Concurrence of anemia and stunting and associated factors among children aged 6 to 59 months in Peru

Anemia and stunting are two health problems in the child population; therefore, their concurrence needs to be quantified. We estimated the prevalence of concurrent anemia and stunting (CAS) in children aged 6-59 months and identified the factors associated with this condition. The data came from the Demographic and Health Survey of Peru (DHS), 2022. The study design was cross-sectional and included 19,191 children. Height and hemoglobin measurement followed the specifications of National Health Institute of Peru. To reduce error in measures, the anthropometry personnel was training, the quality of measuring equipment was ensuring, and protocolized techniques and procedures was applying. Hemoglobin concentration was measured in capillary blood using the Hemocue model Hb 201+. Stunting was defined as a height-for-age Z-score less than minus two standard deviations (SD) from the median, following the 2006 WHO child growth standard. Anemia was classified into mild (10.0 to 10.9 g/dL), moderate (7.0 to 9.9 g/dL), severe (< 7.0 g/dL), and no anemia (11.0 to 14.0 g/dL). We performed a bivariate analysis to evaluate factors associated with CAS. To include variables in the multivariate analysis, we applied a statistical criterion (p < 0.10 in the crude analysis) and an epidemiological criterion. We used a binary logistic hierarchical regression model. The prevalence of CAS was 5.6% (95%CI: 5.2 to 5.9). The modifiable factors associated with higher odds of CAS were: "poorest" (aOR: 3.87, 95%CI: 1.99 to 7.5) and "poorer" (aOR: 2.07, 95%CI: 1.08 to 3.98) wealth quintiles, mother with no formal education or primary (aOR: 2.03, 95%CI: 1.46 to 2. 81), father with no formal education or primary (aOR: 1.55, 95%CI: 1.16 to 2.07), no improved water source (aOR: 1.36, 95%CI: 1.10 to 1.68), no roof with improved material (aOR: 1.49, 95%CI: 1.12 to 1.98) and low birth weight (aOR: 7.31, 95%CI: 4.26 to 12.54). In Peru, five out of every 100 children suffer from anemia and stunting simultaneously; there are modifiable factors that, if addressed, could reduce their prevalence.

Exploring Diet and Nutrient Insufficiencies across Age Groups: Insights from a Population-Based Study of Brazilian Adults

Assessing dietary inadequacies can contribute to understanding the nutritional vulnerabilities of a country. This study aimed to investigate nutrient intakes and micronutrient inadequacies in the Brazilian adult population, with an interest in different age subgroups. We conducted a cross-sectional study with 1812 individuals aged 19 to 65 years from a population-based study with a representative sample of Brazilian adults. Dietary intake was assessed by two 24 h food recalls, and the probabilities of inadequate intake were estimated using the Dietary Reference Intake targets. Adequate macronutrient intake was over 99% for proteins, 84.7% for carbohydrates, and 80.7% for total fats. There was a high probability of inadequacy (above 90%) for vitamins D and E, but vitamin D inadequacy was very similar between the sexes. In contrast, vitamin E was more likely to be inadequately consumed among women. A high probability of inadequacies (above 85%) of calcium and magnesium were found in the population, regardless of age group. Except for iron, the probability of an inadequacy of other minerals increased with age. The results showed a relevant proportion of nutrient inadequacies, with those most at risk being women and older individuals, helping with the better targeting and monitoring of public-health policies that address nutritional problems in the population.

Management of placenta accreta spectrum in low- and middle-income countries

Placenta accreta spectrum (PAS) can be associated massive intra- and post-operative hemorrhage which when not controlled can lead to maternal death. Important advances have occurred in understanding the pathophysiology and therapeutic options for this condition. The prevalence of PAS at birth is direct association with the cesarean delivery (CD) rate in the corresponding population and is increasing worldwide. Limited health infrastructure in low- and middle-income countries increases the morbidity and mortality of patients with PAS at birth. In many cases, obstetricians working in limited resources settings cannot follow some of the international guideline's recommendations and have to opt for low-cost management procedures. In this review, we describe the particularities of managing PAS care in low- and middle-income countries from of prenatal evaluation of patients at risk of PAS at birth, therapeutic options, and inter-institutional collaboration. We also propose a management protocol based on training of the local obstetric teams rather than on sophisticated technological resources that are almost never available in low-resource scenarios.

Associations of dietary, sociodemographic, and anthropometric factors with anemia among the Zhuang ethnic adults: a cross-sectional study in Guangxi Zhuang Autonomous Region, China

BACKGROUND

After decades of rapid economic development, anemia remains a significant public health challenge globally. This study aimed to estimate the associations of sociodemographic, dietary, and body composition factors with anemia among the Zhuang in Guangxi Zhuang Autonomous Region, China.

METHODS

Our study population from the baseline survey of the Guangxi ethnic minority Cohort Study of Chronic Diseases consisted of 13,465 adults (6,779 women and 6,686 men) aged 24-82 years. A validated interviewer-administered laptop-based questionnaire system was used to collect information on participants' sociodemographic, lifestyle, and dietary factors. Each participant underwent a physical examination, and hematological indices were measured. Least absolute shrinkage and selection operator (LASSO) regression was used to select the variables, and logistic regression was applied to estimate the associations of independent risk factors with anemia.

RESULTS

The overall prevalences of anemia in men and women were 9.63% (95% CI: 8.94-10.36%) and 18.33% (95% CI: 17.42─19.28%), respectively. LASSO and logistic regression analyses showed that age was positively associated with anemia for both women and men. For diet in women, red meat consumption for 5-7 days/week (OR = 0.79, 95% CI: 0.65-0.98, p = 0.0290) and corn/sweet potato consumption for 5-7 days/week (OR = 0.73, 95% CI: 0.55-0.96, p = 0.0281) were negatively associated with anemia. For men, fruit consumption for 5-7 days/week (OR = 0.75, 95% CI: 0.60-0.94, p = 0.0130) and corn/sweet potato consumption for 5-7 days/week (OR = 0.66, 95% CI: 0.46-0.91, p = 0.0136) were negatively correlated with anemia. Compared with a normal body water percentage (55-65%), a body water percentage below normal (< 55%) was negatively related to anemia (OR = 0.68, 95% CI: 0.53-0.86, p = 0.0014). Conversely, a body water percentage above normal (> 65%) was positively correlated with anemia in men (OR = 1.73, 95% CI: 1.38-2.17, p < 0.0001).

CONCLUSIONS

Anemia remains a moderate public health problem for premenopausal women and the elderly population in the Guangxi Zhuang minority region. The prevention of anemia at the population level requires multifaceted intervention measures according to sex and age, with a focus on dietary factors and the control of body composition.

Prevalence and risk factors of anemia in the mother-child population from a region of the Colombian Caribbean

BACKGROUND

Despite Colombia's robust well-child visits program, Colombian children and mothers still suffer from anemia, especially in populations of lower socioeconomic status. In this study, we aimed to quantify the prevalence and risk factors among mothers and their children attending their well-child visits in Apartadó, a municipality in the Urabá region of the Colombian Caribbean.

METHODS

There were 100 mother-child pairs enrolled in this secondary data-analysis study from a health facility in the municipality of Apartadó, Urabá, Colombia, during well-child visits. Self-reported data included child illnesses in the past two weeks (diarrheal, fever, or respiratory symptoms), child feeding practices (breastfeeding, complementary feeding), child vaccinations, and demographic characteristics (mother's and child's age, mother's education, marital status, race, and child sex) and socioeconomic status. Mother and child anthropometry data were collected via standardized weight and height measurements. Mother or child anemia status was collected via a blood test. Chi-squared tests and multivariable logistic regression were used to assess associations between risk factors and anemia.

RESULT

The anemia prevalence in children (74%) and mothers (47%) was higher than the Colombian national prevalence. Reported child comorbidities in the preceding two weeks were not significantly associated with child anemia and included respiratory illnesses (60%), fever (46%), and diarrhea (30%). Stunting (8%) was not significantly associated with anemia. Wasting (0%) was not observed in this study. Reported child breastfeeding and complementary feeding were also not significantly associated with child anemia. In adjusted models, the child's significant risk factors for anemia included the mother's "Mestiza" race (OR: 4.681; 95% CI: 1.258, 17.421) versus the Afro-Colombian race. Older children (25-60 months) were less likely to develop anemia than younger (6-24 months) children (OR: 0.073; 95% CI: 0.015, 0.360).

