rates of sickle cell traits (HbAS and HbSC) and sickle cell disorder (HbSS) were 17.5% and 0.5%, respectively. Blood group O was dominant (41.4%), followed by blood group A (29.6%) and blood group B (23.3%), while blood group AB (5.7%) had the least frequency among the study participants. We observed that children on an iron supplement with HbAS had significantly moderate anaemia at the endline (EL) compared to the baseline level (BL) (p = 0.004). However, subjects with HbAS and HbAC and blood groups A and O in the iron group had a significantly increased number of malaria episodes at EL than at BL (p < 0.05). Furthermore, children in the iron group with HbSS (p < 0.001) and the noniron group with HbCC (p = 0.010) were significantly less likely to develop malaria.

CONCLUSIONS

Iron supplementation increased anaemia in children with HbAS genotypes and provided less protection against malaria in children with HbAC and AS and blood groups A and O.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01001871 . Registered 27/10/2009.

REGISTRATION NUMBER

https://clinicaltrials.gov/ct2/show/record/NCT01001871 .

Geographical variation and temporal trend in anemia among children aged 6-59 months in low- and middle-income countries during 2000-2018: forecasting the 2030 SDG target

OBJECTIVE

To examine geographical variations, trends and projections in the prevalence of childhood anemia at national and subpopulation levels.

DESIGN

Repeated cross-sectional Demographic and Health Survey (DHS) conducted during 2000-2018.

SETTING

Fifty-three low- and middle-income countries (LMIC).

PARTICIPANTS

Totally, 776 689 children aged 6-59 months.

RESULTS

During the latest DHS rounds between 2005 and 2018, the prevalence of child anemia was > 20 % in fifty-two out of fifty-three countries and ranged from 15·9 % in Armenia in 2016 to 87·8 % in Burkina Faso in 2010. Out of thirty-six countries with at least two surveys during 2000-2018, the prevalence of child anemia decreased in twenty-two countries, highest in Zimbabwe (-4·2 %) and increased in fourteen countries, highest in Burundi (5·0 %). Based on the trend, eleven and twenty-two out of thirty-six countries are projected to experience, respectively, moderate and severe public health problem according to the WHO criteria (moderate problem: 20-39·9 % and severe problem: ≥ 40 %) due to child anemia in 2030, with the highest prevalence in Liberia (87·5 %, 95 % credible interval 52·0-98·8 %). The prevalence of child anemia varied across the mother's education and age, child sex, wealth quintiles, and place of residence, with the highest rate of child anemia among the poorest, rural and low-educated mothers. These scenarios are projected to continue. The probability of reducing child anemia at < 0·5 % by 2030 is 0 % for all study countries.

CONCLUSIONS

The prevalence of child anemia varied between and within countries. None of the thirty-six LMIC is likely to eradicate child anemia by 2030.

Impact of iron fortification on anaemia and iron deficiency among pre-school children living in Rural Ghana

Anaemia in young sub-Saharan African children may be due to the double burden of malaria and iron deficiency. Primary analysis of a double-blind, cluster randomized trial of iron containing micronutrient powder supplementation in Ghanaian children aged 6 to 35 months found no difference in malaria risk between intervention and placebo groups. Here, we performed a secondary analysis of the trial data to assess the impact of long-term prophylactic iron fortificant on the risk of iron deficiency and anaemia in trial subjects. This population-based randomized-cluster trial involved 1958 children aged between 6 to 35 months, identified at home and able to eat semi-solid foods. The intervention group (n = 967) received a daily dose containing 12.5 mg elemental iron (as ferrous fumarate), vitamin A (400 μg), ascorbic acid (30 mg) and zinc (5 mg). The placebo group (n = 991) received a similar micronutrient powder but without iron. Micronutrient powder was provided daily to both groups for 5 months. At baseline and endline, health assessment questionnaires were administered and blood samples collected for analysis. The two groups had similar baseline anthropometry, anaemia, iron status, demographic characteristics, and dietary intakes (p > 0.05). Of the 1904 (97.2%) children who remained at the end of the intervention, the intervention group had significantly higher haemoglobin (p = 0.0001) and serum ferritin (p = 0.0002) levels than the placebo group. Soluble transferrin receptor levels were more saturated among children from the iron group compared to non-iron group (p = 0.012). Anaemia status in the iron group improved compared to the placebo group (p = 0.03). Continued long-term routine use of micronutrient powder containing prophylactic iron reduced anaemia, iron deficiency and iron deficiency anaemia among pre-school children living in rural Ghana's malaria endemic area.

