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Hackl LS, Karakochuk CD, Mazariegos DI, Jeremiah K, Obeid O, Ravi N, Ayana DA, Varela V, Alayón S, Dary O, Moorthy D. Assessing Accuracy and Precision of Hemoglobin Determination in Venous, Capillary Pool, and Single-Drop Capillary Blood Specimens Using three Different HemoCue® Hb Models: The Multicountry Hemoglobin Measurement (HEME) Study. J Nutr 2024:S0022-3166(24)00168-8. [PMID: 38580209 DOI: 10.1016/j.tjnut.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Anemia prevalence estimates reported in population surveys can vary based on the blood specimen source (capillary or venous) and analytic device (hematology autoanalyzers or portable hemoglobinometers) used for hemoglobin (Hb) determination. OBJECTIVES This study aimed to compare accuracy and precision of Hb measurement in three blood specimen types on three models of hemoglobinometers against the results from venous blood from the same individuals measured on automated analyzers (AAs). METHODS This multisite (Cambodia, Ethiopia, Guatemala, Lebanon, Nigeria, and Tanzania) study assessed Hb measurements in paired venous and capillary blood specimens from apparently healthy women (aged 15-49 y) and children (aged 12-59 mo) using three HemoCue® Hb models (201+, 301, and 801). Measurements were compared against reference values: venous blood in hematology AA and adjusted via regression calibration or mean difference in HemoCue® Hb. Venous, capillary pool, and single-drop capillary blood specimens were assessed for accuracy and precision. RESULTS Venous blood measured using HemoCue® Hb 301 exhibited a positive mean error, whereas responses in HemoCue® Hb 201+ and 801 were nondirectional compared with the reference. Adjustment with the reference harmonized mean errors for all devices across study sites to <1.0 g/L using venous blood. Precision was highest for venous blood (±5-16 g/L) in all sites, lowest for single-drop capillary (±9-37 g/L), and intermediate (±9-28 g/L) for capillary pool blood specimen. Imprecision differed across sites, especially with both capillary blood specimens, suggesting different levels of personnel skills. CONCLUSIONS Findings suggest that venous blood is needed for accurate and precise Hb determination. Single-drop capillary blood use should be discouraged owing to high measurement variability. Further research should evaluate the viability and reliability of capillary pool blood for this purpose. Accuracy of HemoCue® Hb devices can be improved via standardization against results from venous blood assessed using AA.
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Affiliation(s)
- Laura S Hackl
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, USA
| | - Crystal D Karakochuk
- Food, Nutrition and Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Dora Inés Mazariegos
- Department of Nutrition and Micronutrients, Institute of Nutrition of Central America and Panama, Calzada Roosevelt, Guatemala
| | - Kidola Jeremiah
- National Institute of Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Omar Obeid
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut, Riad El-Solh, Beirut, Lebanon
| | | | - Desalegn A Ayana
- School of Medical Laboratory Science, College of Health and Medical Sciences, Haramaya University, Dire Dawa, Ethiopia
| | - Veronica Varela
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, USA
| | - Silvia Alayón
- USAID Advancing Nutrition, Save the Children US, Arlington, VA, United States
| | - Omar Dary
- Bureau for Global Health, United States Agency for International Development, Washington, DC, United States
| | - Denish Moorthy
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, USA.
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Braat S, Fielding KL, Han J, Jackson VE, Zaloumis S, Xu JXH, Moir-Meyer G, Blaauwendraad SM, Jaddoe VWV, Gaillard R, Parkin PC, Borkhoff CM, Keown-Stoneman CDG, Birken CS, Maguire JL, Bahlo M, Davidson EM, Pasricha SR. Haemoglobin thresholds to define anaemia from age 6 months to 65 years: estimates from international data sources. Lancet Haematol 2024; 11:e253-e264. [PMID: 38432242 PMCID: PMC10983828 DOI: 10.1016/s2352-3026(24)00030-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Detection of anaemia is crucial for clinical medicine and public health. Current WHO anaemia definitions are based on statistical thresholds (fifth centiles) set more than 50 years ago. We sought to establish evidence for the statistical haemoglobin thresholds for anaemia that can be applied globally and inform WHO and clinical guidelines. METHODS In this analysis we identified international data sources from populations in the USA, England, Australia, China, the Netherlands, Canada, Ecuador, and Bangladesh with sufficient clinical and laboratory information collected between 1998 and 2020 to obtain a healthy reference sample. Individuals with clinical or biochemical evidence of a condition that could reduce haemoglobin concentrations were excluded. We estimated haemoglobin thresholds (ie, 5th centiles) for children aged 6-23 months, 24-59 months, 5-11 years, and 12-17 years, and adults aged 18-65 years (including during pregnancy) for individual datasets and pooled across data sources. We also collated findings from three large-scale genetic studies to summarise genetic variants affecting haemoglobin concentrations in different ancestral populations. FINDINGS We identified eight data sources comprising 18 individual datasets that were eligible for inclusion in the analysis. In pooled analyses, the haemoglobin fifth centile was 104·4 g/L (90% CI 103·5-105·3) in 924 children aged 6-23 months, 110·2 g/L (109·5-110·9) in 1874 children aged 24-59 months, and 114·4 g/L (113·6-115·2) in 1839 children aged 5-11 years. Values diverged by sex in adolescents and adults. In pooled analyses, the fifth centile was 122·2 g/L (90% CI 121·3-123·1) in 1741 female adolescents aged 12-17 years and 128·2 g/L (126·4-130·0) in 1103 male adolescents aged 12-17 years. In pooled analyses of adults aged 18-65 years, the fifth centile was 119·7 g/L (90% CI 119·1-120·3) in 3640 non-pregnant females and 134·9 g/L (134·2-135·6) in 2377 males. Fifth centiles in pregnancy were 110·3 g/L (90% CI 109·5-111·0) in the first trimester (n=772) and 105·9 g/L (104·0-107·7) in the second trimester (n=111), with insufficient data for analysis in the third trimester. There were insufficient data for adults older than 65 years. We did not identify ancestry-specific high prevalence of non-clinically relevant genetic variants that influence haemoglobin concentrations. INTERPRETATION Our results enable global harmonisation of clinical and public health haemoglobin thresholds for diagnosis of anaemia. Haemoglobin thresholds are similar between sexes until adolescence, after which males have higher thresholds than females. We did not find any evidence that thresholds should differ between people of differering ancestries. FUNDING World Health Organization and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sabine Braat
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine L Fielding
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia; Clinical Haematology, The Austin Hospital, Heidelberg, VIC, Australia
| | - Jiru Han
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Victoria E Jackson
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sophie Zaloumis
- Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Jessica Xu Hui Xu
- Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sophia M Blaauwendraad
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Vincent W V Jaddoe
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Romy Gaillard
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Patricia C Parkin
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cornelia M Borkhoff
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Charles D G Keown-Stoneman
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Unity Health Toronto, Toronto, ON, Canada
| | - Catherine S Birken
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jonathon L Maguire
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Unity Health Toronto, Toronto, ON, Canada
| | - Melanie Bahlo
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Eliza M Davidson
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC, Australia.
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3
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Tang GH, Sholzberg M. Iron deficiency anemia among women: An issue of health equity. Blood Rev 2024; 64:101159. [PMID: 38042684 DOI: 10.1016/j.blre.2023.101159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/16/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
Iron deficiency is the most common and widespread nutritional deficiency in the world. For women, the risk of iron deficiency and iron deficiency anemia increases due to iron demands during pregnancy and regular iron losses due to menstruation during reproductive years. These interrelated conditions are of public health concern as they are highly prevalent, and the negative consequences such as chronic fatigue, cognitive impairment and poor quality of life are broad and multifaceted. People of low socioeconomic status are at higher risk of iron deficiency due to low intake of expensive iron-rich foods, and decreased access to healthcare. In this review, we applied a health equity lens to describe the current state of care for women with iron deficiency with or without anemia. We have highlighted several structural challenges that span from the laboratory diagnosis, inconsistent screening guidelines, and stigma associated with heavy menstrual bleeding, to treatment barriers.
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Affiliation(s)
- Grace H Tang
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine, and Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Canada.
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Brehm R, South A, George EC. Use of point-of-care haemoglobin tests to diagnose childhood anaemia in low- and middle-income countries: A systematic review. Trop Med Int Health 2024; 29:73-87. [PMID: 38044262 PMCID: PMC7615606 DOI: 10.1111/tmi.13957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
OBJECTIVES Anaemia is a major cause of mortality and transfusion in children in low- and middle-income countries (LMICs); however, current diagnostics are slow, costly and frequently unavailable. Point-of-care haemoglobin tests (POC(Hb)Ts) could improve patient outcomes and use of resources by providing rapid and affordable results. We systematically reviewed the literature to investigate what, where and how POC(Hb)Ts are being used by health facilities in LMICs to diagnose childhood anaemia, and to explore challenges to their use. METHODS We searched a total of nine databases and trial registries up to 10 June 2022 using the concepts: anaemia, POC(Hb)T, LMIC and clinical setting. Adults ≥21 years and literature published >15 years ago were excluded. A single reviewer conducted screening, data extraction and quality assessment (of diagnostic studies) using QUADAS-2. Outcomes including POC(Hb)T used, location, setting, challenges and diagnostic accuracy were synthesised. RESULTS Of 626 records screened, 41 studies were included. Evidence is available on the use of 15 POC(Hb)Ts in hospitals (n = 28, 68%), health centres (n = 9, 22%) and clinics/units (n = 10, 24%) across 16 LMICs. HemoCue (HemoCue AB, Ängelholm, Sweden) was the most used test (n = 31, 76%). Key challenges reported were overestimation of haemoglobin concentration, clinically unacceptable limits of agreement, errors/difficulty in sampling, environmental factors, cost, inter-observer variability and supply of consumables. Five POC(Hb)Ts (33%) could not detect haemoglobin levels below 4.5 g/dL. Diagnostic accuracy varied, with sensitivity and specificity to detect anaemia ranging from 24.2% to 92.2% and 70% to 96.7%, respectively. CONCLUSIONS POC(Hb)Ts have been successfully utilised in health facilities in LMICs to diagnose childhood anaemia. However, limited evidence is available, and challenges exist that must be addressed before wider implementation. Further research is required to confirm accuracy, clinical benefits and cost-effectiveness.
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Affiliation(s)
- Rebecca Brehm
- Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Annabelle South
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
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Xi L, Fang F, Zhou J, Xu P, Zhang Y, Zhu P, Tu J, Sun Q. Association of hemoglobin-to-red blood cell distribution width ratio and depression in older adults: A cross sectional study. J Affect Disord 2024; 344:191-197. [PMID: 37832737 DOI: 10.1016/j.jad.2023.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/05/2023] [Accepted: 10/08/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND The association between hemoglobin-to-red blood cell distribution width ratio (HRR) and the depression in old adults was not clear. METHODS We extracted data on depression, general characteristics, lifestyle, medical history, drug use, and blood indicators from the National Health and Nutrition Examination Survey 2005-2018 to investigate the relationship between HRR and depression. RESULTS A total of 4141 individuals were evaluated, among whom 266 (6.4 %) were identified as having depression. HRR was significantly lower in the low depression group, and Spearman correlation analysis revealed an inverse association between HRR and depression scores (r = -0.148, P < 0.001). Multiple linear regression showed that HRR was associated with depression after adjusted for general characteristics, life style, medical history, drug use and blood indicators (P = 0.010). ROC analysis demonstrated that in participants with depression, the area under the curve (AUC) for HRR was 0.612, surpassing both Hb(0.586) and RDW(0.401). These findings were statistically significant (P < 0.05). LIMITATIONS Only participants aged 65-79 years are selected for this study and this was a cross-sectional study that can only represent an association between HRR and depression, but not a cause-and-effect relationship. CONCLUSIONS HRR, being more potent than Hb or RDW, emerges as an independent risk factor for depression. It has the potential to facilitate early depression detection, aiding in the prevention of clinical deterioration or relapses, and could also serve as a viable treatment target.
