Anemia and Micronutrient Status of Women of Childbearing Age and Children 6-59 Months in the Democratic Republic of the Congo

Prevalence and Determinants of Stunting-Anemia and Wasting-Anemia Comorbidities and Micronutrient Deficiencies in Children Under 5 in the Least-Developed Countries: A Systematic Review and Meta-analysis

CONTEXT

Despite shifting from addressing isolated forms of malnutrition to recognizing its multifaceted nature, evidence on the prevalence and determinants of micronutrient deficiencies, and their coexistence with undernutrition in children under 5, remains insufficient, unsystematic, and incohesive.

OBJECTIVE

The aim of this systematic review and meta-analysis was to assess the prevalence and determinants of stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies in children under 5 in the least-developed countries (LDCs).

DATA SOURCES

Electronic searches took place from January 15, 2023, to February 14, 2024, across multiple databases, including PubMed, Embase, Web of Science, SCOPUS, African Index Medicus (AIM), World Health Organization's Institutional Repository for Information Sharing (IRIS), and African Journals Online. The search spanned the years 2000 to 2024, yet it yielded eligible full-text English research articles from only 2005 to 2021 conducted in LDCs. Studies lacking quantitative data on malnutrition types and their determinants were excluded.

DATA EXTRACTION

Two independent authors assessed articles for bias and quality using Hoy et al's 10-item scale and Newcastle-Ottawa Scale (NOS) criteria. Prevalence and other details were extracted using a Joanna Briggs Institute Excel template. Authors extracted adjusted odds ratios (aORs) for determinant factors such as sex and vitamin A and iron supplementation.

DATA ANALYSIS

The search yielded 6248 articles from 46 LDCs. Sixty-nine articles, with a total sample size of 181 605, met inclusion criteria for the final meta-analysis. Vitamin A deficiency affected 16.32% of children, and iodine deficiency affected 43.41% of children. The pooled prevalence of wasting-anemia and stunting-anemia comorbidity was 5.44% and 19.47%, respectively. Stunting was associated with vitamin A deficiency (aOR: 1.54; 95% CI: 1.01-2.37), and not taking vitamin A supplementation was associated with iron-deficiency anemia (aOR: 1.37; 95% CI: 1.21-1.55).

CONCLUSION

A significant proportion of children under 5 in LDCs experienced stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies. This study underscores the urgent need to address factors driving these burdens.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023409483.

Folate and Vitamin B12 Status among Non-Pregnant, Non-Lactating Women of Reproductive Age and Predicted Risk for Neural Tube Defects, Morogoro Region, Tanzania

INTRODUCTION

Population risk for neural tube defects (NTDs) can be determined using red blood cell (RBC) folate. However, a paucity of biomarker and surveillance data among non-lactating, non-pregnant women of reproductive age (NPWRA) from Africa limits accurate assessment. Our study assessed folate and vitamin B12 status among non-lactating NPWRA and predicted population risk of NTDs in Tanzania.

METHODS

A cross-sectional biomarker survey of non-lactating NPWRA (15-49 years) in the Morogoro region, Tanzania was conducted during June-October 2019. Questionnaire interview responses and non-fasting blood samples were collected. Folate was assessed using the CDC microbiologic assay kit and vitamin B12 was measured using an electrochemiluminescence immunoassay. Complex survey design analyses were conducted using SAS-callable SUDAAN (v11.0.1).

RESULTS

Of the 761 participating non-lactating NPWRA, 294 (39.8%) had RBC folate insufficiency (<748 mol/L). The prevalence of RBC folate insufficiency was lower among non-lactating NPWRA living in urban than rural areas (PR: 0.72, 95% CI: 0.52-0.99) but did not differ by age or household wealth index. Vitamin B12 insufficiency was uncommon (< 221 pmol/L, 2.7%). The estimated NTD risk was 10.5 (95% uncertainty interval: 8.1-13.3) per 10,000 births.

DISCUSSION

Elevated NTD risk was predicted in the Morogoro region of Tanzania, where ∼ 40% of non-lactating NPWRA had RBC folate insufficiency and < 3% had vitamin B12 insufficiency. The NTD risk is consistent with surveillance data for the area, limited folic acid fortification of staple foods, and low vitamin B12 insufficiency. Further studies are needed to better understand the context of these findings, especially the impact of micronutrient fortification in Tanzania.

The Epidemiology of Deficiency of Vitamin B12 in Preschool Children in Turkey

Background: Vitamin B12 is a water-soluble vitamin with important cellular functions; it is an essential vitamin. The aim of this study is to determine the B12 levels of children in the period from the 6th month when they start taking additional foods to the age of seven (preschool children) and the risk factors affecting them. Methods: One hundred pediatric patients aged 6-72 months who were diagnosed with vitamin B12 deficiency and their parents who agreed to attend Istanbul Atlas University, Medical Faculty, "Medicine Hospital" Pediatric Clinic between September 2022 and June 2023 were prospectively included in this study. Results: B12 deficiency was significantly higher in the 6-11 (25%)-month group than in the 12-23 (5.8%)- and 24-47 (2.8%)-month groups. Homocysteine levels were highest in those with insufficient B12 levels compared to the other groups. There was no statistically significant difference in weekly dairy and meat consumption levels between age groups. B12 levels were lower in the 6-11-month group than in the other groups. Homocysteine levels were highest in those with insufficient B12 levels (<200 pg/mL (148 pmol/L)). Folic acid levels were lower in the 24-47-month and 48-72-month groups than in the 6-11-month and 12-23-month groups. Conclusions: The results obtained in this study showed that low vitamin B12 and increased homocysteine levels seem to be important risk factors in preschool children, especially from the 6th month when they start consuming additional foods. The diagnosis of B12 deficiency can be confirmed by elevated serum total homocysteine levels, which are evidence of functional cobalamin deficiency.

Folate Deficiency Is Spatially Dependent and Associated with Local Farming Systems among Women in Ethiopia

Background

Folate is essential for the synthesis and integrity of DNA, normal cell formation, and body growth. Folate deficiency among women of reproductive age (WRA) increases the risk of poor birth outcomes including neural tube defect (NTD)-affected pregnancies. Folate status is largely dependent on dietary intakes.