CONCLUSIONS

The finding of high anemia prevalence in this study advances our understanding of child and maternal anemia in populations of low socioeconomic status where health care is regularly accessed through well-child programs.

Childhood Obesity and Plasma Micronutrient Deficit of Chilean Children between 4 and 14 Years Old

Objective: To analyze the nutritional status and plasma levels of vitamins and minerals in a cohort of Chilean children between 4 and 14 years old from three cities in Chile (Santiago, Antofagasta, and Concepcion). Design: This is a descriptive analysis of micronutrient levels in Chilean children as it relates to obesity and food consumption. Setting: This study included 1235 children from schools in Santiago (central area), Antofagasta (northern area), and Concepcion (southern area) in Chile. Results: Plasma levels of micronutrients revealed deficiencies in children from all these cities. Copper (26.4%) and calcium (33.0%) deficiencies were found in the children from Antofagasta, whereas iron (26.7%) and zinc (20.8%) deficiencies were found in the children from Concepcion and Santiago, respectively. The percentage of children with vitamin D deficiencies was exceptionally high in all cities (over 78%). The analysis of micronutrients and nutritional status revealed that vitamin D deficiencies were significantly higher (p = 0.02) in overweight children, particularly in Antofagasta. In the analysis of the nutritional status of children and their food consumption habits, the proportion of overweight and obesity was significantly higher (p = 0.001) in children that skipped breakfast compared to children that did not. Finally, children from low socioeconomic levels were significantly more overweight and obese compared to children from high socioeconomic levels (p < 0.05). Conclusions: this is the first study to describe plasma levels of micronutrients in Chilean children and adolescents. High percentages of obesity, overweight, and vitamin D deficiency were detected in children. These results are of significant relevance to future public health policies in Chile.

Inequalities in anemia among Peruvian children aged 6–59 months: A decomposition analysis

Objective

To quantify the inequalities of anemia in Peruvian children aged 6–59 months and uncover its contributing factors.

Materials and methods

We conducted a cross-sectional study based on the secondary data analysis of the 2021 Peruvian Demographic and Health Survey (DHS). Our sample included Peruvian children aged 6–59 months with complete data for the variables of interest. Anemia was defined as having a hemoglobin level of less than 11 g/dL, adjusted by altitude. Erreygers Concentration Index (ECI) and concentration curves were computed to estimate the socio-economic inequality in anemia among Peruvian children. Moreover, ECI was decomposed to figure out the contributing factors to the inequality of anemia and the residual variation.

Results

Nationwide, the prevalence of anemia in Peruvian children was 29.47%. We found a pro-poor inequality regarding anemia at the national level (ECI = −0.1848). The determinants included in the model explained 81.85% of the overall socio-economic inequality in anemia. The largest contribution to inequality was from household- and community-related factors. Having a higher mother’s education level (26.26%) and being from the highlands (24.91%) were the major significant contributors to the overall health inequality.

Conclusion

Almost one-third of Peruvian children have anemia. A pro-poor inequality of anemia in Peruvian children was found. Public policies ought to address the major contributing factors of anemia inequality.

A review of ancestrality and admixture in Latin America and the caribbean focusing on native American and African descendant populations

Genomics can reveal essential features about the demographic evolution of a population that may not be apparent from historical elements. In recent years, there has been a significant increase in the number of studies applying genomic epidemiological approaches to understand the genetic structure and diversity of human populations in the context of demographic history and for implementing precision medicine. These efforts have traditionally been applied predominantly to populations of European origin. More recently, initiatives in the United States and Africa are including more diverse populations, establishing new horizons for research in human populations with African and/or Native ancestries. Still, even in the most recent projects, the under-representation of genomic data from Latin America and the Caribbean (LAC) is remarkable. In addition, because the region presents the most recent global miscegenation, genomics data from LAC may add relevant information to understand population admixture better. Admixture in LAC started during the colonial period, in the 15th century, with intense miscegenation between European settlers, mainly from Portugal and Spain, with local indigenous and sub-Saharan Africans brought through the slave trade. Since, there are descendants of formerly enslaved and Native American populations in the LAC territory; they are considered vulnerable populations because of their history and current living conditions. In this context, studying LAC Native American and African descendant populations is important for several reasons. First, studying human populations from different origins makes it possible to understand the diversity of the human genome better. Second, it also has an immediate application to these populations, such as empowering communities with the knowledge of their ancestral origins. Furthermore, because knowledge of the population genomic structure is an essential requirement for implementing genomic medicine and precision health practices, population genomics studies may ensure that these communities have access to genomic information for risk assessment, prevention, and the delivery of optimized treatment; thus, helping to reduce inequalities in the Western Hemisphere. Hoping to set the stage for future studies, we review different aspects related to genetic and genomic research in vulnerable populations from LAC countries.

Genetics, genomics, and diet interactions in obesity in the Latin American environment

Obesity is a chronic disease characterized by abnormal or excessive fat accumulation that could impact an individual's health; moreover, the World Health Organization (WHO) has declared obesity a global epidemic since 1997. In Latin America, in 2016, reports indicated that 24.2% of the adult population was obese. The environmental factor or specific behaviors like dietary intake or physical activity have a vital role in the development of a condition like obesity, but the interaction of genes could contribute to that predisposition. Hence, it is vital to understand the relationship between genes and disease. Indeed, genetics in nutrition studies the genetic variations and their effect on dietary response; while genomics in nutrition studies the role of nutrients in gene expression. The present review represents a compendium of the dietary behaviors in the Latin American environment and the interactions of genes with their single nucleotide polymorphisms (SNPs) associated with obesity, including the risk allele frequencies in the Latin American population. Additionally, a bibliographical selection of several studies has been included; these studies examined the impact that dietary patterns in Latin American environments have on the expression of numerous genes involved in obesity-associated metabolic pathways.

Multiple Indicators of Undernutrition, Infection, and Inflammation in Lactating Women Are Associated with Maternal Iron Status and Infant Anthropometry in Panama: The MINDI Cohort

Maternal infections, nutrient deficiencies, and inflammation (MINDI) co-exist in lactating indigenous women in Panama, but their impact on maternal iron status and infant growth is unknown. For this secondary analysis of cross-sectional data of lactating mothers from our MINDI cohort, we investigated associations of MINDI variables with maternal anemia, elevated serum transferrin receptor (sTfR), low serum iron, hepcidin, ferritin, and infant weight-for-age (WAZ), length-for-age (LAZ), and head-circumference-for-age (HCAZ) Z-scores in 99 mother-infant dyads. A bootstrapping resampling procedure preselected covariates for inclusion in multivariable regressions models from chronic maternal infections and nutritional status [folate, vitamins A, D, retinol-binding protein (RBP), insulin-growth factor-1 (IGF-1)] and inflammation [C-reactive protein (CRP), cytokines, platelet indices] indicators. Anemia was prevalent (53.5%) but underestimated due to widespread low plasma volume (<2.2 L, 79.9%) and was associated with indicators of malnutrition [lower IGF-1, body mass index (BMI), vitamin D, and intake of green/leafy vegetables], but not inflammation. Higher CRP was associated with lower serum iron, and higher hepcidin and ferritin, whereas maternal platelets were associated with lower HCAZ (β = −0.22), WAZ (β = −0.17), and LAZ (β = −0.17). Higher LAZ was also associated with maternal serum vitamin D (β = 0.23), whereas maternal iron supplementation lowered LAZ (β = −0.22). Assessment of iron status in this MINDI cohort is complex and supplementation strategies must consider consequences for both the mother and the infant.