Acceptability of multiple micronutrient powders and iron syrup in Bihar, India

Nearly two thirds of young children are anaemic in Bihar, India. Paediatric iron and folic acid syrup (IFAS) and multiple micronutrient powders (MNPs) are two evidence‐based interventions to prevent anaemia. Using a randomized crossover design, we examined the acceptability of IFAS versus MNPs for children 6–23 months. In a catchment area of 2 health centres in Bihar, health front‐line workers (FLWs) delivered either (a) IFAS twice weekly or (b) MNPs for 1 month followed by the other supplementation strategy for 1 month to the same families (NCT02610881). Household surveys were conducted at baseline (N = 100), 1 month after receiving the first intervention (1 month; N = 95), and 1 month after the second intervention (2 months; N = 93). Focus group discussions (10 FLWs) and in‐depth interviews (20 mothers) were held at 1 and 2 months. We used chi‐square and Fisher exact tests to test mothers' product preferences. Qualitative data were analysed using MaxQDA and Excel employing a thematic analysis approach. There was high adherence and acceptability for both products (>80%). There was no significant difference in preference (p < .05) on perceived benefits (39% MNPs, 40% IFAS), side effects (30% MNPs, 30% IFAS), ease of use (42% IFAS, 31% MNPs), child preference (45% IFAS, 37% MNPs), and maternal preference (44% IFAS, 34% MNPs). Mothers and FLWs indicated that the direct administration of IFAS ensured that children consumed the full dose, and MNPs intake depended on the quantity of food consumed, especially among younger children, which emphasizes the need to integrate supplementation with the promotion of optimal child feeding practices.

Iron deficiency anemia in infants and toddlers

Background

In Korea, the prevalence of anemia and iron deficiency anemia (IDA) among older infants and young children remains high. To detect IDA early and to reduce its adverse impact, we assessed the characteristics of infants and young children who had IDA or were at risk of developing IDA, or who exhibited characteristics associated with severe anemia.

Methods

Among the 1,782 IDA-affected children aged 6 months to 18 years who visited the hospital, we retrospectively analyzed the medical records and laboratory data of 1,330 IDA-affected children aged 6–23 months who were diagnosed between 1996 and 2013. We excluded patients with a C-reactive protein level ≥5 mg/dL.

Results

IDA was predominant in boys (2.14:1) during infancy and early childhood. The peak IDA incidence was noted among infants aged 9–12 months. Only 7% patients exhibited symptoms of IDA, while 23.6% patients with severe IDA demonstrated classic symptoms/signs of IDA. Low birth weight (LBW) infants with IDA demonstrated low adherence to iron supplementation. In a multivariate analysis, prolonged breastfeeding without iron fortification (odds ratio [OR] 5.70), and a LBW (OR 6.49) were identified as risk factors of severe anemia.

Conclusion

LBW infants need more attention in order to increase their adherence to iron supplementation. For the early detection of IDA, nutritional status of all infants, and iron batteries of high-risk infants (LBW infants, infants with prolonged breastfeeding, picky eaters, and/or infants with the presence of IDA symptoms) should be evaluated at their health screening visits.

Factors Influencing Child Feeding Practices Related to Home Fortification With Micronutrient Powder Among Caregivers of Under-5 Children in Bangladesh

BACKGROUND

Anemia is a major public health concern in Bangladesh, affecting about 51% of under-5 children. There are a number of strategies to overcome this micronutrient-deficiency burden, and home fortification (HF) with micronutrient powder (MNP) is one of them.