Objectives

We aimed to explore the spatial distribution of biomarkers of folate status and their association with farming systems among nonpregnant WRA in Ethiopia.

Methods

Serum and RBC folate concentration data were derived from the Ethiopia National Micronutrient Survey of 2015. The spatial dependencies of folate concentration of WRA were investigated and its relation with the dominant local farming system was explored.

Results

The median serum folate and RBC folate concentrations were 12.3 nmol/L and 567.3 nmol/L, respectively. The national prevalence of folate deficiency using homocysteine concentration as a metabolic indicator based on serum and RBC folate concentration was 11.6% and 5.7%, respectively. The majority of women (77.9%) had low RBC folate concentrations consistent with increased risk of NTD-affected pregnancies. Folate nutrition was spatially dependent at distances of ≤ 300 km. A marked variability in folate concentration was observed between farming systems: greater RBC folate concentration (median: 1036 nmol/L) was found among women from the Lake Tana fish-based system, whereas the lowest RBC folate concentration (median: 386.7 nmol/L) was observed in the highland sorghum chat mixed system.

Conclusions

The majority (78%) of WRA in Ethiopia had low folate status potentially increasing the risk of NTD-affected pregnancies. These findings may help national and subnational nutrition intervention strategies to target the most affected areas in the country.

Exploration of the relationship between anemia and iron and zinc deficiencies in children under 5 years of age living in the malaria endemic area of South Kivu/Democratic Republic of Congo

The aim of this study was to explore the relationship of iron and zinc deficiencies and anemia in children aged under 5 years living in malaria endemic area of South Kivu/DRC. We conducted a cross-sectional study in the health zone of Miti Murhesa in South Kivu/DRC. A total of 1088 children in good general health were included in this study. Almost 40% of children were anemic. The prevalence of iron deficiency (ID) was found in 34.9% and 49.1% children based on ferritin or free erythrocyte protoporphyrin (FEP), respectively. If anemia is present, we found iron deficiency anemia (IDA) according to the WHO-criteria (ferritin) in 31%, and according to FEP in 66% of children. The overall prevalence of zinc deficiency was 17.6%. If anemia is present, zinc deficiency was found in 24.4% of children. Inflammation/infection, based upon CRP, was present in 39.7% children. The independent factors associated with anemia were recent illness, middle upper arm circumference, weight-for-height, ID according to FEP, zinc deficiency, and submicroscopic Plasmodium infection. A high prevalence of ID was observed in children in South Kivu according to FEP. Ferritin as acute phase protein was less suited in this population due to a high frequency of infection/inflammation. Iron and zinc deficiencies were found to be significantly associated with anemia in this population.

Distribution and Determinants of Serum Zinc, Copper, and Selenium Levels among Children under Five Years from Popokabaka, Democratic Republic of Congo: A Cross-Sectional Study

Information about essential trace elements among children in many African countries, including the Democratic Republic of Congo (DRC), is limited. We aimed to measure the distribution and determinants of serum zinc (Zn), copper (Cu), and selenium (Se) concentrations in a representative sample of children under five years old. We conducted a community-based cross-sectional study in Popokabaka, DRC. Blood samples were drawn from 412 children. The serum concentrations of minerals were measured using inductively coupled plasma−mass spectrometry. The median concentrations (P25−P75) of Zn, Cu, and Se were 61.9 µg/dL (52.8−70.2), 145.5 (120.0−167.0) µg/dL and 5.3 (4.3−6.3) µg/dL. The CRP-adjusted prevalence of serum Se deficiency was 84.1% (95% confidence interval [CI] 81.4−87.0) and of Zn deficiency was 64.6% (95% CI 59.8−69.1%). Only a few children were Cu deficient [1.5% (0.6−3.2)]. Evidence of inflammation (C-reactive protein, >5 mg/L) was associated with a lower Se concentration and higher Cu concentration. Furthermore, serum Se concentration was positively associated with linear growth. The average Cu/Zn molar ratio (2:1) was twice that recommended. Children in western Popokabaka had higher Zn and Se levels than their eastern neighbors. Zinc and selenium deficiencies are common among children in Popokabaka and require attention and prioritization.

Prevalence and Associated Factors of Iron Deficiency and Iron Deficiency Anemia Among Under-5 Children: A Systematic Review and Meta-Analysis

Background. Iron deficiency anemia is a common health problem that affects children under the age of five. Children’s cognitive performance is impaired by iron deficiency, which impacts their psychomotor development. Therefore, the aim of this study was to determine the global prevalence and associated factors of iron deficiency and iron deficiency anemia among under-5 children. Methods. Relevant publications published till March 30, 2021 were identified in databases such as Medline/PubMed, Science Direct, Popline, EMBASE, African Journals Online, Scopus, and Google Scholar. The STATA version 11 software was utilized for the analysis. To determine the level of heterogeneity, I² test statistics were used. To detect publication bias, funnel plots analysis and the Egger weighted regression test were used. Results. The global pooled prevalence of iron deficiency anemia and iron deficiency was 16.42% (95% CI: 10.82, 22.01) and 17.95% (95% CI: 13.49, 22.41), respectively. Age less than 2 years (OR = 1.26; 95% CI: 1.14, 1.38) and living in a large family size (OR = 1.38; 95% CI: 1.18, 1.58) were associated with iron deficiency anemia. Children born from anemic mother, low birth weight, and do not drink iron fortified milk (OR = 1.20; 95% CI: 1.05, 1.36), (OR = 1.15; 95% CI: 1.01, 1.36) and (OR = 1.28; 95% CI: 1.10, 1.46), respectively were associated factors of iron deficiency in under-5 children. Conclusion. The prevalence of iron deficiency anemia and iron deficiency was significant across the globe, particularly in Asia and Africa. Therefore, regular screening and treatment of iron deficiency and iron deficiency anemia are required especially in high-risk children to reduce their complication.