Challenges and perspectives of the double burden of malnutrition in Latin America

Nutrition is a key factor in the development of non-communicable chronic diseases (NCCDs), especially cardiovascular diseases (CVD) and their risk factors. The "double burden of malnutrition" (DBM) is the coexistence of undernutrition and overnutrition in the same population across the life-course. In Latin America, the transition from a predominantly underweight to an overweight and obese population has increased more rapidly than in other regions in the world. Undernutrition and the micronutrient deficiencies particularly iron, zinc, and vitamins A and D, present high heterogeneity in Latin American countries, and are currently considered important public health problems. In this region, NCCDs account for 50% of the disability-adjusted life-years, led by CVD. The most prevalent cardiovascular risk factors are overweight, obesity, hypertension, dyslipidemia and type 2 diabetes mellitus. Because of the cost of treatment and the potential years of life lost due to premature death, CVD is known to affect the poorest segments of the population, affecting communities, and governments. More than 80% of CVD deaths occur in low- and middle-income countries. The persistence of damage in some cells due to undernutrition may explain certain findings regarding the increase in NCCD. These aspects together with epigenetic changes have highlighted the importance of a lifelong approach to nutritional policy development. Reducing DBM requires major societal interventions in public health and nutrition to achieve holistic change that can be sustained over the long term and spread throughout the global food system. The implementation of effective state policies of double impact actions should influence both sides of the burden and be considered an urgent priority, considering country-specific inequalities and socio-demographic differences in the Latin American region, using diverse and multidisciplinary strategies.

Body Composition, Anemia, and Kidney Function among Guatemalan Sugarcane Workers

Rates of anemia among agricultural workers, who are also at risk for kidney injury and chronic kidney disease of unknown cause (CKDu), are unknown. We evaluated body composition through the sum of three skinfolds among 203 male sugarcane cutters and assessed the relationship of variables related to nutrition, anemia (hemoglobin < 13 g/dL), and elevated hemoglobin A1c (HbA1c ≥ 5.7%) with estimated glomerular filtration rate (eGFR) using linear regression. Eleven percent of workers were at the level of essential body fat (2-5%). Anemia was present among 13% of workers, 70% of which were normochromic normocytic, a type of anemia suggesting potential underlying chronic disease. Anemia was more common among those with lower BMI and fat free mass. The prevalence of elevated HbA1c was 21%. A moderate negative correlation was found between hemoglobin and HbA1c (Pearson's r = -0.32, p <0.01) which suggests that HbA1c values should be interpreted with caution in populations that have high rates of anemia. Twelve percent of workers had reduced kidney function with an eGFR < 90 mL/min/1.73 m². On average, the eGFR was 18 mL/min per 1.73 m² lower [(95% CI:-24, -12), p <0.01)] for those with anemia than those without, and 8 mL/min per 1.73 m² lower among those with elevated HbA1c [(95% CI: -13, -2), p < 0.01]. Results will inform future studies examining the role of anemia in the evaluation of CKDu and interventions to improve nutrition for workers in low-resource settings.

[Trend in the prevalence of anemia in children from maroon communities according to two population-based surveys in Alagoas State, Brazil (2008-2018)]

The study aimed to assess trends in the prevalence of anemia in children from quilombos (maroon communities) in Alagoas State, Brazil. This was a descriptive study comparing the results of two household surveys (2008; n = 950 and 2018; n = 426), involving a sample of children from 6 to 59 months of age. Anemia was diagnosed as hemoglobin < 110g/L (HemoCue). Prevalence rates between the two surveys were described by percentage and by prevalence ratio (PR) and 95% confidence interval (95%CI), calculated by Poisson regression. Prevalence rates for anemia in 2008 and 2018 were 53% (95%CI: 49.8-56.1) and 38% (95%CI: 33.4-42.6), respectively, or a decrease of 28.3% (RP = 0.72; 95%CI: 0.63-0.82). Children 6 to 24 months of age had higher anemia rates than those 25 to 59 months of age, both in 2008 (72% vs. 44%) and in 2018 (54.8% vs. 28.3%). There was a reduction in prevalence in both age brackets (23.9% and 35.7%, respectively). This sharper decline in older children meant that younger children had nearly double the prevalence rate compared to older children (PR = 1.94; 95%CI: 1.53-2.46). In conclusion, there was a major decline in prevalence of anemia during the period studied, but anemia persisted as a relevant public health problem, especially in children 6 to 24 months of age. The children in the sample are exposed to harsh social vulnerabilities, evidencing that health promotion for this population requires more than actions in the public health sphere itself. Healthcare workers and administrators should be alert to the data presented here, aimed at implementation of measures to confront the social and health iniquities that contribute to greater vulnerability in this ethnic-racial group.

Blood's Concentration of Lead and Arsenic Associated with Anemia in Peruvian Children

This exploratory, descriptive cohort study (N = 60) determined lead (Pb) and arsenic (As) blood concentrations in Peruvian children and their association with hematological parameters of iron-deficient anemia (IDA) and anthropometric measurement. The mean age of children was 10.8 months (SD = 4.7) and ranged from 3 to 24 months old. Anemia (Hb levels below 10.5 g/dL) was found in 20% of this cohort. Additionally, microcytosis (MCV < 70 fL) was present in 54%, and hypochromia (MCH < 23 pg) in 42% of the group of children. Chi-square analysis showed that 88% of the children with anemia also had microcytosis and hypochromia (p < 0.001). Pb and As were detected in 100% of the infants' blood samples, and the concentrations were significantly higher in older infants than in younger ones. Pb and As were not associated with the sex, anthropomorphic parameters, or infant hemogram changes. Infants who received iron supplementation were 87% less likely to have low Hb compared with those who did not (OR = 0.13, 95% CI = 0.02–0.88, p=0.04). Herbal tea intake was significantly associated with microcytosis and hypochromia. Our finding uncovered that hematological parameters for anemia are modified in Peruvian children with high levels of microcytosis and hypochromia. Concentrations of Pb and As were above method detection limits in all Peruvian children, but these were not associated with IDA or anthropometric measurements. A large study, including other variables, would benefit from allowing a more complex model predicting anemia in Peruvian children.

Launching of the Anaemia Research Peruvian Cohort (ARPEC): a multicentre birth cohort project to explore the iron adaptive homeostasis, infant growth and development in three Peruvian regions

BACKGROUND

Preventing infantile anaemia and ensuring optimal growth and development during early childhood, particularly in resource-constrained settings, represent an ongoing public health challenge. Current responses are aligned to treatment-based solutions, instead of determining the roles of its inter-related causes. This project aims to assess and understand the complex interplay of eco-bio-social-political factors that determine infantile anaemia to inform policy, research design and prevention practices.

METHODS

This is a longitudinal birth cohort study including four components: (1) biological, will assess known blood markers of iron homeostasis and anaemia and stool microbiota to identify and genetically analyse the participants' flora; (2) ecological, will assess and map pollutants in air, water and soil and evaluate features of nutrition and perceived food security; (3) social, which will use different qualitative research methodologies to explore key stakeholders and informants' perceptions related to nutritional, environmental and anaemia topics, participant observations and a participatory approach and (4) a political analysis, to identify and assess the impact of policies, guidelines and programmes at all levels for infantile anaemia in the three regions. Finally, we will also explore the role of social determinants and demographic variables longitudinally for all study participants. This project aims to contribute to the evidence of the inter-related causal factors of infantile anaemia, addressing the complexity of influencing factors from diverse methodological angles. We will assess infantile anaemia in three regions of Peru, including newborns and their mothers as participants, from childbirth until their first year of age.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Research Ethics Committee of the Instituto Nacional de Salud del Niño (Lima, Peru), CIEI-043-2019. An additional opinion has been granted by the Ethical Committee of Queen Mary University of London (London, UK). Dissemination across stakeholders is taking part as a continues part of the research process.

Association of haemoglobin levels in the first trimester and at 26-30 weeks with fetal and neonatal outcomes: a secondary analysis of the Global Network for Women's and Children's Health's ASPIRIN Trial

OBJECTIVE

Limited data are available from low- and middle-income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes.

DESIGN

ASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6⁺⁰ -13⁺⁶  weeks and 26⁺⁰ -30⁺⁰  weeks of gestation with fetal and neonatal outcomes.

SETTING

Obstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala.

POPULATION

A total of 11 976 pregnant women.

METHODS

Generalised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes.

MAIN OUTCOME MEASURES

Preterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g.

RESULTS

The mean haemoglobin levels at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6⁺⁰ -13⁺⁶  weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70-89 g/l compared with haemoglobin of 110-129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26-30 weeks of gestation.

CONCLUSIONS

Both lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger.

