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Apte A, Pahan J. Transdermal delivery of micronutrients through fortified body oil and cosmetics: a potential roadmap for future scale up. Front Public Health 2023; 11:1136912. [PMID: 37408747 PMCID: PMC10318147 DOI: 10.3389/fpubh.2023.1136912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/02/2023] [Indexed: 07/07/2023] Open
Affiliation(s)
- Aditi Apte
- Vadu Rural Health Program, King Edward Memorial (KEM) Hospital Research Centre, Pune, India
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Speich C, Brittenham GM, Cercamondi CI, Zeder C, Nkosi-Gondwe T, Phiri KS, Moretti D, Zimmermann MB. Isotopic measurement of iron requirements in sub-Saharan African children. Am J Clin Nutr 2021; 114:986-996. [PMID: 34113969 DOI: 10.1093/ajcn/nqab161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/19/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Prevention of iron deficiency in African children is a public health priority. Current WHO/FAO estimations of iron requirements are derived from factorial estimates based on healthy, iron-sufficient "model" children using data derived mainly from adults. OBJECTIVES In this study, we aimed to quantify iron absorption, loss, and balance in apparently healthy 5- to 7-y-old children living in rural Africa. METHODS We directly measured long-term iron absorption and iron loss in a 2-y observational study in Malawian children (n = 48) using a novel stable iron isotope method. RESULTS Of the 36 children with height-for-age and weight-for-age z scores ≥-2, 13 (36%) were iron deficient (soluble transferrin receptor >8.3 mg/L) and 23 were iron sufficient. Iron-deficient children weighed more than iron-sufficient children [mean difference (95% CI): +2.1 (1.4, 2.7) kg; P = 0.01]. Mean iron losses did not differ significantly between iron-deficient and iron-sufficient children and were comparable to WHO/FAO median estimates of 19 µg/(d × kg). In iron-sufficient children, median (95% CI) dietary iron absorption was 32 (28, 34) µg/(d × kg), comparable to WHO/FAO-estimated median requirements of 32 µg/(d × kg). In iron-deficient children, absorption of 28 (25, 30) µg/(d × kg) was not increased to correct their iron deficit, likely because of a lack of bioavailable dietary iron. Twelve children (25%) were undernourished (underweight, stunted, or both). CONCLUSIONS Our results suggest that WHO/FAO iron requirements are adequate for healthy iron-sufficient children in this rural area of Malawi, but iron-deficient children require additional bioavailable iron to correct their iron deficit.
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Affiliation(s)
- Cornelia Speich
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
| | - Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Colin I Cercamondi
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
| | - Christophe Zeder
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
| | - Thandile Nkosi-Gondwe
- Training and Research Unit of Excellence, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kamija S Phiri
- Training and Research Unit of Excellence, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Diego Moretti
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland.,Nutrition Group, Health Department, Swiss Distance University of Applied Sciences, Regensdorf, Switzerland
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
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The critical roles of iron during the journey from fetus to adolescent: Developmental aspects of iron homeostasis. Blood Rev 2021; 50:100866. [PMID: 34284901 DOI: 10.1016/j.blre.2021.100866] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 12/12/2022]
Abstract
Iron is indispensable for human life. However, it is also potentially toxic, since it catalyzes the formation of harmful oxidative radicals in unbound form and may facilitate pathogen growth. Therefore, iron homeostasis needs to be tightly regulated. Rapid growth and development require large amounts of iron, while (especially young) children are vulnerable to infections with iron-dependent pathogens due to an immature immune system. Moreover, unbalanced iron status early in life may have effects on the nervous system, immune system and gut microbiota that persist into adulthood. In this narrative review, we assess the critical roles of iron for growth and development and elaborate how the body adapts to physiologically high iron demands during the journey from fetus to adolescent. As a first step towards the development of clinical guidelines for the management of iron disorders in children, we summarize the unmet needs regarding the developmental aspects of iron homeostasis.