PROSPERO registration number: CRD42021267060

Prevalence and Disparities in Folate and Vitamin B12 Deficiency Among Preschool Children in Guatemala

BACKGROUND AND OBJECTIVE

Folate and vitamin B12 deficiencies can impair proper growth and brain development in children. Data on the folate and vitamin B12 status of children aged 6-59 months in Guatemala are scarce. Identification of factors associated with higher prevalence of these micronutrient deficiencies within the population is needed for national and regional policymakers.

OBJECTIVE

To describe national and regional post-fortification folate and vitamin B12 status of children aged 6-59 months in Guatemala.

METHODS

A multistage, cluster probability study was carried out with national and regional representation of children aged 6-59 months. Demographic and health information was collected for 1246 preschool children, but blood samples for red blood cell (RBC) folate and vitamin B12 were collected and analyzed for 1,245 and 1143 preschool children, respectively. We used the following deficiency criteria as cutoff points for the analyses: < 305 nmol/L for RBC folate, < 148 pmol/L for vitamin B12 deficiency, and 148-221 pmol/L for marginal vitamin B12 deficiency. Prevalence of RBC folate deficiency and vitamin B12 deficiency and marginal deficiency were estimated. Prevalence risk ratios of RBC folate and vitamin B12 deficiency were estimated comparing subpopulations of interest.

RESULTS

The national prevalence estimates of RBC folate deficiency among children was 33.5% [95% CI 29.1, 38.3]. The prevalence of RBC folate deficiency showed wide variation by age (20.3-46.6%) and was significantly higher among children 6-11 months and 12-23 months (46.6 and 37.0%, respectively), compared to older children aged 48-59 months (20.3%). RBC folate deficiency also varied widely by household wealth index (22.6-42.0%) and geographic region (27.2-46.7%) though the differences were not statistically significant. The national geometric mean for RBC folate concentrations was 354.2 nmol/L. The national prevalences of vitamin B12 deficiency and marginal deficiency among children were 22.5% [95% CI 18.2, 27.5] and 27.5% [95% CI 23.7, 31.7], respectively. The prevalence of vitamin B12 deficiency was significantly higher among indigenous children than among non-indigenous children (34.5% vs. 13.1%, aPRR 2.1 95% CI 1.4, 3.0). The prevalence of vitamin B12 deficiency also significantly varied between the highest and lowest household wealth index (34.3 and 6.0%, respectively). The national geometric mean for vitamin B12 concentrations was 235.1 pmol/L. The geometric means of folate and B12 concentrations were significantly lower among children who were younger, had a lower household wealth index, and were indigenous (for vitamin B12 only). Folate and vitamin B12 concentrations showed wide variation by region (not statistically significant), and the Petén and Norte regions showed the lowest RBC folate and vitamin B12 concentrations, respectively.

CONCLUSIONS

In this study, a third of all children had RBC folate deficiency and half were vitamin B12 deficient. Folate deficiency was more common in younger children and vitamin B12 deficiency was more common in indigenous children and those from the poorest families. These findings suggest gaps in the coverage of fortification and the need for additional implementation strategies to address these gaps in coverage to help safeguard the health of Guatemalan children.

The Inclusion of Folic Acid in Weekly Iron-Folic Acid Supplements Confers no Additional Benefit on Anemia Reduction in Nonpregnant Women: A Randomized Controlled Trial in Malaysia

BACKGROUND

Weekly iron-folic acid (IFA) supplements are recommended for all menstruating women in countries where anemia prevalence is ≥20%; however, it is unknown whether the inclusion of folic acid in weekly IFA supplements reduces anemia.

OBJECTIVES

We examined whether the inclusion of folic acid in weekly IFA supplements conferred any benefit on hemoglobin (Hb) concentration, anemia reduction, or iron status [ferritin and soluble transferrin receptor (sTfR)], over iron alone.

METHODS

In this secondary analysis of a randomized controlled trial in Malaysia, n = 311 nonpregnant women (18-45 y old) received 60 mg Fe with either 0, 0.4, or 2.8 mg folic acid once-weekly for 16 wk. Fasting blood was collected at baseline and 16 wk. A generalized linear model (normal distribution with identity link) was used to assess Hb concentration at 16 wk (primary outcome).

RESULTS

At baseline, 84% of women had low folate status (plasma folate < 14 nmol/L). At 16 wk, marginal mean (95% CI) Hb was 131 (130, 133), 131 (129, 132), and 132 (130, 133) g/L; ferritin was 58.2 (53.9, 62.5), 56.5 (52.2, 60.9), and 58.0 (53.7, 62.3) μg/L; and sTfR was 5.8 (5.5, 6.1), 5.8 (5.5, 6.1), and 5.9 (5.6, 6.2) mg/L in the 0, 0.4, and 2.8 mg/wk groups, respectively, with no differences between groups (P > 0.05). Baseline plasma folate concentration did not modify the effect of treatment on Hb concentration at 16 wk. Among all women, the risks of anemia [risk ratio (RR): 0.65; 95% CI: 0.45, 0.96; P = 0.03] and iron deficiency based on ferritin (RR: 0.30; 95% CI: 0.20, 0.44; P < 0.001) were lower at 16 wk than at baseline.

CONCLUSIONS

Despite the low folate status among these nonpregnant Malaysian women, the inclusion of folic acid in weekly IFA supplements did not reduce anemia or improve iron status, over iron alone. However, the benefits of folic acid for neural tube defect prevention still warrant its retention in weekly IFA supplements.This trial was registered at www.anzctr.org.au as ACTRN12619000818134.