TWEETABLE ABSTRACT

Both lower and some higher haemoglobin concentrations were associated with adverse fetal and neonatal outcomes at 6-13 weeks and 26-30 weeks of gestation.

Differences in factors associated with anemia in Haitian children from urban and rural areas

BACKGROUND

In Haiti, differences in the prevalence of anemia between urban and rural areas have been observed.

OBJECTIVE

To identify moderating factors that may help explain the difference in the prevalence of anemia in children from poor urban vs. rural areas of Haiti.

METHODS

This cross-sectional study used secondary data from urban and rural school-based trials that assessed the effectiveness of a nutrition intervention. The study was registered at ClinicalTrials.gov as NCT02747524. A total of 300 rural- and 981 urban- children between 2.5-13 years of age were included in this analysis. Effect modification in a binary logistic generalized linear mixed model was conducted using sample weights in SPSS® version 26. Models were adjusted for age and income. School cluster was included as random effect.

RESULTS

In rural areas, stunting was more prevalent in children with anemia vs. no anemia, (16.6%, and 6.3%, P = 0.008), respectively. Also, rural children with anemia lived with fewer adults vs. rural children with no anemia, ([Formula: see text] = 2.83±1.29, and 3.30±1.54, P = 0.005), respectively. In poor urban areas, helminth morbidities were more frequent in children with anemia vs. no anemia, (21.9% vs. 13.9, P = 0.011), respectively. In the combined sample, stunting, [AOR = 2.05; 95%CI (1.32-3.18)], age [AOR = 0.89; 95%CI (0.85-0.93)], and households with more adults [AOR = 0.77; 95%CI (0.67-0.87)] were associated with anemia. Effect modification by place of residence was observed in households with more adults (t = 3.83, P<0.001). No other nutritional, dietary, sanitation or morbidity factors or effect modifiers were observed.

CONCLUSIONS

In this sample, factors associated with anemia differed in poor urban and rural children from Haiti including family structure and helminth morbidities. Stunting and lower age increased the odds of anemia in the combined sample. Family structure appears to have an important role in anemia, and further research understanding the influence of family structures in anemia is needed.

Global cognition modifies the relationship between anemia and depression in old age: A longitudinal analysis of the IMIAS Study

OBJECTIVES

To examine the relationship between anemia and depression and whether sex and global cognition modify this relationship over a 4-year follow-up.

DESIGN

Longitudinal analysis of an international cohort study SETTINGS AND PARTICIPANTS: Older adults from the International Mobility in Aging Study (IMIAS) aged between 65 and 74 years at baseline.

METHODS

Participants were recruited in Natal (Brazil), Manizales (Colombia), Kingston (Ontario, Canada), and Saint-Hyacinthe (Quebec, Canada). The study outcome was depression, defined by a score of ≥16 in the Center for Epidemiologic Studies Depression Scale. Longitudinal associations over a 4-year follow-up were examined using generalized estimating equations. Cognition was ascertained with the Leganes Cognitive Test with scores ≤ 22 indicating poor cognition. Models were also adjusted for research sites, marital status, alcohol drinking status, body mass index, chronic conditions, activities of daily life disabilities, and polypharmacy.

RESULTS

Anemia and poor cognition at baseline were associated with an increased risk of depression at follow-up (OR = 5.73, 95% CI: 1.58-20.78). Global cognition was also an effect modifier of the longitudinal association between the severity of anemia and depression.

CONCLUSIONS

In international samples of older adults, anemia, as well as the severity of anemia, were independent risk factors for depression, and the effect of these associations was modified by global cognition. The findings highlight an important issue as to whether depression in old age may be at least partially preventable through public health interventions to correct low Hb levels.

A Qualitative Assessment of Mothers' Experience With Pediatric Anemia Care in Arequipa, Peru

Background: Despite national efforts to control pediatric anemia in Peru, each year, 67.4% of all newborns are diagnosed with anemia during their first year of life. The literature on Peruvian mothers' understanding and beliefs of pediatric anemia is limited. In the present study, we aimed to understand mother's perspective of pediatric anemia and explore their perceptions on how to prevent and treat anemia in Peru.

Methods: During May–June 2018, we administered a short demographic questionnaire and conducted language-sensitive interviews with mothers of children clinically diagnosed with anemia in three different governmental health centers in Arequipa, Peru. Interviews were audio-recorded and transcribed verbatim. We used the Framework Analysis approach to analyze qualitative data.

Results: A total of 14 Peruvian mothers were interviewed. Across interviews, three main themes emerged: (I) Mothers' Understanding of Pediatric Anemia; (II) Attitudes about Provider Recommendations for Pediatric Anemia Control; and (III) Barriers to Effective Pediatric Anemia Control. Peruvian mothers expressed skepticism toward national pediatric anemia guidelines as they believe recommendations received at health clinics jeopardized their children's overall health. Participants identified several barriers to effective anemia control: limited and confusing health information received during pediatric healthcare appointments, lack of systematic protocols in health clinics, and inconsistent referral processes.

Conclusion: We identified factors that limit the acceptance of current pediatric anemia control guidelines followed at governmental health centers in Arequipa, Peru. Understanding maternal beliefs concerning pediatric anemia can guide future anemia control guidelines at the primary care level for pediatric patients in Peru.

Using Community Health Workers and a Smartphone Application to Improve Diabetes Control in Rural Guatemala

BACKGROUND

The global prevalence of diabetes has nearly doubled since 1980. Seventy-five percent of patients with diabetes live in low- and middle-income countries, such as Guatemala, where health care systems are often poorly equipped for chronic disease management. Community health workers (CHWs) and mobile health technology have increasingly been applied to the diabetes epidemic in these settings, although mostly in supportive rather than primary roles in diabetes management. We sought to improve diabetes care in rural Guatemala through the development of a CHW-led diabetes program and a smartphone application to provide CHWs with clinical decision support.

METHODS

We worked with our local partners to develop a program model and the smartphone application (using the CommCare platform) and to train CHWs. We recruited patients with type 2 diabetes living in rural communities. Program evaluation used a single-group, pre-post design. Primary outcomes were hemoglobin A1c and the percentage of patients meeting A1c goals compared with baseline. We also followed a variety of process metrics, including application reliability.

RESULTS

Eighty-nine patients enrolled during the study period. The hemoglobin A1c percentage decreased significantly at 3 months (-1.0; 95% CI=-1.7, -0.6), 6 months (-1.5; 95% CI=-2.2, -0.8), 9 months (-1.3; 95% CI=-2.0, -0.6), and 12 months (-1.0; 95% CI=-1.7, -0.4). The percentage of patients with A1c ≤ 8% increased significantly at 3 months (23.6% to 44.4%, P=.007), 6 months (22.0% to 44.0%, P=.015), and 9 months (23.9% to 45.7%, P=.03). CHWs and supervising physicians agreed with application medication recommendations >90% of the time.

CONCLUSION

Our results suggest that CHWs can safely and effectively manage diabetes with the assistance of a smartphone application and remote physician supervision. This model should be evaluated versus other standards of care and could be adapted to other low-resource settings and chronic diseases.

Development of a Semaphore of Anemia: Screening Method Based on Photographic Images of the Ungueal Bed Using a Digital Camera

Anemia is a disease present worldwide. High prevalence of anemia (43%) is found in the child population and its main long-term effect (slow cognitive development) can remain even if the disease has disappeared. One of the main reasons for the high prevalence of anemia in Peru is the poor screening coverage during the growth of the child due to the parents' fear of infringing pain on their children. We take advantage that anemia produces pallor in the hands, fingers and ungueal bed to develop a semaphore for this disease. This screening tool uses photographic images of the patient's ungueal bed to determine if they have a high, medium or low possibility of having anemia. Sixty people participated in the study and 6 photographic images for each participant's right hand were captured. The images were processed to extract regions of interest from each of the fingernails. Datasets were generated and a neural network was used to predict the risk of anemia. Initial results show that the proposed semaphore of anemia reaches a sensitivity of 0.79 and specificity of 0.91. These results indicate that the semaphore of anemia may be used as a screening method to reduce the number of blood tests and the time of evaluation from 15 minutes (rapid test with portable hemoglobinometer) to 1 minute.