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Kang W, Baer N, Ramsan M, Vermeylen F, Stoltzfus RJ, O'Brien KO. Iron supplementation in anemic Zanzibari toddlers is associated with greater loss in erythrocyte iron isotope enrichment. Am J Clin Nutr 2021; 114:330-337. [PMID: 33829247 PMCID: PMC8246609 DOI: 10.1093/ajcn/nqab044] [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: 09/16/2020] [Accepted: 02/08/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Heavy parasitic loads increase the risk of iron (Fe) deficiency anemia, which remains prevalent globally. Where parasites are common, understanding the influence of parasitic infections on Fe incorporation and erythropoiesis in toddlers is especially important. OBJECTIVES The aim of this study was to identify the impacts of malarial and helminth infections on red blood cell (RBC) Fe incorporation and subsequent changes in RBC Fe isotope enrichment for 84 days postdosing in toddlers at high risk for parasitic infections. METHODS Fe incorporation was measured in a group of Zanzibari toddlers (n = 71; 16-25 months) using a stable Fe isotopic method. At study entry, an oral stable Fe isotope was administered. Blood was collected 14 (D14) and 84 (D84) days postdosing for the assessment of Fe status indicators and RBC isotopic enrichment. Blood and stool samples were collected and screened for malaria and helminth parasites. Factors associated with changes in RBC Fe isotope enrichment were identified using regression models. RESULTS Toddlers who had larger weight-for-age z-scores, lower total body Fe, and helminth infections (n = 26) exhibited higher RBC Fe incorporation. RBC Fe isotope enrichment decreased from D14 to D84 by -2.75 percentage points (P < 0.0001; n = 66). Greater loss in RBC Fe isotope enrichment from D14 to D84 was observed in those who received Fe supplementation, those with either helminths or both malarial and helminth infections, and in those with greater RBC Fe incorporation on D14. CONCLUSIONS Toddlers who received Fe supplementation exhibited significantly greater losses of RBC Fe isotope enrichment over time. We speculate this greater loss of RBC Fe enrichment is indicative of increased erythropoiesis due to the provision of Fe among anemic or helminth-infected toddlers.
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Affiliation(s)
- Wanhui Kang
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Nathaniel Baer
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Mahdi Ramsan
- Public Health Laboratory Ivo de Carneri, Wawi, Chake Chake, Pemba, Tanzania
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Armitage AE, Moretti D. The Importance of Iron Status for Young Children in Low- and Middle-Income Countries: A Narrative Review. Pharmaceuticals (Basel) 2019; 12:E59. [PMID: 30995720 PMCID: PMC6631790 DOI: 10.3390/ph12020059] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/09/2019] [Accepted: 04/12/2019] [Indexed: 12/21/2022] Open
Abstract
Early childhood is characterised by high physiological iron demand to support processes including blood volume expansion, brain development and tissue growth. Iron is also required for other essential functions including the generation of effective immune responses. Adequate iron status is therefore a prerequisite for optimal child development, yet nutritional iron deficiency and inflammation-related iron restriction are widespread amongst young children in low- and middle-income countries (LMICs), meaning iron demands are frequently not met. Consequently, therapeutic iron interventions are commonly recommended. However, iron also influences infection pathogenesis: iron deficiency reduces the risk of malaria, while therapeutic iron may increase susceptibility to malaria, respiratory and gastrointestinal infections, besides reshaping the intestinal microbiome. This means caution should be employed in administering iron interventions to young children in LMIC settings with high infection burdens. In this narrative review, we first examine demand and supply of iron during early childhood, in relation to the molecular understanding of systemic iron control. We then evaluate the importance of iron for distinct aspects of physiology and development, particularly focusing on young LMIC children. We finally discuss the implications and potential for interventions aimed at improving iron status whilst minimising infection-related risks in such settings. Optimal iron intervention strategies will likely need to be individually or setting-specifically adapted according to iron deficiency, inflammation status and infection risk, while maximising iron bioavailability and considering the trade-offs between benefits and risks for different aspects of physiology. The effectiveness of alternative approaches not centred around nutritional iron interventions for children should also be thoroughly evaluated: these include direct targeting of common causes of infection/inflammation, and maternal iron administration during pregnancy.
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Affiliation(s)
- Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DS, UK.
| | - Diego Moretti
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Sciences and Technology, ETH Zürich, CH-8092 Zürich, Switzerland.
- Nutrition Group, Health Department, Swiss Distance University of Applied Sciences, CH-8105 Regensdorf, Switzerland.