Revisiting Konzo Risk Factors in Three Areas Differently Affected by Spastic Paraparesis in Eastern Democratic Republic of the Congo Discloses a Prominent Role of the Nutritional Status-A Comparative Cross-Sectional Study

This comparative cross-sectional study aimed to better understand the respective contributions of protein malnutrition and cassava-derived cyanide poisoning in the development of konzo. We compared data on nutritional status and cyanide exposure of school-age adolescent konzo-diseased patients to those of non-konzo subjects of similar age from three areas in the Eastern Democratic Republic of the Congo. Our results show that konzo patients had a high prevalence of both wasting (54.5%) and stunting (72.7%), as well as of cyanide poisoning (81.8%). Controls from Burhinyi and those from Idjwi showed a similar profile with a low prevalence of wasting (3.3% and 6.5%, respectively) and intermediate prevalence of stunting (26.7% and 23.9%, respectively). They both had a high prevalence of cyanide poisoning (50.0% and 63.0%, respectively), similar to konzo-patients. On the other hand, controls from Bukavu showed the lowest prevalence of both risk factors, namely chronic malnutrition (12.1%) and cyanide poisoning (27.6%). In conclusion, cassava-derived cyanide poisoning does not necessarily coexist with konzo outbreaks. The only factor differentiating konzo patients from healthy individuals exposed to cyanide poisoning appeared to be their worse nutritional status. This further suggests that, besides the known role of cyanide poisoning in the pathogenesis of konzo, malnutrition may be a key factor for the disease occurrence.

Prevalence of Anemia, Iron-Deficiency Anemia, and Associated Factors among Children Aged 1-5 Years in the Rural, Malaria-Endemic Setting of Popokabaka, Democratic Republic of Congo: A Cross-Sectional Study

Iron deficiency (ID), the leading cause of anemia and the most common nutritional deficiency globally, is not well reported among children in malaria-endemic settings, and little is known about its contribution to anemia in these settings. We aimed to assess the prevalence of anemia, the role of ID using multiple parameters, and the factors associated with anemia in a malaria-endemic rural area. We conducted a community-based cross-sectional study of 432 children aged 1-5 years from the Popokabaka Health Zone, Democratic Republic of Congo. Sociodemographic characteristics, medical history, anthropometric parameters, and biochemical parameters were considered. Hemoglobin and malaria prevalence were assessed using rapid finger-prick capillary blood testing in the field. Venous blood samples were analyzed for serum ferritin, serum iron, total iron-binding capacity, and C-reactive protein (CRP) in a laboratory. Anemia was found in 294 out of 432 (68%) patients. Malaria was found in 375 out of 432 (87%), and ID in 1.8% according to diagnosis by adjusted ferritin only and in 12.9% according to transferrin saturation. ID indicators were not significantly correlated with low hemoglobin levels. Malaria, fever, and CRP > 5 mg/L were major factors associated with anemia in Popokabaka. Anemia control should focus on treating inflammatory conditions and infectious diseases among children in such settings.

Scaled-up nutrition education on pulse-cereal complementary food practice in Ethiopia: a cluster-randomized trial

Background

Improving children’s weight status through nutrition education (NE) for mothers about using pulses in complementary feeding has been demonstrated in pilot studies, but no effect on stunting was reported. The aim of the study was to assess the impact of a 9-month pulse-nutrition education program on improving mothers’ knowledge, attitude, and practices (KAP) towards pulses, as well as its effect on children’s diet diversity, and nutritional status. The NE was delivered by Health Extension Workers (HEWs).

Methods

A cluster randomized study was employed for the community-based interventional study. Twelve randomly selected villages in Sidama Zone, Southern Ethiopia were included in the study. A total of 772 mother-child pairs involved in the study; where 386 mother-child pairs in the intervention group received additional messages about pulse-cereal complementary food, and 386 pairs (the control) received only routine health education for 9 months. A survey on mothers’ KAP and anthropometric measurements of the children were taken at baseline, midpoint, and end point. ANOVA and descriptive statistics were used to analyzed data.

Results

At baseline and end point, maternal KAP and the dietary diversity score of the children (mean age at end point 18.8 ± 2.9 mo) were assessed. Intervention mothers’ KAP improved (p < 0.001) at midpoint and end point compared to that of the control group, as did frequency of pulse consumption and Dietary Diversity Score (DDS) among children. At 9 months, the prevalence of stunting, wasting, and underweight was significantly reduced in the intervention group compared to the control group (p = 0.001).

Conclusions

NE delivered by HEWs improved KAP of mothers regarding pulse consumption and dietary diversity of children led to improved nutritional status of the children. Training HEWs on the use of pulses for complementary food may be an effective way to improve the health of children in Ethiopian communities.

Trial registration

Clinicaltrials.gov #NCT02638571.

Date of registration: 12/18/2015.

Prospectively registered.

Is untargeted iron supplementation harmful when iron deficiency is not the major cause of anaemia? Study protocol for a double-blind, randomised controlled trial among non-pregnant Cambodian women

INTRODUCTION

The WHO recommends daily oral iron supplementation for 12 weeks in women and adolescents where anaemia prevalence is greater than 40%. However, if iron deficiency is not a major cause of anaemia, then, at best, untargeted iron supplementation is a waste of resources; at worst, it could cause harm. Further, different forms of iron with varying bioavailability may present greater risks of harm.

METHODS AND ANALYSIS

A 12-week three-arm, double-blind, randomised controlled supplementation trial was conducted in Cambodia to determine if there is potential harm associated with untargeted iron supplementation. We will recruit and randomise 480 non-pregnant women (ages 18-45 years) to receive one of three interventions: 60 mg elemental iron as ferrous sulfate (the standard, commonly used form), 18 mg ferrous bisglycinate (a highly bioavailable iron amino acid chelate) or placebo. We will measure ferritin concentrations (to evaluate non-inferiority between the two forms of iron), as well as markers of potential harm in blood and stool (faecal calprotectin, gut pathogen abundance and DNA damage) at baseline and 12 weeks. Mixed-effects generalised linear models will be used to assess the effect of iron on ferritin concentration and markers of potential harm at 12 weeks.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of British Columbia Clinical Research Ethics Board (H18-02610), the Children's and Women's Health Centre of British Columbia Research Ethics Board (H18-02610) and the National Ethics Committee for Health Research in Cambodia (273-NECHR). Findings will be published in peer-reviewed journals, presented to stakeholders and policymakers globally and shared within participants' communities.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04017598).