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Affiliation(s)
- Lijuan Xi
- Yangzhou University School of Nursing School of Public Health, Yangzhou, Jiangsu, China.
| | - Fang Fang
- Subei People's Hospital, Yangzhou, Jiangsu, China
| | - Jiajie Zhou
- Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Peirong Xu
- Yangzhou University School of Nursing School of Public Health, Yangzhou, Jiangsu, China
| | - Yan Zhang
- Yangzhou University School of Nursing School of Public Health, Yangzhou, Jiangsu, China
| | - Pingting Zhu
- Yangzhou University School of Nursing School of Public Health, Yangzhou, Jiangsu, China
| | - Jiayuan Tu
- Yangzhou University School of Nursing School of Public Health, Yangzhou, Jiangsu, China
| | - Qiannan Sun
- Subei People's Hospital, Yangzhou, Jiangsu, China
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Bucci T, Shantsila A, Romiti GF, Teo WS, Chao TF, Shimizu W, Boriani G, Tse HF, Krittayaphong R, Lip GY. External Validation of COOL-AF Scores in the Asian Pacific Heart Rhythm Society Atrial Fibrillation Registry. JACC. ASIA 2024; 4:59-69. [PMID: 38222252 PMCID: PMC10782403 DOI: 10.1016/j.jacasi.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 08/07/2023] [Accepted: 09/18/2023] [Indexed: 01/16/2024]
Abstract
Background The COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) risk scores for death, bleeding, and thromboembolic events (TEs) were derived from the COOL-AF cohort from Thailand and require external validation. Objectives The authors sought to externally validate the COOL-AF scores in the APHRS (Asia-Pacific Heart Rhythm Society) registry and to compare their performance in the ESC-EHRA (European Society of Cardiology-European Heart Rhythm Association) EORP-AF (EURObservational Research Programme in Atrial Fibrillation) General Long-Term Registry. Methods We studied 3,628 APHRS and 8,825 EORP-AF patients. Receiver operating characteristic (ROC) curves and Cox regression analyses were used to test the predictive value of COOL-AF scores and to compared them with the CHA2DS2-VASc and HAS-BLED scores. Results Patients in the EORP-AF were older, had a higher prevalence of male sex, and were at higher thromboembolic and hemorrhagic risk than APHRS patients. After 1 year of follow-up in APHRS and EORP-AF, the following events were recorded: 87 (2.4%) and 435 (4.9%) death for any causes, 37 (1.0%) and 111 (1.3%) major bleeding, and 25 (0.7%) and 109 (1.2%) TEs, respectively. In APHRS, the COOL-AF scores showed moderate-to-good predictive value for all-cause mortality (area under the curve [AUC]: 0.77; 95% CI: 0.71-0.83), major bleeding (AUC: 0.68; 95% CI: 0.60-0.76), and TEs (AUC: 0.61; 95% CI: 0.51-0.71), and were similar to the CHA2DS2-VASc and HAS-BLED scores. In EORP-AF, the predictive value of COOL-AF for all-cause mortality (AUC: 0.68; 95% CI: 0.65-0.70) and major bleeding (AUC: 0.61; 95% CI: 0.60-0.62) was modest and lower than in APHRS. In EORP-AF, the COOL-AF score for TE was inferior to the CHA2DS2-VASc score. Conclusions The COOL-AF risk scores may be an easy tool to identify Asian patients with AF at risk for death and major bleeding and performs better in Asian than in European patients with AF. (Clinical Survey on the Stroke Prevention in Atrial Fibrillation in Asia [AF-Registry]; NCT04807049).
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - Alena Shantsila
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Giulio Francesco Romiti
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Wee-Siong Teo
- Department of Cardiology, National Heart Centre, Singapore
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, Cardiology Division, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Hung-Fat Tse
- Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory Y.H. Lip
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Williams AM, Brown KH, Allen LH, Dary O, Moorthy D, Suchdev PS. Improving Anemia Assessment in Clinical and Public Health Settings. J Nutr 2023; 153 Suppl 1:S29-S41. [PMID: 37778891 PMCID: PMC11002965 DOI: 10.1016/j.tjnut.2023.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/28/2023] [Accepted: 05/10/2023] [Indexed: 10/03/2023] Open
Abstract
We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.
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Affiliation(s)
- Anne M Williams
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand; Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States.
| | - Kenneth H Brown
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA, United States
| | - Lindsay H Allen
- United States Department of Agriculture, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA, United States
| | - Omar Dary
- Division of Nutrition and Environmental Health, Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC, United States
| | | | - Parminder S Suchdev
- Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States
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Ghosh S, Palika R, Dasi T, Varshney RK, Parasannanavar DJ, Sen Gupta S, Chitikineni A, Banjara SK, Pullakhandam R, Thomas T, Sachdev HS, Kurpad AV, Kulkarni B. Haemoglobin diagnostic cut-offs for anaemia in Indian women of reproductive age. Eur J Clin Nutr 2023; 77:966-971. [PMID: 37537294 DOI: 10.1038/s41430-023-01308-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND The persistent high prevalence of anaemia among Indian women of reproductive age (WRA) despite aggressive long-term iron supplementation could be related to over-diagnosis from an inappropriately high haemoglobin (Hb) diagnostic cut-off. To develop an appropriate cut-off for Indian WRA, we hypothesized that during iron-folic acid (IFA) supplementation to a mixed (anaemic/non-anaemic) WRA population, the positive slope of the Hb-plasma ferritin (PF) response in anaemic women would inflect into a plateau (zero-response) as a non-anaemic status is reached. The 2.5th percentile of the Hb distribution at this inflection point will be the diagnostic Hb cut-off for iron-responsive anaemia. METHOD A hierarchical mixed effects model, with a polynomial mean and variance model to account for intraclass correlation due to repeated measures, was used to estimate the response curve of Hb to PF, or body iron stores, in anaemic and non-anaemic WRA (without inflammation), who were receiving a 90-day IFA supplementation. RESULTS The Hb response curve at low PF values showed a steep increase, which inflected into a plateau at a PF of 10.1 µg/L and attained a steady state at a PF of 20.6 µg/L. The Hb distribution at the inflection was a normal probability distribution, with a mean of 12.3 g/dL. The 2.5th percentile value of this distribution, or the putative diagnostic Hb cut-off for anaemia, was 10.8 g/dL (~11 g/dL). CONCLUSION The derived Hb cut-off is lower than the current adult values of 12 g/dL and could partly explain the persistently high prevalence of anaemia.
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Affiliation(s)
- Santu Ghosh
- St. John's Medical College, Sarjapur Road, Bengaluru, Karnataka, 560 034, India
| | - Ravindranadh Palika
- ICMR-National Institute of Nutrition, Jamai-Osmania, Hyderabad, Telangana, 500007, India
| | - Teena Dasi
- ICMR-National Institute of Nutrition, Jamai-Osmania, Hyderabad, Telangana, 500007, India
| | - Rajeev K Varshney
- International Crops Research Institute for the Semi-Arid Tropics (ICRISAT), Patancheru, Hyderabad, 502 324, India
- State Agricultural Biotechnology Centre, Centre for Crop & Food Innovation, Food Futures Institute, Murdoch University, Murdoch, 6150, Australia
| | | | - Sourav Sen Gupta
- International Crops Research Institute for the Semi-Arid Tropics (ICRISAT), Patancheru, Hyderabad, 502 324, India
| | - Annapurna Chitikineni
- International Crops Research Institute for the Semi-Arid Tropics (ICRISAT), Patancheru, Hyderabad, 502 324, India
- State Agricultural Biotechnology Centre, Centre for Crop & Food Innovation, Food Futures Institute, Murdoch University, Murdoch, 6150, Australia
| | - Santosh Kumar Banjara
- ICMR-National Institute of Nutrition, Jamai-Osmania, Hyderabad, Telangana, 500007, India
| | - Raghu Pullakhandam
- ICMR-National Institute of Nutrition, Jamai-Osmania, Hyderabad, Telangana, 500007, India
| | - Tinku Thomas
- St. John's Medical College, Sarjapur Road, Bengaluru, Karnataka, 560 034, India
| | - Harshpal S Sachdev
- Sitaram Bhartia Institute of Science and Research, New Delhi, 110016, India
| | - Anura V Kurpad
- St. John's Medical College, Sarjapur Road, Bengaluru, Karnataka, 560 034, India
| | - Bharati Kulkarni
- ICMR-National Institute of Nutrition, Jamai-Osmania, Hyderabad, Telangana, 500007, India.
- Division of Reproductive and Child Health and Nutrition, Indian Council of Medical Research, V. Ramalingaswami Bhawan, Ansari Nagar, New Delhi, 110029, India.
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Prevalence, years lived with disability, and trends in anaemia burden by severity and cause, 1990-2021: findings from the Global Burden of Disease Study 2021. Lancet Haematol 2023; 10:e713-e734. [PMID: 37536353 PMCID: PMC10465717 DOI: 10.1016/s2352-3026(23)00160-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Anaemia is a major health problem worldwide. Global estimates of anaemia burden are crucial for developing appropriate interventions to meet current international targets for disease mitigation. We describe the prevalence, years lived with disability, and trends of anaemia and its underlying causes in 204 countries and territories. METHODS We estimated population-level distributions of haemoglobin concentration by age and sex for each location from 1990 to 2021. We then calculated anaemia burden by severity and associated years lived with disability (YLDs). With data on prevalence of the causes of anaemia and associated cause-specific shifts in haemoglobin concentrations, we modelled the proportion of anaemia attributed to 37 underlying causes for all locations, years, and demographics in the Global Burden of Disease Study 2021. FINDINGS In 2021, the global prevalence of anaemia across all ages was 24·3% (95% uncertainty interval [UI] 23·9-24·7), corresponding to 1·92 billion (1·89-1·95) prevalent cases, compared with a prevalence of 28·2% (27·8-28·5) and 1·50 billion (1·48-1·52) prevalent cases in 1990. Large variations were observed in anaemia burden by age, sex, and geography, with children younger than 5 years, women, and countries in sub-Saharan Africa and south Asia being particularly affected. Anaemia caused 52·0 million (35·1-75·1) YLDs in 2021, and the YLD rate due to anaemia declined with increasing Socio-demographic Index. The most common causes of anaemia YLDs in 2021 were dietary iron deficiency (cause-specific anaemia YLD rate per 100 000 population: 422·4 [95% UI 286·1-612·9]), haemoglobinopathies and haemolytic anaemias (89·0 [58·2-123·7]), and other neglected tropical diseases (36·3 [24·4-52·8]), collectively accounting for 84·7% (84·1-85·2) of anaemia YLDs. INTERPRETATION Anaemia remains a substantial global health challenge, with persistent disparities according to age, sex, and geography. Estimates of cause-specific anaemia burden can be used to design locally relevant health interventions aimed at improving anaemia management and prevention. FUNDING Bill & Melinda Gates Foundation.
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10
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Yourkavitch J, Obara H, Usmanova G, Semrau KEA, Moller AB, Garcia-Casal MN, Daru J. A rapid landscape review of postpartum anaemia measurement: challenges and opportunities. BMC Public Health 2023; 23:1454. [PMID: 37518003 PMCID: PMC10388528 DOI: 10.1186/s12889-023-16383-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Anaemia is a reduction in haemoglobin concentration below a threshold, resulting from various factors including severe blood loss during and after childbirth. Symptoms of anaemia include fatigue and weakness, among others, affecting health and quality of life. Anaemic pregnant women have an increased risk of premature delivery, a low-birthweight infant, and postpartum depression. They are also more likely to have anaemia in the postpartum period which can lead to an ongoing condition and affect subsequent pregnancies. In 2019 nearly 37% of pregnant women globally had anaemia, and estimates suggest that 50-80% of postpartum women in low- and middle-income countries have anaemia, but currently there is no standard measurement or classification for postpartum anaemia. METHODS A rapid landscape review was conducted to identify and characterize postpartum anaemia measurement searching references within three published systematic reviews of anaemia, including studies published between 2012 and 2021. We then conducted a new search for relevant literature from February 2021 to April 2022 in EMBASE and MEDLINE using a similar search strategy as used in the published reviews. RESULTS In total, we identified 53 relevant studies. The timing of haemoglobin measurement ranged from within the immediate postpartum period to over 6 weeks. The thresholds used to diagnose anaemia in postpartum women varied considerably, with < 120, < 110, < 100 and < 80 g/L the most frequently reported. Other laboratory results frequently reported included ferritin and transferrin receptor. Clinical outcomes reported in 32 out of 53 studies included postpartum depression, quality of life, and fatigue. Haemoglobin measurements were performed in a laboratory, although it is unclear from the studies if venous samples and automatic analysers were used in all cases. CONCLUSIONS This review demonstrates the need for improving postpartum anaemia measurement given the variability observed in published measures. With the high prevalence of anaemia, the relatively simple treatment for non-severe cases of iron deficiency anaemia, and its importance to public health with multi-generational effects, it is crucial to develop common measures for women in the postpartum period and promote rapid uptake and reporting.