Anemia in women of reproductive age in Ecuador: Data from a national survey

BACKGROUND

Anemia is a condition characterized by a decline in the number of functional red blood cells or hemoglobin. Women of reproductive age from low- and middle-income countries are at higher risk of anemia, which could lead to prenatal, obstetric and perinatal complications. The aim of our study was to explore associations between anemia status and a set of demographic, socio-economic and reproductive factors, among Ecuadorian women of reproductive age (WRA).

METHODS

We used data from non-pregnant, WRA (≥12 and ≤49 years) women enrolled in the nationally representative cross-sectional Ecuadorian National Health and Nutrition Survey 2012 (ENSANUT-ECU 2012). Anemia and moderate-severe anemia were assessed using hemoglobin concentrations cutoffs of <12 g/dL and <11 g/dL, respectively. Logistic regression was used to obtain unadjusted and adjusted prevalence odds ratios (aOR). All analyzes were adjusted for multi-stage sampling, stratification and clustering.

RESULTS

The study population included a subset of 7415 non-pregnant WRA. Mean hemoglobin concentration was 12.84 g/dL (95% CI = 12.8-12.9). The overall prevalence of anemia and moderate-severe anemia was 16.8% and 5.0%, respectively. Some factors were associated with an increase in anemia prevalence odds: living in Guayaquil (aOR 1.82, 95% CI 1.16-2.84) and Quito (aOR 1.84, 95% CI 1.17-2.90) compared to living in the rural Amazon, having given birth to more than four alive children compared with being nulliparous (aOR 1.85, 95% CI 1.00-3.43), currently taking contraceptives compared with former use (aOR 1.46, 95% CI 1.09-1.97). In addition, moderate-severe anemia was associated with age and region of residence.

CONCLUSION

In 2012, the prevalence of anemia among Ecuadorian WRA was considered a mild public health concern. However, we identified groups with higher anemia prevalence. Thus, emphasizing the importance of analyzing the prevalence in sub-populations of WRA and identifying populations where more frequent surveillance may be helpful.

Nutrition status in adult Chilean population: economic, ethnic and sex inequalities in a post-transitional country

OBJECTIVE

To assess the relationship between malnutrition, socioeconomic status (SES) and ethnicity in Chilean adult population.

DESIGN

Nationally representative survey (ENS) conducted in 2016-2017. Sociodemographic information, weight, height and hemoglobin (Hb) were measured (2003 ENS). Excess weight was defined as BMI ≥25 kg/m2. Undernutrition included underweight (BMI <18·5 kg/m2), short stature (height <1·49 m in women and <1·62 m in men) or anaemia (Hb <12 g/l). Education and household income level were used as indicators of SES; ethnicity was self-reported. We applied linear combinations of estimators to compare the prevalence of excess weight and undernutrition by SES and ethnicity.

SETTING

Chile.

PARTICIPANTS

In total, 5082 adults ≥20 years (64 % women) and 1739 women ≥20 years for anaemia analyses.

RESULTS

Overall, >75 % of women and men had excess weight. Low SES women either by income or education had higher excess weight ((82·0 (77·1, 86·1) v. 65·0 (54·8, 74·1)) by income; (85·3 (80·6, 89·0) v. 68·2 (61·6, 74·1) %) by education) and short stature (20-49 years; 31(17·9, 48·2) v. 5·2 (2·2,11·4) by education); obesity was also more frequent among indigenous women (20-49 years; 55·8 (44·4, 66·6) v. 37·2 (32·7, 42·0) %) than non-indigenous women. In men, excess weight did not significantly differ by SES or ethnicity, but short stature concentrated in low SES (20-49 years; 47·6 (24·6, 71·6) v. 4·5 (2·1, 9·5) by education) and indigenous men (21·5 (11·9, 5·5, 11·9) v. 8·2 (5·5, 11·9)) (P < 0·05 for all).

CONCLUSIONS

In Chile, malnutrition is disproportionately concentrated among women of low SES and indigenous origin; these inequalities should be considered when implementing prevention policies.

Maternal Prenatal Psychosocial Stress and Prepregnancy BMI Associations with Fetal Iron Status

BACKGROUND

Iron accrued in utero is critical for fetal and infant neurocognitive development. Psychosocial stress and obesity can each suppress fetal iron accrual. Their combined effects and differences by fetal sex are not known. In an observational pregnancy cohort study in Mexico City, we investigated associations of maternal prenatal life stressors, psychological dysfunction, and prepregnancy BMI with fetal iron status at delivery.

OBJECTIVES

We hypothesized that greater maternal prenatal psychosocial stress and prepregnancy overweight and obesity are associated with lower cord blood ferritin and hemoglobin (Hb), with stronger associations in boys than girls.

METHODS

Psychosocial stress in multiple domains of life stress (negative life events, perceived stress, exposure to violence) and psychological dysfunction symptoms (depression, generalized anxiety, and pregnancy-specific anxiety) were assessed with validated questionnaires during pregnancy. Prepregnancy BMI was predicted with a validated equation and categorized as normal/overweight/obese. Cord blood ferritin and Hb associations with prenatal psychosocial stress and BMI were modeled in multivariable linear regressions adjusted for maternal age, socioeconomic status, child sex, and prenatal iron supplementation. Interactions with child sex and 3-way stress-overweight/obesity-sex interactions were tested with product terms and likelihood ratio tests.

RESULTS

In 493 dyads, median (IQR) cord blood ferritin and Hb concentrations were 185 µg/L (126-263 g/dL) and 16 g/dL (14.7-17.1 g/dL), respectively. Ferritin was lower in infants of mothers with higher prenatal perceived stress (-23%; 95% CI: -35%, -9%), violence exposure (-28%; 95% CI: -42%, -12%), anxiety symptoms (-16%; 95% CI: -27%, -4%), and obesity (-17%; 95% CI: -31%, 0.2%). Interaction models suggested sex differences and synergism between maternal stress and overweight/obesity. No associations were observed between stress or BMI and Hb.

CONCLUSIONS

Multiple prenatal psychosocial stressors and excess prepregnancy BMI were each inversely associated with fetal iron status at birth. Pregnancies and infants at elevated risk of impaired fetal iron accrual may be identifiable according to observed synergism between maternal stress and obesity and differential associations with fetal iron status by infant sex.

Dried blood spot microbiological assay indicates high prevalence of folate deficiency in rural adult men and women in the Haitian Central Plateau

BACKGROUND

Although folate deficiency is linked to adverse health effects, limited data exist characterizing the problem in rural settings. This study determined the prevalence of folate deficiency and anemia in rural adults in the Haitian Central Plateau using combined laboratory methods.

METHODS

Dried blood spots (DBSs) and hemoglobin measurements were collected from adult men and women selected by cluster random sampling in Haiti's Central Plateau. DBSs were analyzed for folate using a microbiological assay. Hemoglobin levels were determined using both a HemoCue photometer and the sodium lauryl sulfate microplate method. Red cell folate (RCF) levels were determined by normalizing DBS folate to hemoglobin.

RESULTS

Of the 197 subjects assessed for hemoglobin, 11.4% of males and 21.0% of females were anemic (male: hemoglobin<12 g/dL; female: hemoglobin<11 g/dL). Of the 173 subjects assessed for RCF, 27.9% of men and 14.9% of women were folate deficient (RCF<340 nmol/L). Among reproductive-age women, 83.6% had RCF levels associated with a risk of neural tube defects of >14 per 10 000 live births (RCF≤699 nmol/L).

CONCLUSIONS

Adults in the Haitian Central Plateau suffer from high rates of anemia and folate deficiency, putting the population at elevated risk for disease. DBSs and microbiological assay make folate evaluation feasible, even in low-resource regions.