Asymptomatic Submicroscopic Plasmodium Infection Is Highly Prevalent and Is Associated with Anemia in Children Younger than 5 Years in South Kivu/Democratic Republic of Congo

One of the most important problems in controlling malaria is the limited access to effective and accurate diagnosis of malaria parasitemia. In the Democratic Republic of Congo (DRC), malaria is one of the leading causes of morbidity and mortality. The purpose of this study was to assess the prevalence of anemia and the relationship with asymptomatic submicroscopic Plasmodium infection. A cross-sectional study was carried out among 1,088 apparently healthy children aged between 6 and 59 months selected at random in the health zone of Miti Murhesa in South Kivu/DRC. Capillary blood was obtained for hemoglobin (Hb) concentration measurement by Hemocue^® Hb 301. Malaria detection was performed by microscopy and the loop-mediated isothermal amplification (LAMP) assay. Anemia was defined as Hb < 11g/dL. We applied the chi-square test for comparisons, and multiple logistic regression was used to identify the risk factors for anemia and submicroscopic Plasmodium infection. The prevalence of anemia was 39.6%, and the prevalence of parasitemia was 15.9% and 34.0% using microscopy and LAMP test, respectively. Submicroscopic Plasmodium infection was found in 22.3% of the children. The independent risk factors for anemia are Plasmodium infection, children younger than 24 months, low middle-upper arm circumference, and history of illness two weeks before. Otherwise, children with submicroscopic malaria infection have a significantly increased risk for anemia, with a need of transfusion. The prevalence of malaria infection was underestimated, when microscopy was used to diagnose malaria. Children with low parasitemia detected by LAMP but not by microscopy showed a significantly increased prevalence of anemia.

Micronutrient intake and prevalence of micronutrient inadequacy among women (15-49 y) and children (6-59 mo) in South Kivu and Kongo Central, Democratic Republic of the Congo (DRC)

Iron biofortified beans and carotenoid enriched cassava are proposed as a solution to combat iron and vitamin A deficiencies, respectively, in the Democratic Republic of Congo (DRC). To inform the need for biofortified foods, we conducted a survey in 2014 in two provinces of the DRC, South Kivu and Kongo Central. Unexpectedly, women of reproductive age (WRA; 15-49 y) and their children (6-59 m) had a low prevalence of biochemical iron and vitamin A deficiency, based on ferritin and retinol binding protein, respectively. To better understand the lack of biochemical deficiency of these nutrients, we examined the prevalence of inadequate intake for these and other select nutrients. Dietary intake was assessed using 24-hour recalls among 744 mother-child dyads. Repeat recalls on a non-consecutive day were conducted with a subsample of the study population to account for intra-individual variation and estimate usual intake. In WRA, the prevalence of inadequate iron intakes were 33% and 29% in South Kivu and Kongo Central, respecitvely. The prevalence of inadequate vitamin A intakes among WRA was low in South Kivu (18%) and negligible in Kongo Central (1%). Iron inadequacy was highest in infants (6-11 m) at 82% and 64% in South Kivu and Kongo Central, respectively. Among older children (12-59 m) in both provinces, the prevalence of iron inadequacy was similar at ~20%. There was a high prevalence of inadequate zinc intake in women and children (i.e. 79-86% among WRA and 56-91% among children 6-59 m) consistent with our findings of a high prevalence of low serum zinc in the same sample. Dietary data here corroborate the low prevalence of biochemical vitamin A deficiency but not iron. However, any change to the supply of red palm oil (primary source of vitamin A) would dramatically reduce population vitamin A intakes, thus a carotenoid enriched cassava program may be beneficial as a safety net measure. Crops biofortified with zinc also appear warranted. We caution that our findings cannot be extrapolated to the entire Congo where diverse agro-ecological landscape exist or when political and environmental shocks occur which challenge food production.

The increase in hemoglobin concentration with altitude varies among human populations

Decreased oxygen availability at high altitude requires physiological adjustments allowing for adequate tissue oxygenation. One such mechanism is a slow increase in the hemoglobin concentration ([Hb]) resulting in elevated [Hb] in high-altitude residents. Diagnosis of anemia at different altitudes requires reference values for [Hb]. Our aim was to establish such values based on published data of residents living at different altitudes by applying meta-analysis and multiple regressions. Results show that [Hb] is increased in all high-altitude residents. However, the magnitude of increase varies among the regions analyzed and among ethnic groups within a region. The highest increase was found in residents of the Andes (1 g/dL/1000 m), but this increment was smaller in all other regions of the world (0.6 g/dL/1000 m). While sufficient data exist for adult males and females showing that sex differences in [Hb] persist with altitude, data for infants, children, and pregnant women are incomplete preventing such analyses. Because WHO reference values were originally based on [Hb] of South American people, we conclude that individual reference values have to be defined for ethnic groups to reliably diagnose anemia and erythrocytosis in high-altitude residents. Future studies need to test their applicability for children of different ages and pregnant women.

Comparative effectiveness of vitamin-mineral complexes with iron in correcting iron deficiency in women in the outpatient setting

AIM

To compare the efficacy of prophylactic administration of mineral-vitamin complexes &quot;Feroglobin-B12&quot; and &quot;Complivit iron&quot; with different degrees of Fe valence.

MATERIALS AND METHODS

120 female subjects were examined. To determine the quality of life, the SF-36 questionnaire was used. The presence of anxiety was determined on the Spielberger-Khanin Alarm Scale. 30 women with a deficit of Fe were divided into 2 groups of 15 people each. The first group received &quot;Ferroglobin-B12&quot;, the second - &quot;Complivit iron&quot; for a month.

RESULTS

In a month after the initiation of preventive therapy in women of the 1 group the content of Fe serum was normalized. In the second group, its concentration approached the control values. The difference in Fe content in the 1 and 2 groups was of a reliable nature.

CONCLUSION

The intake of &quot;Ferroglobin-B12&quot; was not accompanied by side effects, and performance indicators, social activity and mental health reached control values, unlike the group of patients taking Complivit iron.

Should vitamin B12 status be considered in assessing risk of neural tube defects?