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Affiliation(s)
| | - Hiromi Obara
- National Center for Global Health and Medicine, Bureau of International Health Cooperation, Tokyo, Japan
| | | | - Katherine E A Semrau
- Ariadne Labs | Brigham & Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA and Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ann-Beth Moller
- UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization Department of Sexual and Reproductive Health and Research, Geneva, Switzerland
| | | | - Jahnavi Daru
- Wolfson Institute of Population Health Science, Women's Health Research Unit, Queen Mary University of London, London, UK
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11
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McQuilten ZK, Thao LTP, Pasricha SR, Artz AS, Bailey M, Chan AT, Cohen HJ, Lockery JE, Murray AM, Nelson MR, Schneider HG, Wolfe R, Woods RL, Wood EM, McNeil JJ. Effect of Low-Dose Aspirin Versus Placebo on Incidence of Anemia in the Elderly : A Secondary Analysis of the Aspirin in Reducing Events in the Elderly Trial. Ann Intern Med 2023; 176:913-921. [PMID: 37335992 DOI: 10.7326/m23-0675] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Daily low-dose aspirin increases major bleeding; however, few studies have investigated its effect on iron deficiency and anemia. OBJECTIVE To investigate the effect of low-dose aspirin on incident anemia, hemoglobin, and serum ferritin concentrations. DESIGN Post hoc analysis of the ASPREE (ASPirin in Reducing Events in the Elderly) randomized controlled trial. (ClinicalTrials.gov: NCT01038583). SETTING Primary/community care in Australia and the United States. PARTICIPANTS Community-dwelling persons aged 70 years or older (≥65 years for Black persons and Hispanic persons). INTERVENTION 100 mg of aspirin daily or placebo. MEASUREMENTS Hemoglobin concentration was measured annually in all participants. Ferritin was measured at baseline and 3 years after random assignment in a large subset. RESULTS 19 114 persons were randomly assigned. Anemia incidence in the aspirin and placebo groups was 51.2 events and 42.9 events per 1000 person-years, respectively (hazard ratio, 1.20 [95% CI, 1.12 to 1.29]). Hemoglobin concentrations declined by 3.6 g/L per 5 years in the placebo group and the aspirin group experienced a steeper decline by 0.6 g/L per 5 years (CI, 0.3 to 1.0 g/L). In 7139 participants with ferritin measures at baseline and year 3, the aspirin group had greater prevalence than placebo of ferritin levels less than 45 µg/L at year 3 (465 [13%] vs. 350 [9.8%]) and greater overall decline in ferritin by 11.5% (CI, 9.3% to 13.7%) compared with placebo. A sensitivity analysis quantifying the effect of aspirin in the absence of major bleeding produced similar results. LIMITATIONS Hemoglobin was measured annually. No data were available on causes of anemia. CONCLUSION Low-dose aspirin increased incident anemia and decline in ferritin in otherwise healthy older adults, independent of major bleeding. Periodic monitoring of hemoglobin should be considered in older persons on aspirin. PRIMARY FUNDING SOURCE National Institutes of Health and Australian National Health and Medical Research Council.
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Affiliation(s)
- Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University; Department of Haematology, Monash Health; and Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia (Z.K.M.)
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.T.P.T., R.W., R.L.W., J.J.M.)
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, Victoria; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, Victoria; and Clinical Haematology, The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Victoria; and Department of Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia (S.-R.P.)
| | - Andrew S Artz
- City of Hope National Medical Center, Duarte, California (A.S.A.)
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia (M.B.)
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts (A.T.C.)
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina (H.J.C.)
| | - Jessica E Lockery
- Cancer, Ageing and Vaccines Research Group, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia (J.E.L.)
| | - Anne M Murray
- Berman Center for Outcomes and Clinical Research and Department of Medicine, Geriatrics Division, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (A.M.M.)
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia (M.R.N.)
| | - Hans G Schneider
- School of Public Health and Preventive Medicine, Monash University; and Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Victoria, Australia (H.G.S.)
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.T.P.T., R.W., R.L.W., J.J.M.)
| | - Robyn L Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.T.P.T., R.W., R.L.W., J.J.M.)
- School of Public Health and Preventive Medicine, Monash University; and Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Victoria, Australia (H.G.S.)
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria; and Department of Haematology, Monash Health, Melbourne, Victoria, Australia (E.M.W.)
| | - John J McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.T.P.T., R.W., R.L.W., J.J.M.)
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12
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Wang L, Huo J, Wei Y, Tang Y, Sun J, Huang J. Yingyangbao Reduced Anemia among Infants and Young Children Aged 6-23 Months When Delivered through a Large-Scale Nutrition Improvement Program for Children in Poor Areas in China from 2015 to 2020. Nutrients 2023; 15:nu15112634. [PMID: 37299597 DOI: 10.3390/nu15112634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
The purpose of this study was to assess the effectiveness of intervention with Yingyangbao (YYB) on hemoglobin (Hb) and anemia status among infants and young children (IYC) aged 6-23 months (mo) through a large-scale Nutrition Improvement Program for Children in Poor Areas (NIPCPA) in China from 2015 to 2020. Five rounds of cross-sectional surveys were conducted using a stratified and multi-stage probability proportional to size sampling of IYC in 2015, 2017, 2018, 2019 and 2020. Multivariable regression analyses were fitted to determine the effectiveness of the YYB intervention on Hb and anemia, respectively. A total of 36,325, 40,027, 43,831, 44,375 and 46,050 IYC aged 6-23 mo were included, and the prevalence of anemia was 29.7%, 26.9%, 24.1%, 21.2% and 18.1% in 2015, 2017, 2018, 2019 and 2020, respectively. Compared with the results in 2015, the Hb concentrations significantly improved and anemia prevalence significantly decreased among IYC in 2017, 2018, 2019, and 2020 (p < 0.001). Regression analysis showed that higher YYB consumption was significantly associated with the increment in Hb concentration and reduction in anemia stratified by age group (p < 0.001). The most significant increment in Hb concentration of 2.189 mg/L and the most significant reduction in odds of anemia were observed among IYC aged 12-17 mo who consumed 270 to 359 sachets of YYB (OR: 0.671; 95% CI: 0.627, 0.719; p < 0.001). This study suggests that YYB intervention is a successful public health strategy for reducing the risk of anemia among IYC when delivered through a large-scale NIPCPA in China. It is necessary to continue to advance the program and increase the adherence of YYB.
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Affiliation(s)
- Lijuan Wang
- Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Junsheng Huo
- Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Yanli Wei
- Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Yanbin Tang
- Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Jing Sun
- Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Jian Huang
- Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
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13
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Garcia-Casal MN, Dary O, Jefferds ME, Pasricha SR. Diagnosing anemia: Challenges selecting methods, addressing underlying causes, and implementing actions at the public health level. Ann N Y Acad Sci 2023; 1524:37-50. [PMID: 37061792 PMCID: PMC10880862 DOI: 10.1111/nyas.14996] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Accurate and affordable tools for diagnosing anemia and its main determinants are essential for understanding the magnitude and distribution of the problem and the appropriate interventions needed for its timely prevention and treatment. The objective of this review is to address methods, equipment, and sample-related and quality control aspects of hemoglobin measurement for anemia diagnosis. Also, other iron-, infectious-, and genetic-related causes of anemia are addressed in individuals and populations. The best practice for hemoglobin determination is the use of venous blood, analyzed on automated hematology analyzers, with high-quality control measures in place. The importance of a correct anemia diagnosis is highlighted by the cost of a misdiagnosis. A false-negative diagnosis may result in missing out and not treating anemia, its causes, and its adverse effects. On the other hand, a false-positive diagnosis may result in the provision of unneeded treatment or referral for expensive laboratory tests to determine a cause of anemia, wasting valuable resources and risking causing harm. At the individual level, clinicians must understand the causes of absolute and functional anemia to diagnose and treat anemia at the clinical level. Actions toward anemia diagnosis and control at public health levels require global, regional, and country actions that should cover general and context-specific characteristics.
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Affiliation(s)
| | - Omar Dary
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | - Maria Elena Jefferds
- Division of Nutrition, Physical Activity and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
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14
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Sodde FM, Liga AD, Jabir YN, Tamiru D, Kidane R. Magnitude and predictors of anemia among preschool children (36-59 months) in Atingo town, Jimma, Ethiopia. Health Sci Rep 2023; 6:e1358. [PMID: 37334043 PMCID: PMC10273347 DOI: 10.1002/hsr2.1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction Anemia is a serious public health concern that affects more than 25% of the world's population. It is still widespread and at its most severe in Ethiopia. This study pointed to identify the magnitude and predictors of anemia in preschool children in Atinago. Method A structured interview and anthropometric metrics had been used in a cross-sectional study to collect data from 309 preschool children using a systematic sampling strategy from May 10 to June 25, 2022. Frequencies, percentages, means, and a bar chart were created as descriptive statistics. Factors that were significant at the 25% level in univariate analysis were run through multiple logistic models. Odds ratios with respective 95% confidence intervals were developed to determine the relevant predictors. Result The majority (51.7%) of preschool children in Atinago town had anemia. The finding reveals that poor dietary diversity (adjusted odds ratio [AOR] = 1.77, 95% confidence interval [CI] = 1.02-3.07), children from families with food insecurity (AOR = 2.28, 95% CI = 1.31-3.9), child-mothers used iron folate for less than 3 months during pregnancy (AOR = 1.93, 95% CI = 1.07-3.48), households with more than five children (AOR = 1.880, 95% CI = 1.12-3.18), and stunted children (AOR = 1.78, 95% CI = 1.05-3.01) were highly susceptible to anemia. Conclusion The findings indicate that anemia was a serious issue among preschool children in Atinago. Therefore, stakeholders should provide community-based nutrition training on consuming diverse diets, dietary improvements in the home, consuming iron-rich meals, and the like; encourage mothers to participate in early ANC follow-up; and strengthen activities aimed at identifying households with food insecurity status.
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Affiliation(s)
- Fuad M. Sodde
- Department Medical LaboratoryLimmu Seka Health OfficeJimmaEthiopia
| | - Abebe D. Liga
- Department of Statistics, College of Natural and Computational SciencesWolkite UniversityWolkiteEthiopia
| | - Yasin N. Jabir
- Department of Statistics, College of Natural ScienceJimma UniversityJimmaEthiopia
| | - Dessalegn Tamiru
- Department of Human Nutrition and Dietetics, Institute of HealthJimma UniversityJimmaEthiopia
| | - Rediet Kidane
- Department of Human Nutrition and Dietetics, Institute of HealthJimma UniversityJimmaEthiopia
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15
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Braat S, Fielding K, Han J, Jackson VE, Zaloumis S, Xu JXH, Moir-Meyer G, Blaauwendraad SM, Jaddoe VWV, Gaillard R, Parkin PC, Borkhoff CM, Keown-Stoneman CDG, Birken CS, Maguire JL, Bahlo M, Davidson E, Pasricha SR. Statistical haemoglobin thresholds to define anaemia across the lifecycle. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.22.23290129. [PMID: 37292786 PMCID: PMC10246131 DOI: 10.1101/2023.05.22.23290129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Detection of anaemia is critical for clinical medicine and public health. Current WHO values that define anaemia are statistical thresholds (5 th centile) set over 50 years ago, and are presently <110g/L in children 6-59 months, <115g/L in children 5-11 years, <110g/L in pregnant women, <120g/L in children 12-14 years of age, <120g/L in non-pregnant women, and <130g/L in men. Haemoglobin is sensitive to iron and other nutrient deficiencies, medical illness and inflammation, and is impacted by genetic conditions; thus, careful exclusion of these conditions is crucial to obtain a healthy reference population. We identified data sources from which sufficient clinical and laboratory information was available to determine an apparently healthy reference sample. Individuals were excluded if they had any clinical or biochemical evidence of a condition that may diminish haemoglobin concentration. Discrete 5 th centiles were estimated along with two-sided 90% confidence intervals and estimates combined using a fixed-effect approach. Estimates for the 5 th centile of the healthy reference population in children were similar between sexes. Thresholds in children 6-23 months were 104.4g/L [90% CI 103.5, 105.3]; in children 24-59 months were 110.2g/L [109.5, 110.9]; and in children 5-11 years were 114.1g/L [113.2, 115.0]. Thresholds diverged by sex in adolescents and adults. In females and males 12-17 years, thresholds were 122.2g/L [121.3, 123.1] and 128.2 [126.4, 130.0], respectively. In adults 18-65 years, thresholds were 119.7g/L [119.1, 120.3] in non-pregnant females and 134.9g/L [134.2, 135.6] in males. Limited analyses indicated 5 th centiles in first-trimester pregnancy of 110.3g/L [109.5, 111.0] and 105.9g/L [104.0, 107.7] in the second trimester. All thresholds were robust to variations in definitions and analysis models. Using multiple datasets comprising Asian, African, and European ancestries, we did not identify novel high prevalence genetic variants that influence haemoglobin concentration, other than variants in genes known to cause important clinical disease, suggesting non-clinical genetic factors do not influence the 5 th centile between ancestries. Our results directly inform WHO guideline development and provide a platform for global harmonisation of laboratory, clinical and public health haemoglobin thresholds.