OBJECTIVE

As part of an evaluation of an HF with MNP intervention program, we conducted a qualitative study to understand the factors influencing demand, purchase, and utilization of MNP by caregivers of under-5 children.

METHODS

We purposively selected study participants from 5 subdistricts and 1 urban slum in Bangladesh where HF with Pushtikona (a brand name of MNP) program is available. Data were collected through household observations and conducting in-depth interviews and focus group discussions with caregivers, grandmothers, and fathers of under-5 children.

RESULTS

Our study showed that caregivers were initially cautious, using Pushtikona on a trial basis, and afterward they employed various strategies to get their children to eat food fortified with Pushtikona. Barriers to acceptance and use of Pushtikona included inappropriate initiation of complementary feeding, discouragement from influential family members as well as miscommunication, conflicting information, and irregular visits by the health workers who sell Pushtikona to caregivers. Based on these findings, we characterized the users of Pushtikona as regular, ever, irregular, and never.

CONCLUSION

The evidence suggests that focusing on counseling caregivers and other family members on the importance of MNP and on age-appropriate feeding practices will be critical to the success of this intervention program as will regular visits by health workers and improved service delivery.

Assessment of metal contents in spices and herbs from Saudi Arabia

In the recent years, there has been a growing interest in monitoring heavy metal contamination of spices/herbs. Spices and herbs are sources of many bioactive compounds that can improve the tastes of food as well as influence digestion and metabolism processes. In the present study, the levels of some essential and toxic elements such as iron (Fe), zinc (Zn), copper (Cu), chromium (Cr), manganese (Mn), cobalt (Co), nickel (Ni), lead (Pb), and cadmium (Cd), present in common spices/herbs that were purchased from the local market in Saudi Arabia, were analyzed by atomic absorption spectroscopy after digestion with nitric acid/hydrogen peroxide mixture. Samples from the following spices/herbs were used: turmeric, cloves, black pepper, red pepper, cumin, legume, cinnamon, abazir, white pepper, ginger, and coriander. The concentration ranges for the studied elements were found as 48.8-231, 4.7-19.4, 2.5-10.5, below detection level (BDL)-1.0, 8.8-490, 1.0-2.6, and BDL-3.7 µg g(-1) for Fe, Zn, Cu, Cr, Mn, Ni, and Pb, respectively, while Cd and Co levels were below the detection limit. Consumers of these spices/herbs would not be exposed to any risk associated with the daily intake of 10 g of spices per day as far as metals Fe, Zn, Cu, Cr, Mn, Ni, and Pb are concerned.

Bioavailability of iron, vitamin A, zinc, and folic acid when added to condiments and seasonings

Seasonings and condiments can be candidate vehicles for micronutrient fortification if consumed consistently and if dietary practices ensure bioavailability of the nutrient. In this review, we identify factors that may affect the bioavailability of iron, vitamin A, zinc, and folic acid when added to seasonings and condiments and evaluate their effects on micronutrient status. We take into consideration the chemical and physical properties of different forms of the micronutrients, the influence of the physical and chemical properties of foods and meals to which fortified seasonings and condiments are typically added, and interactions between micronutrients and the physiological and nutritional status of the target population. Bioavailable fortificants of iron have been developed for use in dry or fluid vehicles. For example, sodium iron ethylenediaminetetraacetic acid (NaFeEDTA) and ferrous sulfate with citric acid are options for iron fortification of fish and soy sauce. Furthermore, NaFeEDTA, microencapsulated ferrous fumarate, and micronized elemental iron are potential fortificants in curry powder and salt. Dry forms of retinyl acetate or palmitate are bioavailable fortificants of vitamin A in dry candidate vehicles, but there are no published studies of these fortificants in fluid vehicles. Studies of zinc and folic acid bioavailability in seasonings and condiments are also lacking.