There is a strong biological premise for including vitamin B₁₂ with folic acid in strategies to prevent neural tube defects (NTDs), due to the closely interlinked metabolism of these two vitamins. For example, reduction of B₁₂ deficiency among women of reproductive age could enhance the capacity of folic acid to prevent NTDs by optimizing the cellular uptake and utilization of natural folate cofactors. Vitamin B₁₂ might also have an independent role in NTD prevention, such that adding it in fortification programs might be more effective than fortifying with folic acid alone. Globally, there is ample evidence of widespread vitamin B₁₂ deficiency in low‐ and middle‐income countries, but there is also considerable divergence of vitamin B₁₂ status across regions, likely due to genetic as well as nutritional factors. Here, I consider the evidence that low vitamin B₁₂ status may be an independent factor associated with risk of NTDs, and whether a fortification strategy to improve B₁₂ status would help reduce the prevalence of NTDs. I seek to identify knowledge gaps in this respect and specify research goals that would address these gaps.

Malaria and Iron Load at the First Antenatal Visit in the Rural South Kivu, Democratic Republic of the Congo: Is Iron Supplementation Safe or Could It Be Harmful?

We investigated the relationship between malaria infection and iron status in 531 pregnant women in South Kivu, Democratic Republic of the Congo. Sociodemographic data, information on morbidity, and clinical data were collected. A blood sample was collected at the first antenatal visit to diagnose malaria and measure serum ferritin (SF), soluble transferrin receptor, C-reactive protein, and α1-acid-glycoprotein. Malaria prevalence was 7.5%. Median (interquartile range) SF (adjusted for inflammation) was significantly higher in malaria-infected (82.9 μg/L [56.3-130.4]) than in non-infected (39.8 μg/L [23.6-60.8]) women (P < 0.001). Similarly, estimated mean body iron store was higher in malaria-infected women (P < 0.001). Malaria was significantly and independently associated with high levels of SF. Efforts to improve malaria prevention while correcting iron deficiency and anemia during pregnancy are warranted.

Malaria Is More Prevalent Than Iron Deficiency among Anemic Pregnant Women at the First Antenatal Visit in Rural South Kivu

Anemia is common during pregnancy and is associated with poor outcomes. Objectives were not only 1) to determine the prevalence of anemia and iron deficiency (ID) but also 2) to identify other factors associated with anemia in pregnant women from South Kivu province, in the eastern Democratic Republic of Congo. Between December 2013 and March 2014, 531 women attending the first antenatal visit in their second trimester of pregnancy were recruited. Sociodemographic, clinical, and biological data were collected. Hemoglobin (Hb) was determined by a portable photometer (Hemocue^® Hb201+), and anemia was defined as altitude-adjusted Hb < 110 g/L. ID was defined as serum ferritin < 15 μg/L adjusted for inflammation status (C-reactive protein [CRP] > 5 mg/L and/or α-1-acid glycoprotein > 1 g/L) whereas hypoalbuminemia was defined as serum albumin < 35 g/L. A Giemsa-stained blood smear was used to diagnose malaria. The median age (interquartile range ) was 25.5 (21.1-31.3) years, with anemia in 17.6% and ID in 8%. Malaria was present in 7.5% and hypoalbuminemia among 44%. Soluble transferrin receptor concentration was higher in the presence of inflammation and/or malaria. In the final logistic regression model, factors independently associated with anemia were malaria (adjusted odds ratio [aOR]: 11.24 (4.98-25.37) P < 0.001), hypoalbuminemia [aOR: 2.14 (1.27-3.59); P = 0.004] and elevated CRP [aOR: 1.94 (1.10-3.45); P = 0.022]. ID was not highly prevalent and not associated with anemia in our population. Effective control of anemia during pregnancy in this region should consider fighting malaria and other infectious diseases in combination with measures to improve women's nutrition, both before and during pregnancy.

High Prevalence of Anemia but Low Level of Iron Deficiency in Preschool Children during a Low Transmission Period of Malaria in Rural Kivu, Democratic Republic of the Congo

Anemia is a worldwide public health concern especially in preschool children in developing countries and iron deficiency (ID) is generally assumed to cause at least 50% of the cases. However, data on this contribution are scarce. To close this gap, we determined in 2013 the contribution of ID in the etiology of anemia and measured others factors associated to noniron deficiency anemia (NIDA) in 900 preschool children randomly selected during a two-stage cluster nutritional survey in the Miti-Murhesa health zone, in eastern Democratic Republic of the Congo. In these children, we collected sociodemographic, clinical, and biological parameters and determined the nutritional status according to the World Health Organization 2006 standards. Anemia was defined as altitude-adjusted hemoglobin < 110 g/L and ID was defined as serum ferritin < 12 μg/L or < 30 μg/L in the absence or presence of inflammation, respectively. Median (interquartile range) age was 29.4 (12-45) months. The prevalence of anemia was 46.6% (391/838) among whom only 16.5% (62/377) had ID. Among children without signs of inflammation, only 4.4% (11/251) met the ferritin-based (unadjusted) definition of ID. Logistic regression analysis identified ID, history of fever during the last 2 weeks and mid-upper arm circumference < 125 mm as the only independent factors associated to anemia. In conclusion, anemia is a severe public health problem in the Miti-Murhesa health zone, but NIDA is mostly predominant and needs to be further studied. Control of infections and prevention of acute undernutrition (wasting) are some of appropriate interventions to reduce the burden anemia in this region.