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16
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Fothergill A, Crider KS, Rose CE, Bose B, Guetterman HM, Johnson CB, Jabbar S, Zhang M, Pfeiffer CM, Qi YP, Williams JL, Kuriyan R, Bonam W, Finkelstein JL. Estimating the serum folate concentration that corresponds to the red blood cell folate concentration threshold associated with optimal neural tube defects prevention: A population-based biomarker survey in Southern India. Am J Clin Nutr 2023; 117:985-997. [PMID: 37137617 PMCID: PMC10356561 DOI: 10.1016/j.ajcnut.2023.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND RBC folate concentrations are monitored at the population level, with a recommended threshold for optimal neural tube defect (NTD) prevention. A corresponding threshold for serum folate has not been established. OBJECTIVES This study aimed to estimate the serum folate insufficiency threshold corresponding to the RBC folate threshold for NTD prevention and examine how this threshold is modified by vitamin B12 status. METHODS Participants were women (15-40 y; not pregnant or lactating; n = 977) from a population-based biomarker survey in Southern India. RBC folate and serum folate were measured via microbiologic assay. RBC folate deficiency (<305 nmol/L) and insufficiency (<748 nmol/L), serum vitamin B12 deficiency (<148 pmol/L) and vitamin B12 insufficiency (<221 pmol/L), elevated plasma MMA (>0.26 μmol/L), elevated plasma homocysteine (>10.0 μmol/L), and elevated HbA1c (≥6.5%) were evaluated. Bayesian linear models were used to estimate unadjusted and adjusted thresholds. RESULTS Compared with adequate vitamin B12 status, the estimated serum folate threshold was higher in participants with serum vitamin B12 deficiency (72.5 vs. 28.1 nmol/L) or vitamin B12 insufficiency (48.7 vs. 24.3 nmol/L) and elevated MMA (55.6 vs. 25.9 nmol/L). The threshold was lower in participants with elevated HbA1c (HbA1c ≥6.5% vs. <6.5%; 21.0 vs. 40.5 nmol/L). CONCLUSIONS The estimated serum folate threshold for optimal NTD prevention was similar to previous reports (24.3 vs. 25.6 nmol/L) among participants with sufficient vitamin B12 status. However, this threshold was more than 2-fold higher in participants with vitamin B12 deficiency and substantially higher across all indicators of insufficient vitamin B12 status (<221 pmol/L, elevated MMA, combined B12, impaired vitamin B12 status), and lower in participants with elevated HbA1c. Findings suggest a serum folate threshold for NTD prevention may be possible in some settings; however, it may not be appropriate in populations with high prevalence of vitamin B12 insufficiency. Am J Clin Nutr 2023;xx:xx-xx. This trial was registered at https://clinicaltrials.gov as NCT04048330.
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Affiliation(s)
- Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Beena Bose
- Division of Nutrition, St. John's Research Institute, Bangalore, Karnataka, India
| | | | | | - Shameem Jabbar
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mindy Zhang
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rebecca Kuriyan
- Division of Nutrition, St. John's Research Institute, Bangalore, Karnataka, India
| | - Wesley Bonam
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; Division of Nutrition, St. John's Research Institute, Bangalore, Karnataka, India; Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA.
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17
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Young MF, Oaks BM, Rogers HP, Tandon S, Martorell R, Dewey KG, Wendt AS. Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:264. [PMID: 37076797 PMCID: PMC10114461 DOI: 10.1186/s12884-023-05489-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/02/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment. METHODS We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals. RESULTS The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia. CONCLUSION Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA.
| | - Brietta M Oaks
- Department of Nutrition and Food Sciences, University of Rhode Island, 02881, Kingston, United States
| | - Hannah Paige Rogers
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA
| | - Sonia Tandon
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA
| | - Reynaldo Martorell
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, 95616, Davis, United States
| | - Amanda S Wendt
- Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, PO Box 60 12 03, 14412,, Potsdam, Germany
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18
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Kanu FA, Jefferds MED, Williams AM, Addo OY, Suchdev PS, Sharma AJ. Association between hemoglobin and elevation among school-aged children: a verification of proposed adjustments. Am J Clin Nutr 2023:S0002-9165(23)46843-8. [PMID: 37059418 DOI: 10.1016/j.ajcnut.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Anemia is defined by a hemoglobin (Hb) concentration lower than normal based on cutoffs specific to age, sex, and pregnancy status. Hemoglobin increases with elevation as an adaptive response to lower blood oxygen saturation, thus, adjusting Hb concentration for elevation is necessary before applying cutoffs. OBJECTIVE Recent evidence among preschool-aged children (PSC) and non-pregnant reproductive-aged women (WRA) suggests that current World Health Organization (WHO) recommended Hb adjustments for elevation need updating. To confirm these findings, we examined the cross-sectional association between Hb and elevation among non-pregnant school-age children (SAC). METHODS Using data from 9 population-based surveys, we examined 26,518 SAC 5-14 years (54.5% female) with data on Hb and elevation (-6 to 3,834 meters, m). We used generalized linear models to assess the association between Hb and elevation under varying conditions, including controlling for inflammation-corrected iron and vitamin A deficiency. Hemoglobin adjustments for each 500 m increase in elevation were estimated for SAC and compared to existing adjustments and those estimated for PSC and WRA. We evaluated the impact of adjustments on anemia prevalence. RESULTS Hemoglobin concentration (g/L) was positively associated with elevation (m). The SAC elevation adjustments were consistent with those reported among PSC and WRA and suggest current recommendations may under-adjust Hb for those residing at lower elevations (<3000 m) and over-adjust Hb for those residing at higher elevations (>3000 m). Among the surveys included, proposed elevation adjustments increased anemia prevalence among SAC by 0 (Ghana, United Kingdom) to 15 (Malawi) percentage points relative to current elevation adjustments. CONCLUSION Results confirm that current recommended Hb adjustments for elevation may need updating, and anemia prevalence in SAC may be higher than currently estimated. Findings will inform the WHO reexamination of global guidelines on the use of Hb adjustments for anemia assessment and may result in improved identification and treatment of anemia.
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Affiliation(s)
- Florence A Kanu
- Nutrition Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA; The U.S. Public Health Service Commissioned Corps, Atlanta, Georgia
| | | | - Anne M Williams
- Nutrition Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA; McKing, Atlanta, GA
| | - O Yaw Addo
- Nutrition Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Parminder S Suchdev
- Nutrition Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA; Department of Pediatrics, Emory University, Atlanta, GA
| | - Andrea J Sharma
- Nutrition Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA; The U.S. Public Health Service Commissioned Corps, Atlanta, Georgia
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19
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Young MF, Nguyen P, Tran LM, Khuong LQ, Martorell R, Ramakrishnan U. Long term association between of maternal preconception hemoglobin and anemia and child health and development in Vietnam. J Nutr 2023; 153:1597-1606. [PMID: 36925072 PMCID: PMC10367189 DOI: 10.1016/j.tjnut.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/10/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND The long-term association between preconception maternal hemoglobin (Hb) concentrations and child health and development is unclear. OBJECTIVE We examined associations between maternal preconception Hb concentrations and anemia with: a) birth outcomes (weight, length, preterm, gestational age, small-for-gestational-age); b) child Hb at 3 mo, 6 mo, 12 mo, and 24 mo; c) motor and mental development at 12 mo and 24 mo (Bayley scales for infant development) and cognitive functioning at 6-7y (Wechsler Intelligence Scale for Children). METHODS We used data from a randomized controlled trial (PRECONCEPT) conducted in Vietnam. Over 5000 women who were intending to conceive were recruited and offspring were prospectively followed from birth (n=1599) through 6-7y (n=1318). Multivariable linear and logistic regressions were used to assess the association between preconception Hb or anemia (Hb < 11g/dL) on child health and development outcomes, adjusted by supplementation group (tested for interactions) and confounding at maternal, child and household levels. RESULTS At preconception enrollment, 20% of the women were anemic. Maternal preconception Hb was positively associated with child Hb at 3 mo (0.06; 95% CI: 0.01,0.12), 6 mo (0.08; 95% CI: 0.03,0.13), 12 mo (0.10; 95% CI: 0.04-0.15) and 24 mo (0.07; 95% CI: 0.02,0.12). Likewise, maternal preconception Hb was associated with reduced risk of child anemia at 6mo (0.89; 95% CI: 0.81-0.98), 12 mo (0.81; 95% CI: 0.74-0.89) and 24 mo (0.87; 95% CI: 0.79-0.95). Maternal preconception anemia was negatively associated with cognition (-1.64; 95% CI: -3.09, -0.19) and language development (-1.61; 95% CI: -3.20, -0.03) at 24mo. Preconception Hb was not associated with birth outcomes or cognitive outcomes at 6-7y. CONCLUSION Maternal preconception Hb was associated with child Hb across the first 1000 days of life. However, preconception Hb was not a significant predictor of birth outcomes or cognitive outcomes at 6-7y in this cohort from Vietnam.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Phuong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA; Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Lan Mai Tran
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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20
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Cooper M, Bertinato J, Ennis JK, Sadeghpour A, Weiler HA, Dorais V. Population iron status in Canada: results from the Canadian Health Measures Survey 2012-2019. J Nutr 2023; 153:1534-1543. [PMID: 36918146 DOI: 10.1016/j.tjnut.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/14/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND In Canada, population iron status estimates are dated (2009-2011) and did not consider the presence of inflammation. OBJECTIVE To update iron status estimates in Canada using serum ferritin (SF) and evaluate different correction methods for inflammation based on c-reactive protein (CRP). METHODS Data from the Canadian Health Measures Survey cycles 3 to 6 (2012-2019) formed a multi-year, cross-sectional, nationally representative sample (3 to 79 years) (n=21,453). WHO cut-offs for SF and hemoglobin were used to estimate iron deficiency (ID), iron deficiency anemia (IDA), anemia and elevated iron stores. ID was first estimated without considering inflammation. Correction approaches evaluated were: excluding individuals with CRP>5 mg/L; using modified SF cut-offs; and regression correction. RESULTS Total population uncorrected prevalence estimates were 7% (95%CI: 6.2, 7.9) ID, 6.1% (95%CI: 5.2, 7.0) anemia and 2.0% (95%CI: 1.6, 2.4) IDA. Uncorrected prevalence of ID was highest among females of reproductive age with 21.3% (95%CI: 17.6, 25.0) and 18.2% (95%CI: 15.4, 21.1) in 14-18y and 19-50y respectively. Corrected ID estimates were higher compared to uncorrected values, independent of the correction approach. Regression correction led to a moderate increase in prevalence to 10.5% for the total population while applying the higher modified SF cut-offs (70μg/L for those over 5y) led to the largest increases in prevalence, to 12.6%. Applying modified cut-offs led to implausibly high ID estimates among those with inflammation. Elevated iron stores were identified in 17.2% (95%CI: 16.2, 18.2) of the population, mostly in adult males. CONCLUSIONS Correction methods for estimating population iron status need further research. Considering the fundamental drawbacks of each method, uncorrected and regression corrected estimates provide a reasonable range for ID in the Canadian population. Important sex-based differences in iron status and a public health ID problem of moderate magnitude among females of reproductive age are evident in Canada.
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Affiliation(s)
- Marcia Cooper
- Nutrition Research Division, Bureau of Nutritional Sciences, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada.
| | - Jesse Bertinato
- Nutrition Research Division, Bureau of Nutritional Sciences, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada; Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie K Ennis
- Bureau of Food Surveillance and Science Integration, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | - Alireza Sadeghpour
- Bureau of Food Surveillance and Science Integration, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | - Hope A Weiler
- Nutrition Research Division, Bureau of Nutritional Sciences, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | - Veronique Dorais
- Bureau of Food Surveillance and Science Integration, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
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21
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Young MF. Unpacking perplexing findings on maternal hemoglobin and pregnancy outcomes: call for further research to understand underlying etiology and mechanisms. Am J Clin Nutr 2023; 117:447-448. [PMID: 36872012 DOI: 10.1016/j.ajcnut.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 03/06/2023] Open
Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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22
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Fothergill A, Crider KS, Johnson CB, Raj MP, Guetterman HM, Bose B, Rose CE, Qi YP, Williams JL, Kuriyan R, Bonam W, Finkelstein JL. Comparison of Anemia Screening Methods Using Paired Venous Samples in Women of Reproductive Age in Southern India. J Nutr 2023; 152:2978-2992. [PMID: 36130238 PMCID: PMC9840000 DOI: 10.1093/jn/nxac218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/28/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Anemia is an important public health problem, and accurate estimates may inform policy and programs. Although hemoglobin (Hb) assessment of venous blood via automated hematology analyzers (AHAs) is recommended, most population-based surveys estimate anemia prevalence based on analysis of capillary blood via portable hemoglobinometers. OBJECTIVES We aimed to evaluate screening methods for hemoglobin and anemia assessment using paired venous samples. METHODS Participants were women 15-40 y who were not pregnant or lactating. Paired venous whole blood samples (n = 896) were analyzed for hemoglobin (Hb) via portable hemoglobinometer (HemoCue 301) and Coulter Counter AHA. Anemia and severe anemia were defined as Hb <12.0g/dL and <8.0 g/dL, respectively. Bland-Altman methods were used to assess the level of agreement for Hb results (mean difference, SD of differences, limits of agreement). Diagnostic accuracy parameters (sensitivity, specificity, positive predictive value, negative predictive value, accuracy) were calculated to evaluate HemoCue performance compared to the AHA reference, overall and by sociodemographic, nutritional, and metabolic characteristics. RESULTS The estimated anemia prevalence was significantly lower via HemoCue vs. AHA (36.3% compared with 41.6%; P value < 0.0001). The HemoCue had 84.4% accuracy for anemia screening and 98.8% for severe anemia, compared to the AHA reference. The HemoCue had 74.8% sensitivity and 91.2% specificity, compared to AHA. HemoCue sensitivity was higher in women with iron deficiency [serum ferritin (SF) <15.0 μg/L: 81.6% compared with SF ≥15.0 μg/L: 41.3%], and lower in women with metabolic risk factors, including overweight [BMI ≥25.0 kg/m2: 63.9% vs. BMI <25.0 kg/m2: 78.8%], or elevated CRP (>1.0 mg/L: 67.2% vs. ≤1.0 mg/L: 82.9%), trunk fat (>35%: 62.7% vs. ≤35%: 80.1%), or whole-body fat (>35%: 63.9% vs. ≤35%: 80.3%). CONCLUSIONS Findings suggest that women with anemia may be incorrectly identified as not anemic via portable hemoglobinometer, and anemia prevalence may be underestimated at the population level.This study was registered at clinicaltrials.gov as NCT04048330.