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Castberg FC, Sarbah EW, Koram KA, Opoku N, Ofori MF, Styrishave B, Hviid L, Kurtzhals JAL. Malaria causes long-term effects on markers of iron status in children: a critical assessment of existing clinical and epidemiological tools. Malar J 2018; 17:464. [PMID: 30537973 PMCID: PMC6290551 DOI: 10.1186/s12936-018-2609-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/01/2018] [Indexed: 01/13/2023] Open
Abstract
Background Most epidemiological studies on the interplay between iron deficiency and malaria risk classify individuals as iron-deficient or iron-replete based on inflammation-dependent iron markers and adjustment for inflammation by using C-reactive protein (CRP) or α-1-acid glycoprotein (AGP). The validity of this approach and the usefulness of fibroblast growth factor 23 (FGF23) as a proposed inflammation-independent iron marker were tested. Methods Conventional iron markers and FGF23 were measured in children with acute falciparum malaria and after 1, 2, 4, and 6 weeks. Children, who were transfused or received iron supplementation in the follow-up period, were excluded, and iron stores were considered to be stable throughout. Ferritin levels 6 weeks after admission were used as a reference for admission iron status and compared with iron markers at different time points. Results There were long-term perturbations in iron markers during convalescence from acute malaria. None of the tested iron parameters, including FGF23, were independent of inflammation. CRP and AGP normalized faster than ferritin after malaria episodes. Conclusion Malaria may bias epidemiological studies based on inflammation-dependent iron markers. Better markers of iron status during and after inflammation are needed in order to test strategies for iron supplementation in populations at risk of malaria.
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Affiliation(s)
- Filip C Castberg
- Centre for Medical Parasitology, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Medical Parasitology, Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Edem W Sarbah
- Noguchi Memorial Institute for Medical Research, Accra, Ghana
| | - Kwadwo A Koram
- Noguchi Memorial Institute for Medical Research, Accra, Ghana
| | - Nicholas Opoku
- Hohoe Municipality Hospital, Hohoe, Ghana.,School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Michael F Ofori
- Noguchi Memorial Institute for Medical Research, Accra, Ghana
| | - Bjarne Styrishave
- Toxicology and Drug Metabolism Group, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hviid
- Centre for Medical Parasitology, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Medical Parasitology, Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Jørgen A L Kurtzhals
- Centre for Medical Parasitology, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. .,Centre for Medical Parasitology, Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark.
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Glinz D, Wegmüller R, Ouattara M, Diakité VG, Aaron GJ, Hofer L, Zimmermann MB, Adiossan LG, Utzinger J, N'Goran EK, Hurrell RF. Iron Fortified Complementary Foods Containing a Mixture of Sodium Iron EDTA with Either Ferrous Fumarate or Ferric Pyrophosphate Reduce Iron Deficiency Anemia in 12- to 36-Month-Old Children in a Malaria Endemic Setting: A Secondary Analysis of a Cluster-Randomized Controlled Trial. Nutrients 2017; 9:E759. [PMID: 28708072 PMCID: PMC5537873 DOI: 10.3390/nu9070759] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 12/23/2022] Open
Abstract
Iron deficiency anemia (IDA) is a major public health problem in sub-Saharan Africa. The efficacy of iron fortification against IDA is uncertain in malaria-endemic settings. The objective of this study was to evaluate the efficacy of a complementary food (CF) fortified with sodium iron EDTA (NaFeEDTA) plus either ferrous fumarate (FeFum) or ferric pyrophosphate (FePP) to combat IDA in preschool-age children in a highly malaria endemic region. This is a secondary analysis of a nine-month cluster-randomized controlled trial conducted in south-central Côte d'Ivoire. 378 children aged 12-36 months were randomly assigned to no food intervention (n = 125; control group), CF fortified with 2 mg NaFeEDTA plus 3.8 mg FeFum for six days/week (n = 126; FeFum group), and CF fortified with 2 mg NaFeEDTA and 3.8 mg FePP for six days/week (n = 127; FePP group). The outcome measures were hemoglobin (Hb), plasma ferritin (PF), iron deficiency (PF < 30 μg/L), and anemia (Hb < 11.0 g/dL). Data were analyzed with random-effect models and PF was adjusted for inflammation. The prevalence of Plasmodium falciparum infection and inflammation during the study were 44-66%, and 57-76%, respectively. There was a significant time by treatment interaction on IDA (p = 0.028) and a borderline significant time by treatment interaction on iron deficiency with or without anemia (p = 0.068). IDA prevalence sharply decreased in the FeFum (32.8% to 1.2%, p < 0.001) and FePP group (23.6% to 3.4%, p < 0.001). However, there was no significant time by treatment interaction on Hb or total anemia. These data indicate that, despite the high endemicity of malaria and elevated inflammation biomarkers (C-reactive protein or α-1-acid-glycoprotein), IDA was markedly reduced by provision of iron fortified CF to preschool-age children for 9 months, with no significant differences between a combination of NaFeEDTA with FeFum or NaFeEDTA with FePP. However, there was no overall effect on anemia, suggesting most of the anemia in this setting is not due to ID. This trial is registered at clinicaltrials.gov (NCT01634945).