Serum Soluble Transferrin Receptor Concentrations Are Elevated in Congolese Children with Glucose-6-Phosphate Dehydrogenase Variants, but Not Sickle Cell Variants or α-Thalassemia

Background: Anemia is common in Congolese children, and inherited blood disorders may be a contributing cause. The presence of sickle cell variants, X-linked glucose-6-phosphate dehydrogenase (G6PD) deficiency and α-thalassemia, has been previously reported. G6PD A- deficiency is characterized by the co-inheritance of G6PD 376 and 202 variants and is common in sub-Saharan Africa.Objective: We aimed to measure the associations between inherited blood disorders and hemoglobin, ferritin, and soluble transferrin receptor (sTfR) concentrations in Congolese children.Methods: Venous blood was collected from 744 children aged 6-59 mo from 2 provinces. We measured biomarkers of nutritional and inflammation status and malaria. Pyrosequencing was used to detect sickle cell variants. Polymerase chain reaction was used to detect G6PD variants and α-thalassemia deletions.Results: Overall, 11% of children had a sickle cell variant, 19% of boys were G6PD A- hemizygotes, 12% and 10% of girls were G6PD A- hetero- or homozygotes, respectively, and 12% of children had α-thalassemia. Multivariable linear regression models (adjusted for age, province, altitude, malaria, and biomarkers of nutritional and inflammation status) showed that G6PD A- hemizygous boys and G6PD 376 homozygous girls had higher sTfR concentrations [geometric mean ratios (95% CIs): 1.20 (1.03, 1.39) and 1.25 (1.02, 1.53), respectively] than children with no G6PD variants. Hemoglobin and ferritin concentrations were not independently associated with any of the inherited blood disorder genotypes.Conclusions: We found that 2 G6PD variant genotypes were associated with elevated sTfR concentrations, which limits the accuracy of sTfR as a biomarker of iron status in this population.

The effect of inflammation on serum zinc concentrations and the prevalence estimates of population-level zinc status among Congolese children aged 6-59 months

BACKGROUND/OBJECTIVES

Zinc is a negative acute-phase reactant; hence, its concentration decreases in the presence of inflammation. There is no current consensus on how to control for the effect of inflammation on serum zinc, which has implications for accurate estimates of population-level zinc status. We aimed to measure the association between inflammation and serum zinc concentrations and to compare the means and the prevalence of zinc deficiency using unadjusted and inflammation-adjusted serum zinc concentrations among Congolese children.

SUBJECTS/METHODS

Non-fasting blood was collected in the afternoon in trace element-free vacutainers from 744 apparently healthy children aged 6-59 months in the Democratic Republic of the Congo. Serum was analyzed for zinc, C-reactive protein (CRP) and α-1 acid glycoprotein (AGP) for 665 children with complete data for all three biomarkers. Linear regression was used to generate correction factors (CFs) based on three stages of inflammation: incubation (CRP >5 mg/l and normal AGP), early convalescence (CRP >5 mg/l and AGP >1 g/l) and late convalescence (AGP >1 g/l and normal CRP), relative to no inflammation.

RESULTS

Overall unadjusted mean±s.d. serum zinc concentration was 9.4±2.1 μmol/l. Study-generated CFs (95% confidence interval) for incubation, early and late convalescence were 1.01 (0.88, 1.14), 1.15 (1.11, 1.21) and 1.07 (1.03, 1.11), respectively. After applying the CFs, overall adjusted mean±s.d. serum zinc concentration was 10.1±2.2 μmol/l, and prevalence of zinc deficiency (<8.7 μmol/l) decreased from 35% (n=234/665) to 24% (n=160/665).

CONCLUSIONS

Adjustment of zinc concentrations for inflammation is warranted when assessing population-level zinc status.European Journal of Clinical Nutrition advance online publication, 23 August 2017; doi:10.1038/ejcn.2017.127.

Prevalence of Iron Deficiency and Iron Deficiency Anemia in the Northern and Southern Provinces of Rwanda

Background

Anemia remains a public health problem in Rwanda, affecting 38% of young children and 17% of reproductive-aged women (Demographic and Health Survey [DHS] 2010). The importance of iron deficiency (ID) as a cause of anemia in Rwanda is not known.

Objective

We aimed to estimate the prevalence of ID and iron deficiency anemia (IDA) among young children and women in 2 provinces of Rwanda.

Methods

We conducted a cluster randomized survey, selecting 408 rural households each in the Northern and Southern Provinces of Rwanda in 2010. Anemia was defined as hemoglobin <110 g/L in children and <120 g/L in nonpregnant women after correction for altitude. We defined ID as (1) serum transferrin receptor (TfR) >8.3 mg/L or (2) serum ferritin (SF) <12 µg/L in children and <15 µg/L in nonpregnant women after correction for inflammation.

Results

The prevalence of anemia was 30.9% (95% confidence interval [CI], 26.4-35.8) in children (n = 577) and 11.2% (95% CI, 8.4-14.7) in women (n = 595). The prevalence of ID in children was 3.1% (95% CI, 1.8-5.1) as defined by high TfR and 5.9% (95% CI, 4.0-8.4) as defined by low SF. Similarly, 3.0% (95% CI, 1.8-4.8) of women had high TfR and 4.8% (95% CI, 3.2-7.2) had low SF. The prevalence of IDA (low SF with concurrent anemia) ranged from 1.4% (95% CI, 0.5-3.6) among women in the North to 5.6% (95% CI, 3.1-10.0) among children in the South.

Conclusions

ID is likely not an important contributor to anemia in the Northern and Southern Provinces of Rwanda. This finding warrants further investigation into other causes of anemia.

The effect of oral iron with or without multiple micronutrients on hemoglobin concentration and hemoglobin response among nonpregnant Cambodian women of reproductive age: a 2 x 2 factorial, double-blind, randomized controlled supplementation trial