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Affiliation(s)
- Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA
| | | | - Mical P Raj
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | | | - Beena Bose
- Division of Nutrition, St. John's Research Institute, Bangalore, India
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA
| | - Yan P Qi
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA
| | - Rebecca Kuriyan
- Division of Nutrition, St. John's Research Institute, Bangalore, India
| | - Wesley Bonam
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- Division of Nutrition, St. John's Research Institute, Bangalore, India
- Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
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23
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Neto NJ, Gomes CDS, Sousa ACPDA, Barbosa JFDS, Ahmed TIS, Borrero CLC, Maciel ÁCC, Guerra RO. HbA1c and physical performance in older adults from different aging epidemiological contexts: Longitudinal findings of the International Mobility in Aging Study (IMIAS). Arch Gerontol Geriatr 2023; 104:104823. [PMID: 36179459 DOI: 10.1016/j.archger.2022.104823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to assess the longitudinal predictions between glycated hemoglobin A1c (HbA1c) and physical performance scores in different epidemiological contexts of aging. MATERIAL AND METHODS Longitudinal data of 1,337 older people from three countries (Canada, Brazil and Colombia) of the International Mobility in Aging Study (IMIAS) were used to assess the relationship between HbA1c and Short Physical Performance Battery (SPPB) scores between 2012 and 2016. Linear Mixed Models grouped by sex and adjusted by Age, Study site, Chronic Conditions, Anthropometric Measures, and Inflammatory Level were used to estimate the influence of HbA1c and covariates on SPPB scores. RESULTS At the IMIAS baseline, Latin American (LA) cities had higher HbA1c averages compared to Canadian cities, with Natal (Brazil) being the city with the highest HbA1c averages in men and women (6.32 ± 1.49; 6,56 ± 1.70 respectively). SPPB scores were significantly lower in LA cities, and older people in Natal had lower SPPB averages in men (9.67 ± 2.38; p-value < 0.05) and women (8.52 ± 2.33; p-value <0.05). In the multivariate mixed linear models of longitudinal analyses, HbA1c was significantly associated with lower SPPB scores in men (β = -0.25, 95% CI: -0.39 to -0.12, p-value = 0.02) but not in women. CONCLUSION High HbA1c levels at baseline were longitudinally associated in older adults from different countries, and this association was observed only in men and not in women. This study highlights a possible influence of gender on this relationship.
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Affiliation(s)
- Nailton José Neto
- Graduate Program in Health Sciences; Federal University of Rio Grande do Norte; General Cordeiro de Faria Street, Natal, Brazil.
| | - Cristiano Dos Santos Gomes
- Department of Physiotherapy, Federal University of Rio Grande do Norte, Senador Salgado Filho Avenue, Natal, Brazil
| | | | - Juliana Fernandes de Souza Barbosa
- Laboratory of Physical Therapy and Collective Health, Physical Therapy Department, Federal University of Pernambuco, Jornalista Aníbal Fernandes Avenue Recife, Brazil.
| | | | | | | | - Ricardo Oliveira Guerra
- Graduate Program in Health Sciences; Federal University of Rio Grande do Norte; General Cordeiro de Faria Street, Natal, Brazil.
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24
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Huang J, Xu J, Ye P, Xin X. Association between magnesium intake and the risk of anemia among adults in the United States. Front Nutr 2023; 10:1046749. [PMID: 36908911 PMCID: PMC9996106 DOI: 10.3389/fnut.2023.1046749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/08/2023] [Indexed: 02/25/2023] Open
Abstract
Background Magnesium deficiency is related to an increased risk of anemia, but epidemiological evidence supporting this association remains scarce. The purpose of the present survey was to evaluate the relationship between dietary magnesium intake and the risk of anemia. Methods In total, 13,423 participants aged 20-80 years were enrolled using data from the National Health and Nutrition Examination Survey 2011-2016. Magnesium consumption was evaluated using 24 h dietary recalls. Multivariable generalized linear models were developed to demonstrate the association between dietary magnesium intake and the prevalence of anemia. Results An inverse association between dietary magnesium intake and the risk of anemia was detected based on a full adjustment model. We evaluated magnesium intake as a categorical variable (five quartiles). Compared with the lowest value, the highest multivariate adjusted odds ratio (95% confidence interval) for anemia was 0.64 (0.46-0.89). Stratified analyses revealed a reverse relationship between magnesium intake and anemia in women. However, no significant association was observed in men (p for trend = 0.376). A similar reverse association was found among the older group (aged ≥60 years). Conclusion Magnesium deficiency is closely related to a higher rate of anemia occurrence, especially among women and older Americans. Further larger-scale prospective studies are required to confirm these conclusions.
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Affiliation(s)
- Jungao Huang
- Ganzhou Maternal and Child Health Hospital, Ganzhou, Jiangxi, China
| | - Jing Xu
- Department of Clinical Laboratory, Ganzhou People's Hospital, Ganzhou, Jiangxi, China
| | - Ping Ye
- Department of Clinical Laboratory, Ganzhou People's Hospital, Ganzhou, Jiangxi, China
| | - Xiaoqin Xin
- Department of Clinical Laboratory, Ganzhou People's Hospital, Ganzhou, Jiangxi, China
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Amiri FA, Zhang J. Oxygen transport across tank-treading red blood cell: Individual and joint roles of flow convection and oxygen-hemoglobin reaction. Microvasc Res 2023; 145:104447. [PMID: 36270419 DOI: 10.1016/j.mvr.2022.104447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
Gas, especially oxygen, transport in the microcirculation is a complex phenomenon, however, of critical importance for maintaining normal biological functions, and the cytoplasm fluid in red blood cells (RBCs) is the major vehicle for transporting oxygen from lungs to tissues via the circulatory system. Existing theoretical and numerical studies have neglected the cytoplasm convection effect by treating RBCs as rigid particles undergoing a constant translation velocity. As a consequence, the influence and mechanism of the cytoplasm flow on oxygen transport are still not clear in microcirculation research. In this study, we consider a tank-treading capsule in shear flow, which is generated with two parallel plates moving in opposite directions: the top plate of a higher oxygen pressure (PO2) representing the RBC core in the central region of a microvessel and the bottom plate of a lower PO2 representing the microvessel wall. Numerical simulations are conducted to investigate the individual and combined effects of cytoplasm convection and oxygen-hemoglobin (O2-Hb) reaction on the oxygen transport efficiency across the tank-treading capsule, and different PO2 situations and shear rates are also tested. Due to the lower oxygen diffusivity in cytoplasm, the presence of the capsule reduces the oxygen transfer flux across the gap by 7.34 % in the pure diffusion system where the flow convection and O2-Hb reaction are both neglected. Including the flow convection or the O2-Hb reaction has little influence on the oxygen flux; however, when they act together as in real microcirculation situations, the enhancement in oxygen transport could be significant, especially in the low PO2 and high shear rate situations. In particular, with the respective PO2 at 60 and 30 mmHg on the top and bottom plates and a 400 s-1 shear rate, the oxygen flux reduction is only 0.02 %, suggesting that the cytoplasm convection can improve the oxygen transport across RBCs considerably. The simulation results are scrutinized to explore the underlying mechanism for the enhancement, and a new nondimensional parameter is introduced to characterize the importance of cytoplasm convection in oxygen transport. These simulation results, discussion and analysis could be helpful for a better understanding of the complex oxygen transport process and therefor valuable for relevant studies.
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Affiliation(s)
- Farhad A Amiri
- Bharti School of Engineering and Computer Science, Laurentian University, 935 Ramsey Lake Road, Sudbury, Ontario P3E 2C6, Canada
| | - Junfeng Zhang
- Bharti School of Engineering and Computer Science, Laurentian University, 935 Ramsey Lake Road, Sudbury, Ontario P3E 2C6, Canada.
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Trenado Luengo B, García-Sierra R, Wilke Trinxant M, Naval Pulido M, Lleal Barriga C, Torán-Monserrat P. Epidemiología de la anemia en adultos: estudio observacional de base poblacional. Semergen 2022; 48:101818. [DOI: 10.1016/j.semerg.2022.101818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/15/2022] [Accepted: 07/28/2022] [Indexed: 10/14/2022]
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Pullakhandam R, Ghosh S, Kulkarni B, Reddy GB, Rajkumar H, Kapil U, Deb S, Kurpad AV, Sachdev HS. Reference cut-offs to define low serum zinc concentrations in healthy 1-19 year old Indian children and adolescents. Eur J Clin Nutr 2022; 76:1150-1157. [PMID: 35140314 DOI: 10.1038/s41430-022-01088-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND/OBJECTIVES Population zinc (Zn) status assessment is based on serum zinc concentration (SZC) cut-offs defined by the International Zinc Nutrition Consultative Group (IZiNCG). The objective of this study is to derive reference SZC cut-offs in apparently healthy 1-19 year Indian children and adolescents using comprehensive national nutrition survey (CNNS) data, and to measure the prevalence of Zn deficiency. SUBJECTS/METHODS Apparently healthy children (n = 12,473) were selected from the CNNS, by including the highest 2 wealth quintiles, and excluding stunted, thin and obese children, and those with CRP > 5 mg/L, anaemia, hypo-albuminemia, diabetes, recent diarrhoea and history of smoking. The 2.5th centile of age-based distributions defined the SZC cut-offs, used to measure the prevalence of Zn deficiency in India, as against the IZiNCG cut-offs. RESULTS The present study SZC cut-offs were significantly lower, by 10-18 µg/dL, than the IZiNCG cut-offs; more in adolescents. Prevalence of Zn deficiency in the entire CNNS, with these cut-offs, was 2.7 (<10 years) to 5.5 (10-19 years) times lower than with the IZiNCG cut-offs. No geographical state, nor any age group, had Zn deficiency as a serious public health problem (≥20%). In contrast, with IZiNCG cut-offs, 9-27 states (depending on age group) had a public health problem. CONCLUSIONS The present study reference SZC cut-offs for Zn deficiency are lower than the IZiNCG cut-offs, and their rigorous selection from a national sample makes them more appropriate for use in India. A re-examination of the global applicability of IZiNCG recommended cut-offs in other LMICs appears appropriate.
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Affiliation(s)
- Raghu Pullakhandam
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | | | - Bharati Kulkarni
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - G Bhanuprakash Reddy
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Hemalatha Rajkumar
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Umesh Kapil
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sila Deb
- Ministry of Health and Family Welfare, New Delhi, India
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Finkelstein JL, Fothergill A, Guetterman HM, Johnson CB, Bose B, Qi YP, Rose CE, Williams JL, Mehta S, Kuriyan R, Bonam W, Crider KS. Iron status and inflammation in women of reproductive age: A population-based biomarker survey and clinical study. Clin Nutr ESPEN 2022; 49:483-494. [PMID: 35623855 PMCID: PMC10878764 DOI: 10.1016/j.clnesp.2022.02.123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/18/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Women of reproductive age (WRA) are at increased risk for anemia and iron deficiency. However, there is limited population-level data in India, which could help inform evidence-based recommendations and policy. AIMS To conduct a population-based biomarker survey of anemia, iron deficiency, and inflammation in WRA in Southern India. METHODS Participants were WRA (15-40 y) who were not pregnant or lactating. Blood samples (n = 979) were collected and analyzed for hemoglobin (Hb), serum ferritin (SF), soluble transferrin receptor (sTfR), C-reactive protein (CRP), and alpha-1 acid glycoprotein (AGP). Anemia and severe anemia were defined as Hb < 12.0 and < 8.0 g/dL. Serum ferritin was adjusted for inflammation using BRINDA methods. Iron deficiency was defined as SF <15.0 μg/L, iron insufficiency was defined as SF < 20.0 and < 25.0 μg/L, and iron deficiency anemia was defined as Hb < 12.0 g/dL and SF < 15.0 μg/L. Inflammation was defined as CRP > 5.0 mg/L or AGP > 1.0 g/L. Restricted cubic spline regression models were also used to determine if alternative SF thresholds should be used t to classify iron deficiency. RESULTS A total of 41.5% of WRA had anemia, and 3.0% had severe anemia. Findings from spline analyses suggested a SF cut-off of < 15.0 μg/L, consistent with conventional cut-offs for iron deficiency. 46.3% of WRA had SF < 15.0 μg/L (BRINDA-adjusted: 61.5%), 55.0% had SF < 20.0 μg/L (72.7%), 61.8% had SF < 25.0 μg/L (81.0%), and 30.0% had IDA (34.5%). 17.3% of WRA had CRP > 5.0 mg/L and 22.2% had AGP > 1.0 g/L. The prevalence of ID (rural vs. urban: 49.1% vs. 34.9%; p = 0.0004), iron insufficiency (57.8% vs. 43.8%; p = 0.0005), and IDA (31.8% vs. 22.4%; p = 0.01) were significantly higher in rural areas, although CRP levels were lower and there were no differences in elevated CRP or AGP. CONCLUSIONS The burden of anemia and iron deficiency in this population was substantial, and increased after adjusting for inflammation, suggesting potential to benefit from screening and interventions. REGISTRATION NUMBER NCT04048330.