Prevalence of Iron Deficiency and Anemia among Young Children with Acute Diarrhea in Bhaktapur, Nepal

Iron deficiency anemia is still common in children under five years of age and may impair their growth and cognitive development. Diarrhea is the second most common reason for seeking medical care for young children in Nepal. However, neither screening programs nor effective preventive measures for anemia and iron deficiencies are in place among children with diarrhea in many developing countries. The aims of this study were to determine the prevalence of anemia and iron deficiency and explore their associations with clinical, socioeconomic, and anthropometric parameters in Nepalese children. This was a cross-sectional study based on 1232 children, six to 35 months old, with acute diarrhea participating in a zinc supplementation trial. The mean (SD) hemoglobin was 11.2 g/dL (1.2). Anemia was found in 493 children (40%); this estimate increased to 641 (52%) when we adjusted for the altitude of the study area (hemoglobin <11.3 g/dL). One in every three children had depleted iron stores and 198 (16%) of the children had both depleted iron stores and anemia, indicating iron deficiency anemia. The prevalence of anemia among children presenting with acute diarrhea was high but the degree of severity was mainly mild or moderate. Iron deficiency explained less than half of the total anemia, indicating other nutritional deficiencies inducing anemia might be common in this population.

Home fortification with calcium reduces Hb response to iron among anaemic Bangladeshi infants consuming a new multi-micronutrient powder formulation

OBJECTIVE

To investigate whether the recommended dietary intake of Ca in anaemic infants compromises the expected Hb response, via home fortification with a new Ca- and Fe-containing Sprinkles™ micronutrient powder (MNP).

DESIGN

A double-blind, randomized controlled, 2-month trial was conducted in Bangladesh. Infants were randomized to one of two MNP intervention groups containing Fe and other micronutrients, with or without Ca. Hb, anthropometrics and dietary intake were measured pre- and post-intervention while family demographics were collected at baseline.

SETTING

Twenty-six rural villages in the Kaliganj sub-district of Gazipur, Bangladesh.

SUBJECTS

One hundred infants aged 6-11 months.

RESULTS

A significant increase in Hb (MNP, 13·3 (sd 12·6) g/l v. Ca-MNP, 7·6 (sd 11·6) g/l; P < 0·0001) was noted in infants from both groups. However, infants receiving MNP without Ca had a significantly higher end-point Hb concentration (P = 0·024) and rate of anaemia recovery (P = 0·008). Infants receiving MNP with Ca were more likely to remain anaemic (OR 3·2; 95 % CI 1·4, 7·5). Groups did not differ in dietary intake or demographic and anthropometric indicators.

CONCLUSIONS

Although both groups showed significant improvement in Hb status, the nutrient-nutrient interaction between Fe and Ca may have diminished the Hb response in infants receiving the Ca-containing MNP.

Delivering Sprinkles Plus through the Integrated Child Development Services (ICDS) to reduce anemia in pre-school children in India

OBJECTIVE

To assess the effectiveness of micronutrient powder (MNP) supplementation in reducing anemia levels in children aged 6 mo to 6 y in India.

METHODS

Sixty sachets of MNP (Sprinkles Plus) were administered flexibly over a 4 mo period to 17,124 children at anganwadi centers or at home through Integrated Child Development Services (ICDS). Compliance was monitored using compliance cards and an assessment of mother's recall at post-intervention survey. Hemoglobin was measured in separate random samples of 1,786 children before and 1,782 children after MNP supplementation.

RESULTS

Mean compliance rate was estimated at 56.4 % (based on mother's recall) and 91.7 % (based on compliance cards) for children who received MNP at home. Mean compliance was 96.9 % (based on compliance cards) for children who received MNP at anganwadis. A significant reduction in anemia (50 % to 33 % in boys; p-value <.000; 47.4 % to 34.2 % in girls) was seen following MNP supplementation.

CONCLUSIONS

Integration of a flexibly administered MNP supplementation into the ICDS is effective in reducing and treating anemia in children 6 mo to 6 y age.

Effect of daily versus weekly home fortification with multiple micronutrient powder on haemoglobin concentration of young children in a rural area, Lao People's Democratic Republic: a randomised trial

BACKGROUND

Multiple micronutrient deficiencies, in particular iron deficiency anaemia (IDA) is a severe public health problem in Lao People's Democratic Republic (Lao PDR). Because of the practical difficulties encountered in improving the nutritional adequacy of traditional complementary foods and the limitations associated with the use of liquid iron supplementation for the treatment and prevention of IDA in infants and young children, recently, home-fortification with multivitamins and minerals sprinkles was recommended. This study aims to compare the effect of twice weekly versus daily supplementation with multivitamins and minerals powder (MMP) on anaemia prevalence, haemoglobin concentration, and growth in infants and young children in a rural community in Lao PDR.