Benefit-Cost Analysis of a Package of Early Childhood Interventions to Improve Nutrition in Haiti

We conduct a benefit-cost analysis of a package of early childhood interventions that can improve nutrition outcomes in Haiti. Using the Lives Saved Tool, we expect that this package can prevent approximately 55,000 cases of child stunting, 7,600 low-weight births and 28,000 cases of maternal anemia annually, if coverage reaches 90% of the target population. In addition, we expect these nutrition improvements will avoid 1,830 under-five deaths, 80 maternal deaths and 900,000 episodes of child illness every year. Those who avoid stunting will experience lifetime productivity benefits equivalent to five times gross national income per capita in present value terms, at a 5% discount rate. While previous benefit-cost analyses of this specific package have only estimated the lifetime productivity benefits of avoided stunting, this paper also accounts for reductions in fatal and non-fatal health risks. In the base case scenario, the annualized net benefits of the intervention equal Haitian gourdes 13.4 billion (USD 211 million) and the benefit-cost ratio (BCR) is 5.2. Despite these substantial benefits, the package may not be the most efficient use of a marginal dollar, with alternative interventions to improve human capital yielding BCRs approximately three to four times higher than the base estimate.

Education and Income Levels are Associated With Energy and Micronutrient Intake

Introduction: According to the literature, education and income are determinants factors of diet quality and consequently of micronutrient intake. However, this association is still little known among adults who live in middle-income countries. Objective: To estimate energy and micronutrients intake by men and women living in a capital city in southern Brazil, according to education and income levels, and to identify prevalence of inadequate micronutrient intake according also to education and income levels. Method: This is a second wave cross-sectional analysis of a population-based longitudinal study, the EpiFloripa Adultos, including 1,222 individuals of 22-63 years. Data on food consumption were obtained through applying two 24-hour dietary recalls, and the prevalence of inadequate micronutrient intake, following the recommendations of the Institute of Medicine and from the National Research Council. Results: A tendency of increased intake with an increase in income (calcium, vitamins C, E) and education levels (calcium, vitamins A, C, D) was observed for most of the micronutrients analyzed (p<0.05 in all cases); still, a prevalence of inadequacy according to Estimated Average Requirement (EAR) between 85.5-100% in intake of vitamins A, D and E were found for the whole sample. Iron inadequate intake was associated with education level and among women less than 50 years of age (p=0.018). Conclusion: The results showed an influence of the education and income levels on micronutrient intake, point to the need of daily food consumption, of minimally processed and in natura foods (as fruits, vegetables, whole grains, milk and its derivatives) as a means to reduce the encountered inadequacies.

Prevalence of Anemia in Children from Latin America and the Caribbean and Effectiveness of Nutritional Interventions: Systematic Review and Meta⁻Analysis

Anemia affects 1.62 billion people worldwide. Latin America and the Caribbean (LAC) comprise several developing countries where children are a population at risk. This systematic review and meta-analysis aimed to estimate the prevalence of anemia in this population. Electronic databases, reference lists, and websites of health ministries were searched until December 2018. Stratified analyses were performed using RevMan5.3 to estimate the overall prevalence of anemia in preschool and school-age children. The effectiveness of nutritional interventions was also evaluated. We included 61 studies from the 917 reviewed, which included 128,311 preschool- and 38,028 school-age children from 21 LAC countries. The number of anemic children was 32.93% and 17.49%, respectively, demonstrating a significant difference according to age (p < 0.01). No difference was observed by gender and only school-age children from low/very low socioeconomic status (SES) (25.75%) were more prone to anemia than those from middle SES (7.90%). It was not a concern in the Southern Cone but constituted a serious public health problem in the Latin Caribbean. Nutritional interventions reduced the prevalence from 45% to 25% (p < 0.01). Anemia is still a public health problem for children in LAC countries. National surveys should include school-age children. Further nutritional interventions are required to control anemia.

Soil-Transmitted Helminth Infections and Anemia in Schoolchildren from Corn Island Archipelago (RAAS, Nicaragua)

The prevalence and intensity of soil-transmitted helminth (STH) infections in schoolchildren from Corn Islands (Nicaragua) were examined to detect mono- or poly-STH infected children, measuring different intensity levels, and to elucidate measurably increased odds of being anemic. A total of 341 stool samples provided by 2- to 15-year-old children were examined using a concentration technique and a Kato-Katz slide. Intensity of infection was expressed as eggs per gram (epg) of feces to classify light, moderate, or heavy intensity infection. A finger-prick blood sample was obtained from each student in the field. Soil-transmitted helminth prevalence was 54.3%, with Trichuris trichiura as the most prevalent species (48.9%). The combination T. trichiura/Ascaris lumbricoides (12.6%) was the most common. When T. trichiura or A. lumbricoides appeared as a single infection, light or moderate intensity infections were seen, whereas when multiple species were identified, heavy infections were present. Anemia was detected in those with any kind of STH infection (42.7%), with statistically significant differences (P = 0.004) when compared with uninfected individuals (28.2%). Polyparasite infection with one parasite species at moderate intensity and the other parasite species at light intensity or absent was found to be a significant factor for the odds of being anemic (odds ratio = 2.07). The present study reveals a high level of STH transmission requiring a deworming control program in Corn Islands and pointing to the need of improving the education and sanitary conditions of the population to avoid environmental contamination and reinfection.

Factors associated with anemia in young children in Brazil

BACKGROUND

Anemia is recognized as a major public health problem in childhood, especially in children under 24 months of age. Despite improvements in public health strategies to prevent and control anemia in Brazilian young children in the last decade, few studies have assessed the predictors for this condition in primary health care. Thus, this study aimed to assess the associated factors of anemia in young children who visited primary public health care facilities in Brazil.

METHODS

A cross-sectional study was conducted with 520 children aged 11 to 15 months who visited the primary health care in four Brazilian cities. Anemia was defined as hemoglobin concentration < 110 g/L in venous blood samples. Multilevel Poisson regression models were used to describe the associations between anemia and independent variables.

RESULTS

The frequency of anemia was 23.1%. A higher frequency was observed in children who live with more than one other child younger than 5 years in the house (Prevalence Ratio [PR] 1.47; 95% Confidence Interval [CI] 1.01-2.14), who started to receive fruits and vegetables after 8 months of age (PR 1.92; 95% CI 1.19-3.10), who were stunted (PR 2.44; 95% CI 1.32-4.50), who were hospitalized at least once in their life (PR 1.55; 95% CI 1.03-2.33) and who were in the lower tertile of serum folate concentration (PR 2.24; 95% CI 1.30-3.85).

CONCLUSIONS

Inadequate complementary feeding practices and morbidity were the main predictors for anemia in early childhood in this population. Improvements in current strategies to promote healthy complementary feeding along with better control of morbidities are recommended to reduce anemia in Brazilian young children.

Understanding the determinants of hemoglobin and iron status: adolescent-adult women comparisons in SANHANES-1

The study compared hemoglobin (Hb) and serum ferritin levels between adolescent and adult women with different body mass indices, dietary intake, and sociodemography. A secondary analysis of data for 3177 South African women ⩾15 years of age who participated in the SANHANES-1 study was undertaken. Abnormal Hb (≤12 g/dL) and serum ferritin (<15 μg/mL) were based on the World Health Organization's criteria for nonpregnant women aged ⩾15 years. Data were analyzed using STATA version 11. Overall, anemia was detected in 740 (23.3%) participants. Of the individuals in the subsample (n = 1123, 15-35 years) who had serum ferritin measured, 6.0% presented with iron depletion (ID) and 10.8% presented with iron-deficiency anemia (IDA). The highest prevalences of anemia, ID, and IDA were in 15- to 18-year-olds (11.2%, 8.8%, and 20.2%, respectively). Black young adults (19-24 years) were up to 40 times more likely to present with ID compared with their non-black counterparts. While overweight adolescents were three times more likely to be anemic, overweight and obese young adults, as well as obese older adults (25-35 years), were less likely to be anemic compared with normal-weight women of all age groups. Overconsumption of dietary fat increased ID by up to 54- and 11-fold (adolescents and 25- to 35-year-olds, respectively). In South Africa, anemia is most prevalent in adolescents and black women. Anemia is also an indicator of overconsumption of dietary fat and a marker of socioeconomic disadvantage.