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Affiliation(s)
- Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca NY, USA; Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA; Institute for Nutritional Sciences, Global Health, and Technology, Cornell University, Ithaca, NY, USA; St. John's Research Institute, Bangalore, Karnataka, India.
| | - Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca NY, USA
| | | | | | - Beena Bose
- St. John's Research Institute, Bangalore, Karnataka, India
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca NY, USA; Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA; Institute for Nutritional Sciences, Global Health, and Technology, Cornell University, Ithaca, NY, USA
| | | | - Wesley Bonam
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Stevens GA, Paciorek CJ, Flores-Urrutia MC, Borghi E, Namaste S, Wirth JP, Suchdev PS, Ezzati M, Rohner F, Flaxman SR, Rogers LM. National, regional, and global estimates of anaemia by severity in women and children for 2000-19: a pooled analysis of population-representative data. Lancet Glob Health 2022; 10:e627-e639. [PMID: 35427520 PMCID: PMC9023869 DOI: 10.1016/s2214-109x(22)00084-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/23/2022] [Accepted: 02/21/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anaemia causes health and economic harms. The prevalence of anaemia in women aged 15-49 years, by pregnancy status, is indicator 2.2.3 of the UN Sustainable Development Goals, and the aim of halving the anaemia prevalence in women of reproductive age by 2030 is an extension of the 2025 global nutrition targets endorsed by the World Health Assembly (WHA). We aimed to estimate the prevalence of anaemia by severity for children aged 6-59 months, non-pregnant women aged 15-49 years, and pregnant women aged 15-49 years in 197 countries and territories and globally for the period 2000-19. METHODS For this pooled analysis of population-representative data, we collated 489 data sources on haemoglobin distribution in children and women from 133 countries, including 4·5 million haemoglobin measurements. Our data sources comprised health examination, nutrition, and household surveys, accessed as anonymised individual records or as summary statistics such as mean haemoglobin and anaemia prevalence. We used a Bayesian hierarchical mixture model to estimate haemoglobin distributions in each population and country-year. This model allowed for coherent estimation of mean haemoglobin and prevalence of anaemia by severity. FINDINGS Globally, in 2019, 40% (95% uncertainty interval [UI] 36-44) of children aged 6-59 months were anaemic, compared to 48% (45-51) in 2000. Globally, the prevalence of anaemia in non-pregnant women aged 15-49 years changed little between 2000 and 2019, from 31% (95% UI 28-34) to 30% (27-33), while in pregnant women aged 15-49 years it decreased from 41% (39-43) to 36% (34-39). In 2019, the prevalence of anaemia in children aged 6-59 months exceeded 70% in 11 countries and exceeded 50% in all women aged 15-49 years in ten countries. Globally in all populations and in most countries and regions, the prevalence of mild anaemia changed little, while moderate and severe anaemia declined in most populations and geographical locations, indicating a shift towards mild anaemia. INTERPRETATION Globally, regionally, and in nearly all countries, progress on anaemia in women aged 15-49 years is insufficient to meet the WHA global nutrition target to halve anaemia prevalence by 2030, and the prevalence of anaemia in children also remains high. A better understanding of the context-specific causes of anaemia and quality implementation of effective multisectoral actions to address these causes are needed. FUNDING USAID, US Centers for Disease Control and Prevention, and Bill & Melinda Gates Foundation.
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Affiliation(s)
- Gretchen A Stevens
- Independent researcher, Los Angeles, CA, USA; School of Public Health, Imperial College London, London, UK
| | | | | | - Elaine Borghi
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
| | | | | | - Parminder S Suchdev
- Department of Pediatrics and Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Majid Ezzati
- School of Public Health, Imperial College London, London, UK; Regional Institute for Population Studies, University of Ghana, Legon, Ghana
| | | | - Seth R Flaxman
- Department of Computer Science, University of Oxford, Oxford, UK
| | - Lisa M Rogers
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland.
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Efficacy of iron-folic acid treatment for reducing anemia prevalence and improving iron status in women of reproductive age: A one-year longitudinal study. Clin Nutr ESPEN 2022; 49:390-397. [DOI: 10.1016/j.clnesp.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/18/2022]
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Addo OY, Yu EX, Williams AM, Young MF, Sharma AJ, Mei Z, Kassebaum NJ, Jefferds MED, Suchdev PS. Evaluation of Hemoglobin Cutoff Levels to Define Anemia Among Healthy Individuals. JAMA Netw Open 2021; 4:e2119123. [PMID: 34357395 PMCID: PMC8346941 DOI: 10.1001/jamanetworkopen.2021.19123] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/27/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Anemia, defined as low hemoglobin (Hb) concentration insufficient to meet an individual's physiological needs, is the most common blood condition worldwide. Objective To evaluate the current World Health Organization (WHO) Hb cutoffs for defining anemia among persons who are apparently healthy and to assess threshold validity with a biomarker of tissue iron deficiency and physiological indicator of erythropoiesis (soluble transferrin receptor [sTfR]) using multinational data. Design, Setting, and Participants In this cross-sectional study, data were collected and evaluated from 30 household, population-based nutrition surveys of preschool children aged 6 to 59 months and nonpregnant women aged 15 to 49 years during 2005 to 2016 across 25 countries. Data analysis was performed from March 2020 to April 2021. Exposure Anemia defined according to WHO Hb cutoffs. Main Outcomes and Measures To define the healthy population, persons with iron deficiency (ferritin <12 ng/mL for children or <15 ng/mL for women), vitamin A deficiency (retinol-binding protein or retinol <20.1 μg/dL), inflammation (C-reactive protein >0.5 mg/dL or α-1-acid glycoprotein >1 g/L), or known malaria were excluded. Survey-specific, pooled Hb fifth percentile cutoffs were estimated. Among individuals with Hb and sTfR data, Hb-for-sTfR curve analysis was conducted to identify Hb inflection points that reflect tissue iron deficiency and increased erythropoiesis induced by anemia. Results A total of 79 950 individuals were included in the original surveys. The final healthy sample was 13 445 children (39.9% of the original sample of 33 699 children; 6750 boys [50.2%]; mean [SD] age 32.9 [16.0] months) and 25 880 women (56.0% of the original sample of 46 251 women; mean [SD] age, 31.0 [9.5] years). Survey-specific Hb fifth percentile among children ranged from 7.90 g/dL (95% CI, 7.54-8.26 g/dL in Pakistan) to 11.23 g/dL (95% CI, 11.14-11.33 g/dL in the US), and among women from 8.83 g/dL (95% CI, 7.77-9.88 g/dL in Gujarat, India) to 12.09 g/dL (95% CI, 12.00-12.17 g/dL in the US). Intersurvey variance around the Hb fifth percentile was low (3.5% for women and 3.6% for children). Pooled fifth percentile estimates were 9.65 g/dL (95% CI, 9.26-10.04 g/dL) for children and 10.81 g/dL (95% CI, 10.35-11.27 g/dL) for women. The Hb-for-sTfR curve demonstrated curvilinear associations with sTfR inflection points occurring at Hb of 9.61 g/dL (95% CI, 9.55-9.67 g/dL) among children and 11.01 g/dL (95% CI, 10.95-11.09 g/dL) among women. Conclusions and Relevance Current WHO cutoffs to define anemia are higher than the pooled fifth percentile of Hb among persons who are outwardly healthy and from nearly all survey-specific estimates. The lower proposed Hb cutoffs are statistically significant but also reflect compensatory increased erythropoiesis. More studies based on clinical outcomes could further confirm the validity of these Hb cutoffs for anemia.
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Affiliation(s)
- O. Yaw Addo
- Nutrition Branch, International Micronutrient Malnutrition Prevention and Control Program Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Emma X. Yu
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Anne M. Williams
- Nutrition Branch, International Micronutrient Malnutrition Prevention and Control Program Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
- Emory University Rollins School of Public Health, Atlanta, Georgia
- McKing Consulting Corporation, Atlanta, Georgia
| | | | - Andrea J. Sharma
- Nutrition Branch, International Micronutrient Malnutrition Prevention and Control Program Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
- USPHS Commissioned Corps, Atlanta, Georgia
| | - Zuguo Mei
- Nutrition Branch, International Micronutrient Malnutrition Prevention and Control Program Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Maria Elena D. Jefferds
- Nutrition Branch, International Micronutrient Malnutrition Prevention and Control Program Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Parminder S. Suchdev
- Nutrition Branch, International Micronutrient Malnutrition Prevention and Control Program Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
- Emory University Rollins School of Public Health, Atlanta, Georgia
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Rogozińska E, Daru J, Nicolaides M, Amezcua-Prieto C, Robinson S, Wang R, Godolphin PJ, Saborido CM, Zamora J, Khan KS, Thangaratinam S. Iron preparations for women of reproductive age with iron deficiency anaemia in pregnancy (FRIDA): a systematic review and network meta-analysis. Lancet Haematol 2021; 8:e503-e512. [PMID: 34171281 PMCID: PMC7612251 DOI: 10.1016/s2352-3026(21)00137-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Numerous iron preparations are available for the treatment of iron deficiency anaemia in pregnancy. We aimed to provide a summary of the effectiveness and safety of iron preparations used in this setting. METHODS We did a systematic review and network meta-analysis of randomised trials. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature for trials published in any language from Jan 1, 2011, to Feb 28, 2021. We included trials including pregnant women with iron deficiency anaemia and evaluating iron preparations, irrespective of administration route, with at least 60 mg of elemental iron, in comparison with another iron or non-iron preparation. Three authors independently selected studies, extracted data, and did a risk of bias assessment using the Cochrane tool (version 1.0). The primary outcome was the effectiveness of iron preparations, evaluated by changes in haemoglobin concentration at 4 weeks from baseline. The secondary outcomes were change in serum ferritin concentration at 4 weeks from baseline and treatment-related severe and non-severe adverse events. We did random-effects pairwise and network meta-analyses. Side-effects were reported descriptively for each trial. This study is registered with PROSPERO, CRD42018100822. FINDINGS Among 3037 records screened, 128 full-text articles were further assessed for eligibility. Of the 53 eligible trials (reporting on 9145 women), 30 (15 interventions; 3243 women) contributed data to the network meta-analysis for haemoglobin and 15 (nine interventions; 1396 women) for serum ferritin. The risk of bias varied across the trials contributing to network meta-analysis, with 22 of 30 trials in the network meta-analysis for haemoglobin judged to have a high or medium global risk of bias. Compared with oral ferrous sulfate, intravenous iron sucrose improved both haemoglobin (mean difference 7·17 g/L, 95% CI 2·62-11·73; seven trials) and serum ferritin (mean difference 49·66 μg/L, 13·63-85·69; four trials), and intravenous ferric carboxymaltose improved haemoglobin (mean difference 8·52 g/L, 0·51-16·53; one trial). The evidence for other interventions compared with ferrous sulfate was insufficient. The most common side-effects with oral iron preparations were gastrointestinal effects (nausea, vomiting, and altered bowel movements). Side-effects were less common with parenteral iron preparations, although these included local pain, skin irratation, and, on rare occasions, allergic reactions. INTERPRETATION Iron preparations for treatment of iron deficiency anaemia in pregnancy vary in effectiveness, with good evidence of benefit for intravenous iron sucrose and some evidence for intravenous ferric carboxymaltose. Clinicians and policy makers should consider the effectiveness of individual preparations before administration, to ensure effective treatment. FUNDING None.