Background: Despite a high prevalence of anemia among nonpregnant Cambodian women, current reports suggest that iron deficiency (ID) prevalence is low. If true, iron supplementation will not be an effective anemia reduction strategy.Objective: We measured the effect of daily oral iron with or without multiple micronutrients (MMNs) on hemoglobin concentration in nonpregnant Cambodian women screened as anemic.Design: In this 2 × 2 factorial, double-blind, randomized trial, nonpregnant women (aged 18-45 y) with hemoglobin concentrations ≤117 g/L (capillary blood) were recruited from 26 villages in Kampong Chhnang province and randomly assigned to receive 12 wk of iron (60 mg; Fe group), MMNs (14 other micronutrients; MMN group), iron plus MMNs (Fe+MMN group), or placebo capsules. A 2 × 2 factorial intention-to-treat analysis with the use of a generalized mixed-effects model was used to assess the effects of iron and MMNs and the interaction between these factors. Results: In July 2015, 809 women were recruited and 760 (94%) completed the trial. Baseline anemia prevalence was 58% (venous blood). Mean (95% CI) hemoglobin concentrations at 12 wk in the Fe, MMN, Fe+MMN, and placebo groups were 121 (120, 121), 116 (116, 117), 123 (122, 123), and 116 (116, 117) g/L, with no iron × MMN interaction (P = 0.66). Mean (95% CI) increases in hemoglobin were 5.6 g/L (3.8, 7.4 g/L) (P < 0.001) among women who received iron (n = 407) and 1.2 g/L (-0.6, 3.0 g/L) (P = 0.18) among women who received MMNs (n = 407). The predicted proportions (95% CIs) of women with a hemoglobin response (≥10 g/L at 12 wk) were 19% (14%, 24%), 9% (5%, 12%), 30% (24%, 35%), and 5% (2%, 9%) in the Fe, MMN, Fe+MMN, and placebo groups, respectively.Conclusions: Daily iron supplementation for 12 wk increased hemoglobin in nonpregnant Cambodian women; however, MMNs did not confer additional significant benefit. Overall, ∼24% of women who received iron responded after 12 wk; even fewer would be likely to respond in the wider population. This trial was registered at clinicaltrials.gov as NCT02481375.

Predictors of anemia in preschool children: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Background: A lack of information on the etiology of anemia has hampered the design and monitoring of anemia-control efforts.Objective: We aimed to evaluate predictors of anemia in preschool children (PSC) (age range: 6-59 mo) by country and infection-burden category.Design: Cross-sectional data from 16 surveys (n = 29,293) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed separately and pooled by category of infection burden. We assessed relations between anemia (hemoglobin concentration <110 g/L) and severe anemia (hemoglobin concentration <70 g/L) and individual-level (age, anthropometric measures, micronutrient deficiencies, malaria, and inflammation) and household-level predictors; we also examined the proportion of anemia with concomitant iron deficiency (defined as an inflammation-adjusted ferritin concentration <12 μg/L). Countries were grouped into 4 categories on the basis of risk and burden of infectious disease, and a pooled multivariable logistic regression analysis was conducted for each group.Results: Iron deficiency, malaria, breastfeeding, stunting, underweight, inflammation, low socioeconomic status, and poor sanitation were each associated with anemia in >50% of surveys. Associations between breastfeeding and anemia were attenuated by controlling for child age, which was negatively associated with anemia. The most consistent predictors of severe anemia were malaria, poor sanitation, and underweight. In multivariable pooled models, child age, iron deficiency, and stunting independently predicted anemia and severe anemia. Inflammation was generally associated with anemia in the high- and very high-infection groups but not in the low- and medium-infection groups. In PSC with anemia, 50%, 30%, 55%, and 58% of children had concomitant iron deficiency in low-, medium-, high-, and very high-infection categories, respectively.Conclusions: Although causal inference is limited by cross-sectional survey data, results suggest anemia-control programs should address both iron deficiency and infections. The relative importance of factors that are associated with anemia varies by setting, and thus, country-specific data are needed to guide programs.

Predictors of anemia in women of reproductive age: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Background: Anemia in women of reproductive age (WRA) (age range: 15-49 y) remains a public health problem globally, and reducing anemia in women by 50% by 2025 is a goal of the World Health Assembly.Objective: We assessed the associations between anemia and multiple proximal risk factors (e.g., iron and vitamin A deficiencies, inflammation, malaria, and body mass index) and distal risk factors (e.g., education status, household sanitation and hygiene, and urban or rural residence) in nonpregnant WRA.Design: Cross-sectional, nationally representative data from 10 surveys (n = 27,018) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and pooled by the infection burden and risk in the country. We examined the severity of anemia and measured the bivariate associations between anemia and factors at the country level and by infection burden, which we classified with the use of the national prevalences of malaria, HIV, schistosomiasis, sanitation, and water-quality indicators. Pooled multivariate logistic regression models were constructed for each infection-burden category to identify independent determinants of anemia (hemoglobin concertation <120 g/L).Results: Anemia prevalence was ∼40% in countries with a high infection burden and 12% and 7% in countries with moderate and low infection burdens, respectively. Iron deficiency was consistently associated with anemia in multivariate models, but the proportion of anemic women who were iron deficient was considerably lower in the high-infection group (35%) than in the moderate- and low-infection groups (65% and 71%, respectively). In the multivariate analysis, inflammation, vitamin A insufficiency, socioeconomic status, and age were also significantly associated with anemia, but malaria and vitamin B-12 and folate deficiencies were not.Conclusions: The contribution of iron deficiency to anemia varies according to a country's infection burden. Anemia-reduction programs for WRA can be improved by considering the underlying infection burden of the population and by assessing the overlap of micronutrient deficiencies and anemia.

Comparison of four immunoassays to measure serum ferritin concentrations and iron deficiency prevalence among non-pregnant Cambodian women and Congolese children

BACKGROUND

Global standardization of ferritin assays is lacking, which could have direct implications on the accurate measurement and comparability of ferritin concentration and iron deficiency (ID) prevalence rates in at-risk populations.

METHODS

We measured serum ferritin concentrations using four immunoassays: the s-ELISA and the AxSYM™ analyzer were compared among 420 non-pregnant Cambodian women; the Centaur® XP analyzer, s-ELISA, and AxSYM™ analyzer were compared among a subset of 100 Cambodian women; and the s-ELISA and the Elecsys® 2010 analyzer were compared among 226 Congolese children aged 6-59 months.

RESULTS

Median ferritin concentrations (adjusted for inflammation) ranged between 48 and 91 μg/L among Cambodian women and between 54 and 55 μg/L among Congolese children. ID prevalence ranged from 2% to 10% among Cambodian women and 5% to 7% among Congolese children. Bias between methods varied widely (-9 to 45 μg/L) among women, and was 43 μg/L among children. Bias was lower when ferritin values outside of the s-ELISA measurement range (>250 μg/L) were excluded.

CONCLUSIONS

The observed differences in ferritin concentrations likely reflect different ferritin isoforms, antibodies, and calibrators used across assays and by different laboratories. However, despite differences in ferritin concentrations, ID prevalence was relatively similar and low across all methods.