METHODS

A randomized trial was conducted in six rural communities. Children aged 6 to 52 months (n = 336) were randomly assigned to a control group (n = 110) or to one of two intervention groups receiving either two sachets per week (n = 115) or a daily sachet (n = 111) of MMP for 24 weeks; 331 children completed the study. A finger prick of blood was taken at baseline, at week 12, and again at week 24 to determine haemoglobin concentration. Anthropometric measurements were taken every 4 weeks. The McNemar test was used to assess within group differences at three time points in the study subjects with anaemia and one-way ANOVA was used to assess changes in mean haemoglobin concentration in the treatment groups.

RESULTS

MMP supplementation resulted in significant improvements in haemoglobin concentration and in the reduction of anaemia prevalence in the two treatment groups compared with the control group (p <0.001). The severely to moderately anaemic children (Hb <100 g/L) on daily supplementation recovered faster than those on twice weekly supplementation. MMP was well accepted and compliance was high in both treatment groups. Overall, the improvement in the weight for age Z-score was very small and not statistically significant across the three study groups.

CONCLUSIONS

MMP supplementation had positive effects in reduction of anaemia prevalence and in improving haemoglobin concentration. For severely to moderately anaemic children, daily MMP supplementation was more effective in improving haemoglobin concentration and reducing anaemia prevalence. A longer intervention period is probably needed to have a positive effect on growth.

Daily Use of Sprinkles Micronutrient Powder for 2 Months Reduces Anemia among Children 6 to 36 Months of Age in the Kyrgyz Republic: A Cluster-Randomized Trial

Background

Iron-deficiency anemia is widespread among young children in the Kyrgyz Republic, and there is an urgent need to identify an effective intervention to address this significant public health problem.

Objective

To test the effectiveness of a 2-month intervention with daily home fortification of complementary food using micronutrient powder (Sprinkles) in reducing anemia among children 6 to 36 months of age in the Kyrgyz Republic.

Methods

In this cluster-randomized, community-based effectiveness trial conducted in three regions of the Kyrgyz Republic, 24 clusters of children aged 6 to 36 months were randomly assigned to two groups. The intervention group (12 clusters, n = 1,103) received 60 sachets of micronutrient powder (12.5 mg elemental iron), which were taken as one sachet daily for 2 months. The control group (12 clusters, n = 1,090) did not receive micronutrient powder until after the study period. Blood hemoglobin concentration was assessed at the start and end of the intervention.

Results

From baseline to follow-up, the mean hemoglobin concentration in the intervention group increased by 7 g/L, whereas it decreased by 2 g/L in the control group ( p < .001). The prevalence of anemia (hemoglobin < 110 g/L) in the intervention group decreased from 72% at baseline to 52% at follow-up, whereas it increased from 72% to 75% in the control group ( p < .001). Compliance with the intervention was high, with children consuming on average 45 of the 60 sachets given.

Conclusions

A course of 60 Sprinkles micronutrient powder sachets taken daily for 2 months is effective in improving hemoglobin levels and reducing the prevalence of anemia among young children in the Kyrgyz Republic.

Effects of Bifidobacterium lactis HN019 and prebiotic oligosaccharide added to milk on iron status, anemia, and growth among children 1 to 4 years old

OBJECTIVE

To evaluate the effect of Bifidobacterium lactis HN019 and prebiotic-fortified milk on iron status, anemia, and growth among 1- to 4-year-old children.