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Affiliation(s)
| | - Jahnavi Daru
- Institute for Population Health Science, Queen Mary University of London, London, UK.
| | - Marios Nicolaides
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Carmen Amezcua-Prieto
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Susan Robinson
- Department of Haematology, Guy's and St Thomas' Hospital, London, UK
| | - Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Peter J Godolphin
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - Carlos Martín Saborido
- Department of Health Planning and Economics, National School of Public Health, Institute of Health Carlos III, Madrid, Spain
| | - Javier Zamora
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Hospital Universitario Ramón y Cajal (IRYCIS), CIBERESP, Madrid, Spain
| | - Khalid S Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Machado MMA, Lopes MDP, Schincaglia RM, da Costa PSS, Coelho ASG, Hadler MCCM. Effect of Fortification with Multiple Micronutrient Powder on the Prevention and Treatment of Iron Deficiency and Anaemia in Brazilian Children: A Randomized Clinical Trial. Nutrients 2021; 13:nu13072160. [PMID: 34201821 PMCID: PMC8308208 DOI: 10.3390/nu13072160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/28/2021] [Accepted: 05/30/2021] [Indexed: 11/16/2022] Open
Abstract
Fortification with multiple micronutrient powder has been proposed as a public health intervention able to reduce micronutrient deficiencies in children. Our objective was to compare the effectiveness of fortification with multiple micronutrient powder with drug supplementation in the prevention and treatment of iron deficiency and anaemia. This was a cluster trial with anemic and non-anaemic children between six and 42 months old, in randomization data. Non anaemic children received fortification with multiple micronutrient powder or standard drug supplementation of ferrous sulfate associated with folic acid in a prevention dose. Anaemic children who were randomized to receive multiple micronutrient powder also received the recommended iron complementation for anaemia treatment. A total of 162 children were evaluated. The prevalence of anaemia decreased from 13.58 to 1.85%. Iron deficiency decreased from 21.74% to 7.89% (by serum ferritin) and iron deficiency decreased from 66.81 to 38.27% (by soluble transferrin receptor). No difference was identified between interventions for hemoglobin (p = 0.142), serum ferritin (p = 0.288), and soluble transferrin receptor (p = 0.156). Fortification with multiple micronutrient powder was effective in preventing iron deficiency and anaemia in children aged six to 48 months. In anaemic children; it was necessary to supplement the dose of multiple micronutrient powder with ferrous sulfate.
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Affiliation(s)
- Malaine Morais Alves Machado
- Graduate Program in Health Sciences of the Federal University of Goiás, Faculty of Medicine, Federal University of Goiás, Goiânia 74605-050, Goiás, Brazil;
| | | | - Raquel Machado Schincaglia
- Research Laboratory in Clinical and Sports Nutrition, Faculty of Nutrition, Federal University of Goiás, Goiânia 74605-050, Goiás, Brazil;
| | | | - Alexandre Siqueira Guedes Coelho
- Graduate Program in Nutrition and Health of the Federal University of Goiás, Faculty of Nutrition Goiânia, Federal University of Goiás, Goiânia 74605-050, Goiás, Brazil;
| | - Maria Claret Costa Monteiro Hadler
- Graduate Program in Health Sciences of the Federal University of Goiás, Faculty of Medicine, Federal University of Goiás, Goiânia 74605-050, Goiás, Brazil;
- Faculty of Nutrition, Federal University of Goiás, Goiânia 74605-050, Goiás, Brazil;
- Graduate Program in Nutrition and Health of the Federal University of Goiás, Faculty of Nutrition Goiânia, Federal University of Goiás, Goiânia 74605-050, Goiás, Brazil;
- Correspondence: ; Tel.: +55-62-3209-6270
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Zhou Q, Zhang B, Chen X, Chen Q, Hao L. Association of serum selenium with anemia-related indicators and risk of anemia. Food Sci Nutr 2021; 9:3039-3047. [PMID: 34136169 PMCID: PMC8194763 DOI: 10.1002/fsn3.2261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 01/07/2023] Open
Abstract
Few studies have examined the association of serum selenium with anemia-related indicators and risk of anemia. We conducted a cross-sectional analysis of 2,902 adults in 2003-2004 National Health and Nutrition Examination Survey database. Multivariable linear and logistic regression models were used to examine the association of serum selenium with anemia-related indicators and risk of anemia. The nonlinear relationship was analyzed using a generalized additive model with the smoothing plot. A total of 1,472 males and 1,430 females with a mean age of 61.94 ± 13.73 years were included. Compared with the lowest quintile, the highest quintile of serum selenium was associated with increased level of serum iron (β = 12.44, 95% confidence interval [CI]: 7.14, 17.75, p < .001), mean corpuscular hemoglobin concentration (MCHC) (β = 0.14, 95%CI: 0.02, 0.26, p = .020), and hemoglobin (β = 0.40, 95%CI: 0.19, 0.61, p < .001), and decreased risk of anemia (odds ratio [OR] = 0.47, 95%CI: 0.28, 0.77, p = .002). Furthermore, smoothed plots suggested the nonlinear relationships between serum selenium and MCHC, hemoglobin level, and risk of anemia. Interestingly, on the left of inflection point, serum selenium was associated with decreased risk of anemia (OR = 0.972, 95%CI: 0.960, 0.985, p < .001), and then, the risk of anemia increased with increasing serum selenium concentration (OR = 1.011, 95%CI: 1.002, 1.021, p = .023). Future large-scale, polycentric prospective studies should be conducted to verify our results.
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Affiliation(s)
- Qing Zhou
- Central LaboratoryPeople’s Hospital of Baoan DistrictThe Second Affiliated Hospital of Shenzhen UniversityShenzhenChina
| | - Baozhu Zhang
- Department of OncologyPeople’s Hospital of Baoan DistrictThe Second Affiliated Hospital of Shenzhen UniversityShenzhenChina
| | - Xi Chen
- Central LaboratoryPeople’s Hospital of Baoan DistrictThe Second Affiliated Hospital of Shenzhen UniversityShenzhenChina
| | - Qiuyan Chen
- Science and Education DepartmentShenzhen Baoan Shiyan People’s HospitalShenzhenChina
| | - Lu Hao
- Science and Education DepartmentShenzhen Baoan Shiyan People’s HospitalShenzhenChina
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Sachdev HS, Porwal A, Acharya R, Ashraf S, Ramesh S, Khan N, Kapil U, Kurpad AV, Sarna A. Haemoglobin thresholds to define anaemia in a national sample of healthy children and adolescents aged 1-19 years in India: a population-based study. Lancet Glob Health 2021; 9:e822-e831. [PMID: 33872581 PMCID: PMC7612991 DOI: 10.1016/s2214-109x(21)00077-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND WHO's haemoglobin cutoffs to define anemia were based on five studies of predominantly White adult populations, done over 50 years ago. Therefore, a general re-examination of the existing haemoglobin cutoffs is warranted for global application, in representative healthy populations of children and adults. Such data are scarce in low-income and middle-income countries; however, a 2019, large-scale, nationally representative survey of children and adolescents aged 0-19 years in India (Comprehensive National Nutrition Survey [CNNS]) offered an opportunity for this re-examination. Using this survey, we aimed to assess the age-specific and sex-specific percentiles of haemoglobin and cutoffs to define anaemia in the CNNS population. METHODS For this population-based study, we constructed age-specific and sex-specific haemoglobin percentiles from values reported for a defined healthy population in the CNNS, which used rigorous quality control measures during sample collection and in the laboratory analyses. To obtain a healthy population, we excluded participants with iron, folate, vitamin B12, and retinol deficiencies; inflammation; variant haemoglobins (haemoglobin A2 and haemoglobin S); and history of smoking. We considered age-specific and sex-specific 5th percentiles of haemoglobin derived for this healthy population as the study cutoff to define anaemia. We compared these with existing WHO cutoffs to assess significant differences between them at each year of age and sex for quantifying the prevalence of anaemia in the entire CNNS sample. FINDINGS Between Feb 24, 2016, and Oct 26, 2018, the CNNS survey collected blood samples from 49 486 individuals. 41 210 participants had a haemoglobin value, 8087 of whom were included in our study and comprised the primary analytical sample. Compared with existing WHO cutoffs, the study cutoffs for haemoglobin were lower at all ages, usually by 1-2 g/dL, but more so in children of both sexes aged 1-2 years and in girls aged 10 years or older. Aanemia prevalence with the study cutoffs was 19·2 percentage points lower than with WHO cutoffs in the entire CNNS sample with valid haemoglobin values across all ages and sexes (10·8% with study cutoffs vs 30·0% with WHO cutoffs). INTERPRETATION These findings support the re-examination of WHO haemoglobin cutoffs to define anaemia. Our haemoglobin reference percentiles, derived from healthy participants in a large representative Indian survey, are suitable for national use in India. Substantial variations in the 5th percentile of haemoglobin values across the 1-19 years age range and between sexes argue against constructing common cutoffs in stratified age groups for convenience. FUNDING None. TRANSLATIONS For the Hindi, Punjabi, Tamil and Kannada translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Harshpal Singh Sachdev
- Paediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi, India.
| | - Akash Porwal
- Population Council, India Habitat Centre, New Delhi, India
| | - Rajib Acharya
- Population Council, India Habitat Centre, New Delhi, India
| | - Sana Ashraf
- Population Council, India Habitat Centre, New Delhi, India
| | - Sowmya Ramesh
- Population Council, India Habitat Centre, New Delhi, India
| | | | - Umesh Kapil
- Department of Epidemiology, Biostatistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Anura V Kurpad
- Department of Physiology, St John's Medical College, Bengaluru, India
| | - Avina Sarna
- Population Council, India Habitat Centre, New Delhi, India
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Garcia-Casal MN, Pasricha SR, Martinez RX, Lopez-Perez L, Peña-Rosas JP. Serum or plasma ferritin concentration as an index of iron deficiency and overload. Cochrane Database Syst Rev 2021; 5:CD011817. [PMID: 34028001 PMCID: PMC8142307 DOI: 10.1002/14651858.cd011817.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Reference standard indices of iron deficiency and iron overload are generally invasive, expensive, and can be unpleasant or occasionally risky. Ferritin is an iron storage protein and its concentration in the plasma or serum reflects iron stores; low ferritin indicates iron deficiency, while elevated ferritin reflects risk of iron overload. However, ferritin is also an acute-phase protein and its levels are elevated in inflammation and infection. The use of ferritin as a diagnostic test of iron deficiency and overload is a common clinical practice. OBJECTIVES To determine the diagnostic accuracy of ferritin concentrations (serum or plasma) for detecting iron deficiency and risk of iron overload in primary and secondary iron-loading syndromes. SEARCH METHODS We searched the following databases (10 June 2020): DARE (Cochrane Library) Issue 2 of 4 2015, HTA (Cochrane Library) Issue 4 of 4 2016, CENTRAL (Cochrane Library) Issue 6 of 12 2020, MEDLINE (OVID) 1946 to 9 June 2020, Embase (OVID) 1947 to week 23 2020, CINAHL (Ebsco) 1982 to June 2020, Web of Science (ISI) SCI, SSCI, CPCI-exp & CPCI-SSH to June 2020, POPLINE 16/8/18, Open Grey (10/6/20), TRoPHI (10/6/20), Bibliomap (10/6/20), IBECS (10/6/20), SCIELO (10/6/20), Global Index Medicus (10/6/20) AIM, IMSEAR, WPRIM, IMEMR, LILACS (10/6/20), PAHO (10/6/20), WHOLIS 10/6/20, IndMED (16/8/18) and Native Health Research Database (10/6/20). We also searched two trials registers and contacted relevant organisations for unpublished studies. SELECTION CRITERIA We included all study designs seeking to evaluate serum or plasma ferritin concentrations measured by any current or previously available quantitative assay as an index of iron status in individuals of any age, sex, clinical and physiological status from any country. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. We designed the data extraction form to record results for ferritin concentration as the index test, and bone marrow iron content for iron deficiency and liver iron content for iron overload as the reference standards. Two other authors further extracted and validated the number of true positive, true negative, false positive, false negative cases, and extracted or derived the sensitivity, specificity, positive and negative predictive values for each threshold presented for iron deficiency and iron overload in included studies. We assessed risk of bias and applicability using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. We used GRADE assessment to enable the quality of evidence and hence strength of evidence for our conclusions. MAIN RESULTS Our search was conducted initially in 2014 and updated in 2017, 2018 and 2020 (10 June). We identified 21,217 records and screened 14,244 records after duplicates were removed. We assessed 316 records in full text. We excluded 190 studies (193 records) with reasons and included 108 studies (111 records) in the qualitative and quantitative analysis. There were 11 studies (12 records) that we screened from the last search update and appeared eligible for a future analysis. We decided to enter these as awaiting classification. We stratified the analysis first by participant clinical status: apparently healthy and non-healthy populations. We then stratified by age and pregnancy status as: infants and children, adolescents, pregnant women, and adults. Iron deficiency We included 72 studies (75 records) involving 6059 participants. Apparently healthy populations Five studies screened for iron deficiency in people without apparent illness. In the general adult population, three studies reported sensitivities of 63% to 100% at the optimum cutoff for ferritin, with corresponding specificities of 92% to 98%, but the ferritin cutoffs varied between studies. One study in healthy children reported a sensitivity of 74% and a specificity of 77%. One study in pregnant women reported a sensitivity of 88% and a specificity of 100%. Overall confidence in these estimates was very low because of potential bias, indirectness, and sparse and heterogenous evidence. No studies screened for iron overload in apparently healthy people. People presenting for medical care There were 63 studies among adults presenting for medical care (5042 participants). For a sample of 1000 subjects with a 35% prevalence of iron deficiency (of the included studies in this category) and supposing a 85% specificity, there would be 315 iron-deficient subjects correctly classified as having iron deficiency and 35 iron-deficient subjects incorrectly classified as not having iron deficiency, leading to a 90% sensitivity. Thresholds proposed by the authors of the included studies ranged between 12 to 200 µg/L. The estimated diagnostic odds ratio was 50. Among non-healthy adults using a fixed threshold of 30 μg/L (nine studies, 512 participants, low-certainty evidence), the pooled estimate for sensitivity was 79% with a 95% confidence interval of (58%, 91%) and specificity of 98%, with a 95% confidence interval of (91%, 100%). The estimated diagnostic odds ratio was 140, a relatively highly informative test. Iron overload We included 36 studies (36 records) involving 1927 participants. All studies concerned non-healthy populations. There were no studies targeting either infants, children, or pregnant women. Among all populations (one threshold for males and females; 36 studies, 1927 participants, very low-certainty evidence): for a sample of 1000 subjects with a 42% prevalence of iron overload (of the included studies in this category) and supposing a 65% specificity, there would be 332 iron-overloaded subjects correctly classified as having iron overload and 85 iron-overloaded subjects incorrectly classified as not having iron overload, leading to a 80% sensitivity. The estimated diagnostic odds ratio was 8. AUTHORS' CONCLUSIONS At a threshold of 30 micrograms/L, there is low-certainty evidence that blood ferritin concentration is reasonably sensitive and a very specific test for iron deficiency in people presenting for medical care. There is very low certainty that high concentrations of ferritin provide a sensitive test for iron overload in people where this condition is suspected. There is insufficient evidence to know whether ferritin concentration performs similarly when screening asymptomatic people for iron deficiency or overload.