Fortifying pork liver mixture: Evaluation of protein quality and iron bioavailability – Part 2

ABSTRACT Objective To evaluate the protein quality and iron bioavailability of a fortifying mixture based on pork liver. Methods Determinations of protein efficiency ratio, net protein utilization, true digestibility and hemoglobin regeneration efficiency by depletion and repletion were performed. In the depletion phase, the animals (male Wistar rats) received an iron-free AIN–93G diet and in the repletion phase they received the following diets: standard AIN–93G diet, fortifying mixture and standard diet containing heptahydrated ferrous sulfate for comparison. Results For standard AIN–93G diet and fortifying mixture the results were 3.75 and 4.04 for protein efficiency ratio and 3.53 and 3.63 for net protein retention, showing that the presence of pork liver in the diet promoted an increase in protein efficiency ratio and net protein retention (not statistically significant). True digestibility results obtained with the fortifying mixture (97.16%) were higher than those obtained with the standard AIN–93G diet (casein), but without significant difference. The hemoglobin regeneration efficiency values obtained for standard AIN–93G diet, fortifying mixture and standard diet containing heptahydrated ferrous sulfate were 50.69, 31.96 and 29.96%, respectively, showing a statistically significant difference between the control (standard AIN–93G diet) and test (fortifying mixture and standard diet containing heptahydrated ferrous sulfate) samples, but not between the test samples. Conclusion The fortifying mixture showed a high protein efficiency ratio value of 4.04 and a high relative biological value (108%) and it can be added to soups, creams and meats in day-care centers for the prevention of iron-deficiency in children of school age.

Modelo para mejorar la anemia y el cuidado infantil en un ámbito rural del Perú

Objetivo.

Determinar la efectividad de la Estrategia para el Crecimiento y Desarrollo Integral (ECDI) de World Vision Perú sobre la anemia, desnutrición, desarrollo psicomotor y cuidado y protección infantil en niños menores de tres años de edad que residían en tres comunidades rurales de la Región Ayacucho del Perú.

Métodos.

Se realizó un estudio cuasiexperimental en tres distritos rurales de la región Ayacucho, Perú. La medición de anemia se realizó con sangre capilar y el analizador HemoCue®, con ajuste de los valores de hemoglobina según a la altitud. La desnutrición se midió a través de los indicadores antropométricos de talla y peso; para ello se utilizó la herramienta Anthro de la Organización Mundial de la Salud. El desarrollo psicomotor se midió mediante el Test Abreviado del Ministerio de Salud del Perú. El cuidado y protección de los niños se midió a través de una ficha especialmente elaborada para este fin. Se realizaron tres mediciones, la línea basal en mayo del 2013, la medición intermedia en noviembre del mismo año y la final en mayo del 2014. En total, 283 niños tuvieron dos o más mediciones incluida la medición final y 205 tuvieron las tres mediciones.

Resultados.

El análisis multivariado para medidas repetidas mostró una efectividad estimada de la ECDI para reducir la anemia de 33,1% (intervalo de confianza del 95%: 1,0%-54,7%) ajustada para la edad, sexo, consumo de alimentos ricos en hierro, consumo de alimentos potenciadores de la absorción de hierro, consumo de alimento inhibidores de la absorción de hierro, haber recibido suplementación de hierro en los últimos seis meses y haber participado del Programa Cuna Más.

Conclusiones.

La ECDI fue efectiva para mejorar la nutrición de los menores de 36 meses de edad a través de la reducción de la anemia y el incremento del consumo de potenciadores de la absorción de hierro. Las intervenciones que incluyen componentes educativos y de seguimiento comunitarios podrían ser de gran ayuda para combatir la anemia en los niños menores de 36 meses de edad en comunidades rurales.

Hair Mercury Level is Associated with Anemia and Micronutrient Status in Children Living Near Artisanal and Small-Scale Gold Mining in the Peruvian Amazon

Anemia has been widely studied in global health contexts because of severe nutritional deficiency, and more recently, inflammatory status, but chemical exposures are rarely considered. Until recently, "anemia" was used synonymously with "iron deficiency anemia (IDA)" in global health settings. However, only 50% of anemia cases worldwide are IDA. Environmental toxicology studies of anemia risk have generally focused on populations in developed countries, albeit with high exposure to environmental toxicants, such as lead or cadmium. In the developing world, toxicant exposures commonly coexist with other risk factors for anemia. In particular, artisanal and small-scale gold mining (ASGM) communities are at risk for dietary methylmercury exposure through contaminated fish consumption, and for anemia due to food insecurity and infectious and chronic diseases. Here, we report analysis of total hair mercury content, hemoglobin, and serum micronutrient levels in children < 12 years of age (N = 83) near ASGM in the Peruvian Amazon. Forty-nine percent (N = 29/59) of those aged < 5 years were anemic (< 11 g/dL) and 52% (N = 12/23) of those aged 5-11 years (< 11.5 g/dL). Few children were stunted, wasted, or micronutrient deficient. Median total hair mercury was 1.18 μg/g (range: 0.06-9.70 μg/g). We found an inverse association between total mercury and hemoglobin (β = -0.12 g/dL, P = 0.06) that persisted (β = -0.14 g/dL, P = 0.04) after adjusting for age, sex, anthropometrics, and vitamin B₁₂ in multivariate regression. This study provides preliminary evidence that methylmercury exposure is associated with anemia, which is especially relevant to children living near ASGM.

Anemia in young children living in the Surinamese interior: the influence of age, nutritional status and ethnicity

Purpose

This study investigates the prevalence of anemia in young children living in the interior of Suriname and the influence of the associated factors age, nutritional status and ethnicity.

Results

In this cross-sectional observational study, 606 children aged 1-5 years from three different regions of Suriname's interior were included, and hemoglobin levels and anthropometric measurements were collected. Logistic regression models were computed to examine independent associations between anemic and nonanemic groups and to measure the influence of age, nutritional status and ethnicity.

Results

A total of 606 children were included, of whom 330 (55%) were aged 1-3 years and 276 were aged 4-5 years. The overall prevalence of anemia was 63%. Younger age was associated with anemia (odds ratio [OR]=1.78; 95% confidence interval [CI]: 1.27-2.51). Anemia was less prevalent in Amerindian than in Maroon children (OR=0.51; 95% CI: 0.34-0.76). Hemoglobin level was not influenced by nutritional status nor by sex.

Conclusion

The prevalence of anemia in children aged 1-5 years living in Suriname's interior is high (63%) compared to that in similar aged children in Latin America and the Caribbean (4-45%). Children aged 1-3 years were more affected than those aged 4-5 years as were Maroon children compared to Amerindian children. Nutritional status and sex were not of influence.

Factors Influencing the Use of Biomedical Health Care by Rural Bolivian Anemic Women: Structural Barriers, Reproductive Status, Gender Roles, and Concepts of Anemia

METHODS

Non-pregnant women from a rural town and its surrounding region were tested for anemia. During phase 1 (n = 181), anemic women received a written recommendation for low-cost purchase of iron pills at the nearest health center. They were subsequently interviewed on their actions and experiences.

RESULTS

Estimated anemia prevalence among these non-pregnant women was 50% higher than the national average. Despite holding conceptualizations of anemia generally aligned with biomedical concepts, only 40% of anemic women attempted to obtain iron supplements from the health center. Town residents were about twice as likely to attempt to purchase pills as outside-town residents. Town women who were concurrently breastfeeding and menstruating, considered anemia most serious for women, and considered family health the shared responsibility of spouses were most likely to decide to purchase iron pills. Age, education, or native language did not negatively influence this health care behavior.

CONCLUSIONS

Securing iron supplements involves individual trade-offs in the allocation of time, cost and effort. Nonetheless, suitably tailored programs can potentially harness local perceptions in the service of reducing anemia. Because of their comparatively high motivation to obtain iron supplements, targeting concurrently breastfeeding and menstruating women could have a positive cascade effect such that these women continue attending to their iron needs once they stop breastfeeding and if they become pregnant again. Because a sense of shared responsibility for family health appears to encourage women to attend to their own health, programs for women could involve their spouses. Complementing centralized availability, biomedical and traditional healers could distribute iron supplements on rotating visits to outlying areas and/or at highly attended weekly markets.