PATIENTS AND METHODS

In a community-based double-masked, controlled trial in a periurban population, 624 children were enrolled and randomly allocated to receive either milk fortified with additional probiotic and prebiotic (n = 312) or control milk (n = 312) for 1 year. Probiotic and prebiotic milk contained an additional 1.9 x 10 colony-forming units per day of probiotic B lactis HN019 and 2.4 g/day of prebiotic oligosaccharides milk. Hematological parameters were estimated at baseline and at the end of the study. Height and weight measurements were recorded at baseline, mid study, and the end of the study. Difference of means and multivariate regression models was used to examine the effect of intervention.

RESULTS

Both study groups were similar at baseline. Compliance was high (>85%) and did not vary by intervention groups. As compared with non-fortified milk, consumption of probiotic- and prebiotic-fortified milk for a period of 1 year reduced the risk of being anemic and iron deficient by 45% (95% CI 11%, 66%; P = 0.01) and increased weight gain by 0.13 kg/year (95% CI 0.03, 0.23; P = 0.02).

CONCLUSIONS

Preschoolers are usually fed milk, which has good acceptance and can be easily fortified for delivery of probiotics. Consumption of B lactis HN019 and prebiotic-fortified milk resulted in a smaller number of iron-deficient preschoolers and increased weight gain.

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.

Impact of Zinc Fortification on Zinc Nutrition

Food fortification is increasingly recognized as an effective approach to improve a population's micronutrient status. The present report provides a critical review of the scientific evidence currently available on the impact of zinc fortification on zinc nutrition.

The available studies clearly show that zinc fortification can increase dietary zinc intake and total daily zinc absorption. Most absorption studies also indicate that adding zinc to food does not adversely affect the absorption of other minerals, such as iron. Despite the positive effect of zinc fortification on total zinc absorption, only a few studies have found positive impacts of zinc fortification on serum zinc concentrations or functional indicators of zinc status. The reasons for these inconsistent results are uncertain but may relate to the choice of food vehicles, the age group and zinc status of the study populations, or particular aspects of the study design. Thus, additional research is needed to determine the impact of zinc fortification, with or without other micronutrients, in populations at risk for zinc deficiency.

Because of the benefits of increasing intake in populations at high risk for zinc deficiency, the documented increase in total zinc absorption that occurs following zinc fortification, the absence of any adverse effects, and the relatively low cost of adding zinc, public health planners should consider including zinc in mass and targeted fortification programs in such populations. Because of the limited available information on program impact, it will be important to evaluate the outcomes of such programs.

Efeito da fortificação semanal do arroz com ferro quelato sobre a freqüência de anemia e concentração de hemoglobina em crianças de creches municipais do Rio de Janeiro, Brasil

Trata-se de um ensaio clínico comunitário, duplo-cego, controlado por placebo. Durante 16 semanas, as crianças do grupo intervenção (GI, n = 180) receberam arroz fortificado com ferro, e as do grupo controle (GC, n = 174) receberam arroz com placebo. Considerou-se presença de anemia quando hemoglobina < 11,0g/dL. A comparação da variação média na hemoglobina intergrupos, ajustada por idade e uso de outros suplementos de ferro, foi feita pelo teste t de Student. A concentração de hemoglobina aumentou em ambos os grupos, com incremento médio de 0,42g/dL no GI (11,28±1,23g/dL para 11,75±1,16g/dL; p < 0,001) e de 0,49g/dL no GC (11,06±1,13g/dL para 11,51±1,16g/dL; p < 0,001). A freqüência de anemia reduziu (p < 0,01) em ambos os grupos (37,8% para 23,3% em GI e 45,4% para 33,3% em GC), sem diferença entre os mesmos. As crianças que receberam quantidade total de ferro > 53,76mg pelo arroz fortificado tiveram maior aumento na hemoglobina do que aquelas que receberam quantidades inferiores (0,94g/dL vs. 0,39g/dL; p = 0,03). Sugere-se que esse tipo de intervenção pode ser útil no controle da anemia quando o consumo do alimento fortificado é adequado.