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Affiliation(s)
| | - Sant-Rayn Pasricha
- Division: Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, Australia
| | | | | | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
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Leepile TT, Mokomo K, Bolaane MMM, Jones AD, Takada A, Black JL, Jovel E, Karakochuk CD. Anemia Prevalence and Anthropometric Status of Indigenous Women and Young Children in Rural Botswana: The San People. Nutrients 2021; 13:1105. [PMID: 33800575 PMCID: PMC8066262 DOI: 10.3390/nu13041105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/18/2021] [Accepted: 03/23/2021] [Indexed: 11/16/2022] Open
Abstract
In Botswana, there is limited data available on the health and nutritional status of the San People (also known as the Basarwa or Bushmen), an Indigenous minority group primarily living in the Ghanzi District. Our aim in this study was to assess anemia prevalence among and anthropometric indices of women and young children in Ghanzi District through a cross-sectional survey. We recruited 367 mother-child pairs (women 15-49 years and children 6-59 months) in nine randomly selected areas. A capillary blood sample was collected, and weight and height were measured. Hemoglobin (Hb) concentration was measured with use of a hemoglobinometer (HemoCue, AB), as per global recommendations. Overall, adjusted anemia prevalence was 12% in non-pregnant women (Hb < 120 g/L), 26% in pregnant women (Hb < 110 g/L), and 42% in children (Hb < 110 g/L), but it varied widely depending on whether or not the controversial factor of ethnicity was adjusted for (range of 6-26%, 22-30%, and 35-68% prevalence, respectively). Thirty-nine percent (n = 133/344) of non-pregnant women and 52% (n = 12/23) of pregnant women were underweight (BMI < 18.5 kg/m2). In children aged 6-23 months, 41% were underweight (weight-for-age z-score < -2 SD), 13% were wasted (weight-for-height z-score < -2 SD), and 65% were stunted (height-for-age z-score < -2 SD); in children aged 24-59 months, 57% were underweight, 13% were wasted, and 66% were stunted. Fifty-six percent (n = 205/367) of women self-reported smoking in any form (rolled cigarettes or snuffing). The high prevalence of smoking among women, underweight status among pregnant women, and anemia, stunting, and wasting among children is of the highest concern for public health and should be addressed in future health and nutrition programming.
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Affiliation(s)
- Tebogo T. Leepile
- Integrated Studies in Land and Food Systems, The University of British Columbia, Vancouver, BC V6T 1Z4, Canada; (T.T.L.); (J.L.B.); (E.J.)
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
| | | | - Maitseo M. M. Bolaane
- San Research Centre, Botswana and the Department of History, University of Botswana, Gaborone, Botswana;
| | - Andrew D. Jones
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA;
| | - Akira Takada
- Centre for African Area Studies, Kyoto University, Kyoto 606-8304, Japan;
| | - Jennifer L. Black
- Integrated Studies in Land and Food Systems, The University of British Columbia, Vancouver, BC V6T 1Z4, Canada; (T.T.L.); (J.L.B.); (E.J.)
- Department of Food, Nutrition, and Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- The Peter Wall Institute for Advanced Studies, University of British Columbia, Vancouver, BC V6T 1Z2, Canada
| | - Eduardo Jovel
- Integrated Studies in Land and Food Systems, The University of British Columbia, Vancouver, BC V6T 1Z4, Canada; (T.T.L.); (J.L.B.); (E.J.)
| | - Crystal D. Karakochuk
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Department of Food, Nutrition, and Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
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Field MS, Mithra P, Peña-Rosas JP. Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations. Cochrane Database Syst Rev 2021; 1:CD011302. [PMID: 33461239 PMCID: PMC8407500 DOI: 10.1002/14651858.cd011302.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Anaemia is a condition where the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. OBJECTIVES To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health-related outcomes in populations over two years of age. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. SELECTION CRITERIA We included cluster- or individually-randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. MAIN RESULTS Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta-analyses. Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low-certainty evidence). It is uncertain whether iron-fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low-certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low-certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C-reactive protein (CRP) (mean difference (MD) 0.04, 95% CI -0.02 to 0.11; 2 studies, 558 participants; moderate-certainty evidence). Iron-fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low-certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate-certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI -0.39 to 5.45; 4 studies, 532 participants; very low-certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. AUTHORS' CONCLUSIONS Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron-fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom.
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Affiliation(s)
- Martha S Field
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Prasanna Mithra
- Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
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Ohuma EO, Young MF, Martorell R, Ismail LC, Peña-Rosas JP, Purwar M, Garcia-Casal MN, Gravett MG, de Onis M, Wu Q, Carvalho M, Jaffer YA, Lambert A, Bertino E, Papageorghiou AT, Barros FC, Bhutta ZA, Kennedy SH, Villar J. International values for haemoglobin distributions in healthy pregnant women. EClinicalMedicine 2020; 29-30:100660. [PMID: 33437954 PMCID: PMC7788439 DOI: 10.1016/j.eclinm.2020.100660] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Anaemia in pregnancy is a global health problem with associated morbidity and mortality. METHODS A secondary analysis of prospective, population-based study from 2009 to 2016 to generate maternal haemoglobin normative centiles in uncomplicated pregnancies in women receiving optimal antenatal care. Pregnant women were enrolled <14 weeks' gestation in the Fetal Growth Longitudinal Study (FGLS) of the INTERGROWTH-21st Project which involved eight geographically diverse urban areas in Brazil, China, India, Italy, Kenya, Oman, United Kingdom and United States. At each 5 ± 1 weekly visit until delivery, information was collected about the pregnancy, as well as the results of blood tests taken as part of routine antenatal care that complemented the study's requirements, including haemoglobin values. FINDINGS A total of 3502 (81%) of 4321 women who delivered a live, singleton newborn with no visible congenital anomalies, contributed at least one haemoglobin value. Median haemoglobin concentrations ranged from 114.6 to 121.4 g/L, 94 to 103 g/L at the 3rd centile, and from 135 to 141 g/L at the 97th centile. The lowest values were seen between 31 and 32 weeks' gestation, representing a mean drop of 6.8 g/L compared to 14 weeks' gestation. The percentage variation in maternal haemoglobin within-site was 47% of the total variance compared to 13% between sites. INTERPRETATION We have generated International, gestational age-specific, smoothed centiles for maternal haemoglobin concentration compatible with better pregnancy outcomes, as well as adequate neonatal and early childhood morbidity, growth and development up to 2 years of age. FUNDING Bill & Melinda Gates Foundation Grant number 49038.
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Affiliation(s)
- Eric O. Ohuma
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Melissa F. Young
- Hubert Department of Global Health, Emory University, Atlanta, Georgia
| | | | - Leila Cheikh Ismail
- Clinical Nutrition and Dietetics Department, University of Sharjah, Sharjah, United Arab Emirates
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
| | - Manorama Purwar
- Nagpur INTERGROWTH-21st Research Centre, Ketkar Hospital, Nagpur, India
| | | | - Michael G. Gravett
- Departments of Obstetrics and Gynecology and of Global Health, University of Washington, Seattle, WA, USA
| | - Mercedes de Onis
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
| | - QingQing Wu
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Maria Carvalho
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Aga Khan University Hospital, Nairobi, Kenya
| | - Yasmin A. Jaffer
- Department of Family and Community Health, Ministry of Health, Muscat, Oman
| | - Ann Lambert
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Enrico Bertino
- Unit of the University, AOU City of Health and Science of Turin, Turin, Italy
| | - Aris T. Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Fernando C. Barros
- Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Zulfiqar A. Bhutta
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Stephen H. Kennedy
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Jose Villar
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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Sayers DR, Witkop CT, Webber BJ. Impact of Altitude-based Hemoglobin Modification on Pediatric Iron Deficiency Anemia Screening. J Pediatr 2020; 221:196-200. [PMID: 32446480 DOI: 10.1016/j.jpeds.2020.02.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/04/2020] [Accepted: 02/28/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine if additional children attending primary care clinics in moderate-altitude areas would screen positive for anemia if the hemoglobin cutoff were modified for altitude. STUDY DESIGN This cross-sectional study evaluated children aged 11-19 months of age who had a screening hemoglobin conducted between January 2011 and December 2017 at 4 moderate-altitude (1726-2212 m) and 8 low-altitude (1-20 m) US military clinics. The primary outcome was anemia prevalence (hemoglobin <11 g/dL) in moderate-altitude and low-altitude groups, before and after applying the current World Health Organization model for altitude-based hemoglobin modification. Groups were compared with prevalence ORs adjusted for age, sex, weight-for-length percentile, and parental military rank, and the false-negative proportion was calculated for children with anemia at moderate altitude. RESULTS Before altitude modification, anemia prevalence was 4.4% in the moderate-altitude group (n = 1488) and 16.8% in the low-altitude group (n = 7090) (prevalence OR, 0.23; 95% CI, 0.17-0.29). After applying the World Health Organization model, anemia prevalence in the moderate-altitude group increased to 14.7% (prevalence OR, 0.82; 95% CI, 0.70-0.97). Nonapplication of the model at moderate altitude resulted in a false-negative proportion of 0.70 (95% CI, 0.63-0.76). CONCLUSIONS Nonuse of the World Health Organization altitude-based modification model for hemoglobin may result in a large percentage of US children with anemia at moderate altitude screening falsely negative for anemia. Although ancestry disparities in altitude acclimatization may limit universal application of the current World Health Organization model, the existing standard of care may leave children at moderate altitude at risk for complications from iron deficiency anemia.
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Affiliation(s)
- David R Sayers
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Catherine T Witkop
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Bryant J Webber
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD; Public Health and Preventive Medicine Department, US Air Force School of Aerospace Medicine, Dayton, OH
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Sarna K, Brittenham GM, Beall CM. Current WHO hemoglobin thresholds for altitude and misdiagnosis of anemia among Tibetan highlanders. Am J Hematol 2020; 95:E134-E136. [PMID: 32096880 DOI: 10.1002/ajh.25765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Kaylee Sarna
- Department of AnthropologyCase Western Reserve University Cleveland Ohio
| | | | - Cynthia M. Beall
- Department of AnthropologyCase Western Reserve University Cleveland Ohio
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Sarna K, Brittenham GM, Beall CM. Detecting anaemia at high altitude. Evol Med Public Health 2020; 2020:68-69. [PMID: 32382420 PMCID: PMC7196337 DOI: 10.1093/emph/eoaa011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/12/2020] [Accepted: 04/07/2020] [Indexed: 01/10/2023] Open
Affiliation(s)
- Kaylee Sarna
- Department of Anthropology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Gary M Brittenham
- Department of Pediatrics, Columbia University, New York, NY 10027, USA
| | - Cynthia M Beall
- Department of Anthropology, Case Western Reserve University, Cleveland, OH 44106, USA
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Abstract
Iron deficiency anaemia is a global health concern affecting children, women and the elderly, whilst also being a common comorbidity in multiple medical conditions. The aetiology is variable and attributed to several risk factors decreasing iron intake and absorption or increasing demand and loss, with multiple aetiologies often coexisting in an individual patient. Although presenting symptoms may be nonspecific, there is emerging evidence on the detrimental effects of iron deficiency anaemia on clinical outcomes across several medical conditions. Increased awareness about the consequences and prevalence of iron deficiency anaemia can aid early detection and management. Diagnosis can be easily made by measurement of haemoglobin and serum ferritin levels, whilst in chronic inflammatory conditions, diagnosis may be more challenging and necessitates consideration of higher serum ferritin thresholds and evaluation of transferrin saturation. Oral and intravenous formulations of iron supplementation are available, and several patient and disease-related factors need to be considered before management decisions are made. This review provides recent updates and guidance on the diagnosis and management of iron deficiency anaemia in multiple clinical settings.
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Affiliation(s)
- M D Cappellini
- Department of Clinical Sciences and Community, IRCCS Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | | | - A T Taher
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
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