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Affiliation(s)
- Dominik Glinz
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, CH-4031 Basel, Switzerland.
- University of Basel, CH-4003 Basel, Switzerland.
| | - Rita Wegmüller
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
| | - Mamadou Ouattara
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, 01 BP V34 Abidjan, Cote d'Ivoire.
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, 01 BP 1303 Abidjan, Côte d'Ivoire.
| | - Victorine G Diakité
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, 01 BP 1303 Abidjan, Côte d'Ivoire.
- Département de Sociologie, Université Alassane Ouattara, 01 BP V18 Bouaké, Côte d'Ivoire.
| | - Grant J Aaron
- Global Alliance for Improved Nutrition, CH-1202 Geneva, Switzerland.
| | - Lorenz Hofer
- Swiss Tropical and Public Health Institute, CH-4051 Basel, Switzerland.
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
| | - Lukas G Adiossan
- Hôpital Général de Taabo, Taabo Cité, BP 700 Toumodi, Côte d'Ivoire.
| | - Jürg Utzinger
- University of Basel, CH-4003 Basel, Switzerland.
- Swiss Tropical and Public Health Institute, CH-4051 Basel, Switzerland.
| | - Eliézer K N'Goran
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, 01 BP V34 Abidjan, Cote d'Ivoire.
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, 01 BP 1303 Abidjan, Côte d'Ivoire.
| | - Richard F Hurrell
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
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Cusick SE, Opoka RO, Abrams SA, John CC, Georgieff MK, Mupere E. Delaying Iron Therapy until 28 Days after Antimalarial Treatment Is Associated with Greater Iron Incorporation and Equivalent Hematologic Recovery after 56 Days in Children: A Randomized Controlled Trial. J Nutr 2016; 146:1769-74. [PMID: 27358418 PMCID: PMC4997284 DOI: 10.3945/jn.116.233239] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/18/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Iron therapy begun concurrently with antimalarial treatment may not be well absorbed because of malaria-induced inflammation. Delaying the start of iron therapy may permit better iron absorption and distribution. OBJECTIVE We compared erythrocyte iron incorporation in children who started iron supplementation concurrently with antimalarial treatment or 28 d later. We hypothesized that delayed iron supplementation would be associated with greater incorporation and better hematologic recovery. METHODS We enrolled 100 children aged 6-59 mo with malaria and hemoglobin concentrations of 50.0-99.9 g/L who presented to Mulago Hospital, Kampala, into a randomized trial of iron therapy. All children were administered antimalarial treatment. Children with zinc protoporphyrin (ZPP) ≥80 μmol/mol heme were randomly assigned to start iron supplementation concurrently with the antimalarial treatment [immediate iron (I) group] or 28 d later [delayed iron (D) group]. All children were administered iron-stable isotope (57)Fe on day 0 and (58)Fe on day 28. We compared the percentage of iron incorporation at the start of supplementation (I group at day 0 compared with D group at day 28, aim 1) and hematologic recovery at day 56 (aim 2). RESULTS The percentage of iron incorporation (mean ± SE) was greater at day 28 in the D group (16.5% ± 1.7%) than at day 0 in the I group (7.9% ± 0.5%; P < 0.001). On day 56, concentrations of hemoglobin and ZPP and plasma ferritin, soluble transferrin receptor (sTfR), hepcidin, and C-reactive protein did not differ between the groups. On day 28, the hemoglobin (mean ± SD) and plasma iron markers (geometric mean; 95% CI) reflected poorer iron status in the D group than in the I group at this intervening time as follows: hemoglobin (105 ± 15.9 compared with 112 ± 12.4 g/L; P = 0.04), ferritin (39.3 μg/L; 23.5, 65.7 μg/L compared with 79.9 μg/L; 58.3, 110 μg/L; P = 0.02), sTfR (8.9 mg/L; 7.4, 10.7 mg/L compared with 6.7 mg/L; 6.1, 7.5 mg/L; P = 0.01), and hepcidin (13.3 ng/mL; 8.3, 21.2 ng/mL compared with 38.8 ng/mL; 28.3, 53.3 ng/mL; P < 0.001). CONCLUSIONS Delaying the start of iron improves incorporation but leads to equivalent hematologic recovery at day 56 in Ugandan children with malaria and anemia. These results do not demonstrate a clear, short-term benefit of delaying iron. This trial was registered at clinicaltrials.gov as NCT01754701.