Iron deficiency in young children in low-income countries and new approaches for its prevention

Anemia resulting from severe iron deficiency (ID) is the most prevalent and widespread nutrition-related health problem in infants and young children in low-income countries and has proven very resistant to prevention through public health interventions. Accumulative evidence from animal and human studies suggests that such deficiencies are associated with large adverse effects on child cognitive and motor development. Therefore, effective interventions to improve iron status will have large health benefits. Action to reduce young child ID would benefit from overarching policy and programmatic guidance that informs decision makers about what to do, when to do it, and how to do it. The impetus for new approaches to prevent ID in young children reflects growing recognition of the need to intervene early and often and for better vehicles to deliver iron. Prevention of ID requires strong delivery systems that enhance consumer demand and promote compliance. When this occurs, the prevalence of anemia is greatly reduced.

Maternal and child nutrition in Sub-Saharan Africa: challenges and interventions

Women of child-bearing age (especially pregnant and lactating women), infants and young children are in the most nutritionally-vulnerable stages of the life cycle. Maternal malnutrition is a major predisposing factor for morbidity and mortality among African women. The causes include inadequate food intake, poor nutritional quality of diets, frequent infections and short inter-pregnancy intervals. Evidence for maternal malnutrition is provided by the fact that between 5 and 20% of African women have a low BMI as a result of chronic hunger. Across the continent the prevalence of anaemia ranges from 21 to 80%, with similarly high values for both vitamin A and Zn deficiency levels. Another challenge is the high rates of HIV infection, which compromise maternal nutritional status. The consequences of poor maternal nutritional status are reflected in low pregnancy weight gain and high infant and maternal morbidity and mortality. Suboptimal infant feeding practices, poor quality of complementary foods, frequent infections and micronutrient deficiencies have largely contributed to the high mortality among infants and young children in the region. Feeding children whose mothers are infected with HIV continues to remain an issue requiring urgent attention. There are successful interventions to improve the nutrition of mothers, infants and young children, which will be addressed. Interventions to improve the nutrition of infants and young children, particularly in relation to the improvement of micronutrient intakes of young children, will be discussed. The recent release by WHO of new international growth standards for assessing the growth and nutritional status of children provides the tool for early detection of growth faltering and for appropriate intervention.

Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana

BACKGROUND

Micronutrient deficiencies are common during infancy, and optimal approaches for their prevention need to be identified.

OBJECTIVE

The objective was to compare the efficacy and acceptability of Sprinkles (SP), crushable Nutritabs (NT), and fat-based Nutributter (NB; 108 kcal/d), which provide 6, 16, and 19 vitamins and minerals, respectively, when used for home fortification of complementary foods.

DESIGN

Ghanaian infants were randomly assigned to receive SP (n = 105), NT (n = 105), or NB (n = 103) daily from 6 to 12 mo of age. We assessed dietary intake, morbidity, and compliance weekly. Hemoglobin and plasma ferritin, TfR, C-reactive protein, and zinc were measured at 6 and 12 mo. We used an exit interview to assess acceptability. A randomly selected control group of infants who received no intervention (NI; n = 96) were assessed at 12 mo.

RESULTS

All supplements were well accepted, and the mean percentage of days that supplements were consumed (87%) did not differ between groups. At 12 mo, all 3 intervention groups had significantly higher ferritin and lower TfR concentrations than did the NI control group. Mean (+/- SD) hemoglobin was significantly higher in NT (112 +/- 14 g/L) and NB (114 +/- 14 g/L) but not in SP (110 +/- 14 g/L) infants than in NI infants (106 +/- 14 g/L). The prevalence of iron deficiency anemia was 31% in the NI control group compared with 10% in the intervention groups combined (P < 0.0001).

CONCLUSION

All 3 options for home fortification of complementary foods are effective for reducing the prevalence of iron deficiency in such populations.

[Dietary iron and iron deficiency anemia among adolescent girls from Benin]

BACKGROUND

Iron deficiency anemia affects a large number of women in developing countries, especially during childbearing years. Few studies determined the association between estimated absorbable iron intakes and iron deficiency.

METHODS

The association between dietary iron intake and iron status was studied in 100 adolescent girls aged 14-16 years from Benin. Fifty adolescents were boarding at the school, while 50 lived at home. Biochemical indices of iron status included: hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, serum iron, total iron-binding capacity and % transferrin saturation. Dietary intakes were obtained by two 24-hour recalls and absorbable iron intakes were estimated using Monsen's model. The probability approach was used to estimate inadequacy in iron intake.