Early deterioration of iron status among a cohort of Bolivian infants

Iron deficiency (ID) and iron deficiency anemia (IDA) are major contributors to infant and maternal morbidity worldwide. There is limited longitudinal data on iron status in young infants and on methods to adjust iron biomarkers for inflammation. We aimed to quantify the prevalence of inflammation-adjusted ID, anemia, and IDA over the first year in a cohort of Bolivian infants and their mothers. Healthy mother-infant dyads were recruited from two peri-urban hospitals. Infants provided three blood draws (2, 6-8, and 12-18 months; N = 160); mothers provided two blood draws (1 and 6-8 months postpartum [plus third anemia measurement at 12-18 months]; N = 250). Blood was analyzed for hemoglobin, ferritin, soluble transferrin receptor, C-reactive protein (CRP), and alpha(1)-acid glycoprotein (AGP). Iron biomarkers were adjusted for inflammation using CRP and AGP; hemoglobin cutoffs were adjusted for altitude. Inflammation (elevated CRP or AGP) was 17% among toddlers 12-18 months of age. ID (inflammation-adjusted ferritin) increased with age (<1%, 56%, and 79% at each blood draw), as did anemia and IDA (anemia: 70%, 76%, and 81%; IDA: <1%, 46%, and 68%). Maternal ID declined from the first to second assessment (39% vs. 27%). Inflammation-adjusted ID prevalence was up to 15 percentage points higher than unadjusted estimates. The high prevalence of ID, anemia, and IDA in this cohort of Bolivian infants beginning at 6-8 months of age suggests that early interventions may be necessary in vulnerable populations.

[Inadequate dietary micronutrient intake in men and women in southern Brazil: the EpiFloripa Adults Study, 2012]

This study aimed to estimate dietary intake of micronutrients among adults in a city in Southern Brazil according to sex and age, and to measure the prevalence of inadequate dietary micronutrient intake according to sex. This is a cross-sectional, population-based study with 1,222 adults 22 to 63 years of age living in Florianópolis, Santa Catarina State, Brazil. Data on dietary intake were obtained from two 24-hour recalls (one in the total sample and the other in a subsample of 40% of the research subjects). Micronutrient intake and prevalence rates for inadequate intake were estimated according to the guidelines of the National Research Council and Institute of Medicine. High prevalence rates of inadequate intake in the entire sample were seen for vitamins A, C, D, and E (range, 52%-100%). Calcium and iron intake were more inadequate in women (87.3% and 13.7%, respectively), as was zinc in men (25.1%). Adults in Florianópolis, showed high prevalence rates of inadequate intake of essential micronutrients.

Prevalence of and factors associated with anemia in school children from Maceió, northeastern Brazil

Background

Anemia is a major public health problem in preschool children in Alagoas, Brazil, especially in the younger population, because of a positive correlation between hemoglobin level and age. However, due to the lack of studies, it is not known how widespread this condition is among older children or how it is associated with socioeconomic status. The aim of this study was to investigate the prevalence of and factors associated with anemia in school children from the city of Maceió, Alagoas state, Brazil. The analysis was stratified to identify any effect modification according to whether they attend public or private schools.

Methods

A cross-sectional study was conducted using probability sampling of 1518 children (9.8 ± 0.5 years of age) attending public (n = 931) and private (n = 587) elementary schools in the municipality. Semi-structured questionnaires were used to obtain socioeconomic, demographic, anthropomorphic, hemoglobin (Hb), and dietary data. Anemia (Hb <11.5 g/dL) was the dependent variable. The measure of association used was prevalence ratio (PR) and respective CI95 %, calculated by Poisson regression with robust variance adjustment, for the crude and adjusted analyses.

Results

The prevalence of anemia was found to be higher amongst the public school children than the private school children (10.8 % vs. 7.0 %; PR = 1.54; CI95 %: 1.1; 2.2). At the public schools, the variables that remained significantly associated with anemia after the multivariate analysis were “consumption of fruits/fruit juices < 2 portions/day” (PR = 2.19; CI95 %: 1.18; 4.06) and “male” (PR = 1.51; CI95 %: 1.001; 2.30). At the private schools, these variables were “working mother” (PR = 2.83; CI95 %: 1.23; 6.52) and “monthly school fees < R$ 188.00” (PR = 3.20; CI95 %: 1.46; 7.03).

Conclusions

In the population under study, anemia constitutes a major health problem, especially among children from public schools. Considering the associated factors and the fact that these children are in a school environment, the promotion of healthy eating habits could constitute an important approach for reducing the prevalence of anemia.

Ferritin Levels in Colombian Children: Findings from the 2010 National Nutrition Survey (ENSIN)

Low ferritin is associated with many adverse health outcomes and is highly prevalent worldwide. The aim of this study was to describe the key findings related to plasma ferritin levels to identify the prevalence and associated sociodemographic factors in a representative sample of children in Colombia, based on the 2010 National Nutrition Survey. We analyzed cross-sectional data from 6650 Colombian children between the ages of 5 and 12. Plasma ferritin levels were determined by chemiluminescence. Sociodemographic data was assessed by computer-assisted personal interview technology. All analyses were conducted considering the complex nature of the sample. Of the children assessed, 3.5% had low ferritin, defined as levels <12 µg/L. A multivariate logistic regression analysis revealed increased risks for low ferritin levels among black or Afro-Colombian ethnic group and for those living in the northern, western and southern regions of the country. In conclusion, a significant prevalence of anemia caused by low ferritin levels was found and various sociodemographic factors were associated with this finding in Colombia. Continued surveillance and implementation of interventions to improve dietary patterns among the identified high-risk groups should be considered. Implementing these recommendations can help reduce manifestations of iron deficiency (e.g., delays in infant and child development) and thus improve public health.

Impacts of anemia on 3-year ischemic events in patients undergoing percutaneous coronary intervention: a propensity-matched study

BACKGROUND

Anemia correlates with worse outcomes in patients undergoing percutaneous coronary intervention (PCI), improved anemia can improve the outcomes in patients who underwent PCI. But the influence of anemia on long-term ischemic events after PCI remains unknown.

METHODS

We analyzed 8,825 consecutive patients who underwent PCI at General Hospital of Shenyang Military Region and identified 581 patients with anemia. Patients (anemia vs. no anemia) were compared using a propensity score analysis to best match between groups. The main outcome of this study is 3-year ischemic events after PCI, the secondary outcome of this study is 3-year mortality and major adverse cardiac events (MACE) after PCI.

RESULTS

Compared with nonanemic patients, anemic patients were often female (38.90% vs. 14.51%) and elder patients (66.44% vs. 34.95%). Anemic patients have lower left ventricular ejection fraction (LVEF) and creatinine clearance (Ccr) and were more likely to have history of cardiovascular and cerebrovascular diseases, hypertension, peripheral vascular diseases (PVD) (P<0.05). However, the prevalences of diabetes and hyperlipidemia were lower in anemic patients (P<0.01). Anemia was an independent predictor for 3-year ischemic events [hazard ratio (HR): 2.20, 95% confidence intervals (CI): 1.61-3.00, P<0.01], 3-year mortality (HR: 3.58, 95% CI: 1.75-7.32, P<0.01) and 3-year MACE (HR: 2.14, 95% CI: 1.64-2.79, P<0.01) after PCI in post-match samples. The incidence of 3-year ischemic events was 41.0% and 19.3% in anemic and nonanemic patients, respectively.

CONCLUSIONS

Anemia is an independent predictor for 3-year ischemic events, 3-year mortality and 3-year MACE in patients who underwent PCI. Further studies need to explore the impact of the pathogenesis and progress, prevention and therapy of anemia on the outcome of patients undergoing PCI.

Introduction: Prevalence of Micronutrient Deficiencies in Latin America and the Caribbean

This Food and Nutrition Bulletin supplement summarizes updated prevalence data on micronutrient deficiencies in Latin America and the Caribbean (LAC). In order to provide an updated view of micronutrient status in LAC, systematic reviews were performed utilizing national health surveys and research-oriented studies focused on the prevalence of deficiencies of vitamin A, folate, anemia (as a proxy of iron deficiency), and zinc. Results show that the prevalence of vitamin A deficiency has been reduced in many countries, folate deficiency is now almost non-existent, low or marginal vitamin B12 status is still prevalent in most locations, anemia remains a public health problem among children under 6 years of age and women of childbearing age in most surveyed countries, and there is a high prevalence of zinc deficiency in children under 6 years of age and girls and women 12 to 49 years of age. Thus, regardless of improvements in the overall rates of economic growth in LAC, deficiencies of these micronutrients still remain a public health problem.