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Affiliation(s)
- Sarah E Cusick
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN;
| | - Robert O Opoka
- Departament of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Steven A Abrams
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX; and
| | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Michael K Georgieff
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN
| | - Ezekiel Mupere
- Departament of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Bahwere P, Balaluka B, Wells JCK, Mbiribindi CN, Sadler K, Akomo P, Dramaix-Wilmet M, Collins S. Cereals and pulse-based ready-to-use therapeutic food as an alternative to the standard milk- and peanut paste-based formulation for treating severe acute malnutrition: a noninferiority, individually randomized controlled efficacy clinical trial. Am J Clin Nutr 2016; 103:1145-61. [PMID: 26984485 DOI: 10.3945/ajcn.115.119537] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 01/26/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The cost of current standard ready-to-use therapeutic food (RUTF) is among the major obstacles to scaling up community-based management of acute malnutrition (CMAM), an important child survival strategy. Identifying a cheaper alternative is a global public health priority. OBJECTIVE We sought to compare the efficacy of soya-maize-sorghum RUTF (SMS-RUTF) with that of standard peanut paste-based RUTF (P-RUTF). DESIGN We used a nonblinded, parallel-group, simple randomized controlled trial along with a day care approach that enrolled 2 groups of children aged 6-23 and 24-59 mo, respectively, with severe acute malnutrition (SAM). RESULTS Intention-to-treat (ITT) and per-protocol (PP) analyses showed noninferiority of SMS-RUTF compared with P-RUTF for the recovery rate [ITT: Δ = -2.0% (95% CI: -7.6%, 3.6%); PP: -1.9% (95% CI: -5.3%, 1.4%)], weight gain [Δ = -0.7 g · kg(-1)· d(-1)(95% CI: -1.3, 0.0 g · kg(-1)· d(-1))], and length of stay [Δ = 2.0 d (95% CI: -1.7, 5.8 d)] in children ≥24 mo of age. In children ≤23 mo of age, the recovery rate of SMS-RUTF was inferior to that of P-RUTF [ITT: Δ = -20.8% (95% CI: -29.9%, -11.7%); PP: -17.2% (95% CI: -25.6%, -8.7%)]. Treatment with SMS-RUTF resulted in a greater increase in hemoglobin [0.670 g/dL (95% CI: 0.420, 0.921 g/dL);P< 0.001]. Treatment with both RUTFs resulted in the replenishment of all of the amino acids tested except for methionine. There were no differences at discharge between RUTF groups in fat mass [Δ = 0.3 kg (95% CI: -0.6, 1.6 kg);P= 0.341] or fat mass index [Δ = 0.4 kg/m(2)(95% CI: -0.3, 1.1 kg/m(2));P= 0.262]. By contrast, comparisons of fat-free mass indicated lower concentrations than the community controls after treatment with either of the 2 RUTFs [Δ = -1.3 kg (95% CI: -2.4, -0.1 kg) andP= 0.034 for comparison between community controls and the SMS-RUTF group; Δ = -1.8 kg (95% CI: -2.9, -0.6 kg) andP= 0.003 for comparison between community controls and the P-RUTF group]. CONCLUSION SMS-RUTF can be used to treat SAM in children aged ≥24 mo to reduce the costs of CMAM programs. More research is required to optimize SMS-RUTF for younger children. This trial was registered in the Pan African Clinical Trial Registry as PACTR201303000475166.