RESULTS

While 73% of adolescents met the recommendations for dietary iron intake, only 27% had estimated absorbable iron intake above the average requirement for absorbed iron. Non-heme iron represented 97.2% of the total iron intake. Forty three percent of subjects were anemic (hemoglobin<120 g/l). Iron deficiency defined by a four-model index based on > or =2 abnormal values in the four independent indicators of iron status used (serum iron, total iron-binding capacity, mean corpuscular volume, mean corpuscular hemoglobin concentration) was present in 14% of the subjects, while 13% had iron deficiency anaemia (hemoglobin<120 g/l+four-model index). Using a multiple regression analysis, total absorbable iron intakes (including iron supplements) were highly and positively associated with hemoglobin and hematocrit concentrations (P=0.000001 and P=0.00007 respectively).

CONCLUSION

In this group of adolescents, total absorbable iron intakes were related to iron deficiency. Efforts should be made to increase the heme iron content of the diet and the bioavailability of non-heme iron by promoting affordable local foods rich in iron and promoters of iron absorption (Vitamin C and meat, poultry and fish factor).

Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development

BACKGROUND

The low micronutrient content of complementary foods is associated with growth faltering in many populations. A potential low-cost solution is the home fortification of complementary foods with Sprinkles (SP) powder, crushable Nutritabs (NT) tablets, or energy-dense (108 kcal/d), fat-based Nutributter (NB).

OBJECTIVE

The objective was to test the hypothesis that multiple micronutrients added to home-prepared complementary foods would increase growth and that the effect would be greatest in the presence of added energy from fat.

DESIGN

We randomly assigned 313 Ghanaian infants to receive SP, NT, or NB containing 6, 16, and 19 vitamins and minerals, respectively, daily from 6 to 12 mo of age. We assessed anthropometric status at 6, 9, and 12 mo; micronutrient status at 6 and 12 mo; motor development at 12 mo; and morbidity weekly. Infants (n = 96) not randomly selected for the intervention (nonintervention; NI) were assessed at 12 mo.

RESULTS

The groups did not differ significantly at baseline, except that the NB group had a higher proportion of boys and weighed slightly more. The dropout rate (15/313) was low. At 12 mo, after control for initial size, the NB group had a significantly greater weight-for-age z score (WAZ) (-0.49 +/- 0.54) and length-for-age z score (LAZ) (-0.20 +/- 0.54) than did the NT group (WAZ: -0.67 +/- 0.54; LAZ: -0.39 +/- 0.54) and the NT and SP groups combined (WAZ: -0.65 +/- 0.54; LAZ: -0.38 +/- 0.54); the difference with the NI group (WAZ: -0.74 +/- 1.1; LAZ: -0.40 +/- 1.0) was not significant. A lower percentage of the NI infants (25%) than of the intervention groups (SP: 39%; NT: 36%; NB: 49%) could walk independently by 12 mo.

CONCLUSION

All 3 supplements had positive effects on motor milestone acquisition by 12 mo compared with no intervention, but only NB affected growth.

Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world

This paper is the third in the Child Development Series. The first paper showed that more than 200 million children under 5 years of age in developing countries do not reach their developmental potential. The second paper identified four well-documented risks: stunting, iodine deficiency, iron deficiency anaemia, and inadequate cognitive stimulation, plus four potential risks based on epidemiological evidence: maternal depression, violence exposure, environmental contamination, and malaria. This paper assesses strategies to promote child development and to prevent or ameliorate the loss of developmental potential. The most effective early child development programmes provide direct learning experiences to children and families, are targeted toward younger and disadvantaged children, are of longer duration, high quality, and high intensity, and are integrated with family support, health, nutrition, or educational systems and services. Despite convincing evidence, programme coverage is low. To achieve the Millennium Development Goals of reducing poverty and ensuring primary school completion for both girls and boys, governments and civil society should consider expanding high quality, cost-effective early child development programmes.