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Affiliation(s)
- Paluku Bahwere
- Valid International, Oxford, United Kingdom; Centre for Research in Epidemiology, Biostatistics and Clinical Research, School of Public Health, University of Brussels, Brussels, Belgium;
| | - Bisimwa Balaluka
- Lwiro Natural Science Research Centre, South Kivu, Democratic Republic of Congo; College of Medicine, Catholic University of Bukavu, South Kivu, Democratic Republic of Congo
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, University College London Institute of Child Health, London, United Kingdom; and
| | | | | | | | - Michèle Dramaix-Wilmet
- Centre for Research in Epidemiology, Biostatistics and Clinical Research, School of Public Health, University of Brussels, Brussels, Belgium
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Cusick SE, Opoka RO, Ssemata AS, Georgieff MK, John CC. Comparison of iron status 28 d after provision of antimalarial treatment with iron therapy compared with antimalarial treatment alone in Ugandan children with severe malaria. Am J Clin Nutr 2016; 103:919-25. [PMID: 26843153 PMCID: PMC4763490 DOI: 10.3945/ajcn.115.117820] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/18/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The provision of iron with antimalarial treatment is the standard of care for concurrent iron deficiency and malaria. However, iron that is given during a malaria episode may not be well absorbed or used, particularly in children with severe malaria and profound inflammation. OBJECTIVES We aimed to 1) determine baseline values of iron and inflammatory markers in children with severe malarial anemia (SMA), children with cerebral malaria (CM), and community children (CC) and 2) compare markers in iron-deficient children in each group who received 28 d of iron supplementation during antimalarial treatment with those in children who did not receive iron during treatment.. DESIGN Seventy-nine children with CM, 77 children with SMA, and 83 CC who presented to Mulago Hospital, Kampala, Uganda, were enrolled in a 28-d iron-therapy study. Children with malaria received antimalarial treatment. All children with CM or SMA, as well as 35 CC, had zinc protoporphyrin (ZPP) concentrations ≥80 μmol/mol heme and were randomly assigned to receive a 28-d course of iron or no iron. We compared iron markers at day 0 among study groups (CM, SMA, and CC groups) and at day 28 between children in each group who were randomly assigned to receive iron or to not receive iron. RESULTS At day 0, children with CM and SMA had greater values of C-reactive protein, ferritin, and hepcidin than those of CC. At day 28, interactions between study and treatment group were NS. Children in the no-iron compared with iron groups had similar mean values for hemoglobin (115 compared with 113 g/L, respectively; P = 0.73) and ZPP (124 compared with 124 μmol/mol heme, respectively; P = 0.96) but had lower median ferritin [101.0 μg/L (95% CI: 84.2, 121.0 μg/L) compared with 152.9 μg/L (128.8, 181.6 μg/L), respectively; P ≤ 0.001] and hepcidin [45.8 ng/mL (36.8, 56.9 ng/mL) compared with 83.1 ng/mL (67.6, 102.2 ng/mL), respectively; P < 0.011]. CONCLUSIONS Severe inflammation is a characterization of children with CM and SMA. The withholding of iron from children with severe malaria is associated with lower ferritin and hepcidin at day 28 but not a lower hemoglobin concentration. This trial was registered at clinicaltrials.gov as NCT01093989.
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Affiliation(s)
- Sarah E Cusick
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN; and
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew S Ssemata
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael K Georgieff
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN; and
| | - Chandy C John
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN; and
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Raiten DJ, Neufeld LM, De-Regil LM, Pasricha SR, Darnton-Hill I, Hurrell R, Murray-Kolb LE, Nair KM, Wefwafwa T, Kupka R, Phall MC, Sakr Ashour FA. Integration to Implementation and the Micronutrient Forum: A Coordinated Approach for Global Nutrition. Case Study Application: Safety and Effectiveness of Iron Interventions. Adv Nutr 2016; 7:135-48. [PMID: 26773021 PMCID: PMC4717873 DOI: 10.3945/an.115.008581] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Paramount among the challenges to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance. The Integration to Effective Implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the food and nutrition enterprise. The 2014 Micronutrient Forum (MNF) Global Conference held in Addis Ababa, Ethiopia, in June 2014 offered the opportunity to apply the I-to-I approach with the use of current concerns about the safety and effectiveness of interventions to prevent and treat iron deficiency (ID) as a case study. ID is associated with a range of adverse outcomes, especially in pregnant and nonpregnant women, infants, and primary school-age children. Strategies to combat ID include iron supplementation, multiple micronutrient powders, and food-based interventions to enhance dietary iron intake. Recent reports indicate potential increased adverse risks when iron is provided in areas with high infection burdens (e.g., malaria). This paradox has weakened iron intervention programs. Furthermore, the selection and interpretation of available biomarkers for assessing iron nutrition have been found to be compromised by the inflammatory process. These issues highlight the need for a comprehensive approach that considers basic biology, assessment, interventions, and how these can be translated into appropriate programs and policies. The application of the I-to-I with the use of the MNF offered an opportunity to explore how that might be achieved.
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Affiliation(s)
- Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD;
| | | | | | - Sant-Rayn Pasricha
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Ian Darnton-Hill
- The Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Richard Hurrell
- Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology, Zurich, Switzerland
| | | | - K Madhavan Nair
- Department of Biophysics, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Terry Wefwafwa
- Division of Nutrition, Ministry of Health, Nairobi, Kenya
| | | | | | - Fayrouz A Sakr Ashour
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
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