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Yunus FM, Jalal C, Das A, Afsana K, Podder R, Vandenberg A, DellaValle DM. Consumption of Iron-Fortified Lentils Is Protective against Declining Iron Status among Adolescent Girls in Bangladesh: Evidence from a Community-Based Double-Blind, Cluster-Randomized Controlled Trial. J Nutr 2024:S0022-3166(24)00153-6. [PMID: 38458577 DOI: 10.1016/j.tjnut.2024.03.005] [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: 10/18/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND In many low-income countries, iron deficiency (ID) and its anemia (IDA) pose significant health challenges, particularly among females and girls. Finding sustainable and effective solutions to address this issue is critical. OBJECTIVES This study aimed to evaluate the efficacy of incorporating iron-fortified lentils (IFLs) into the diets of rural Bangladeshi adolescent girls on their body iron (Fe) status. METHODS A community-based, double-blind, cluster-randomized controlled trial involved n = 1195 girls aged 10-17 y. A total of 48 adolescent clubs (n = ∼27 girls each) were randomized into 3 groups: 1) 200 g cooked IFLs, 2) 200 g cooked noniron-fortified lentils (NIFLs), and 3) a control group with no lentils (usual dietary intake). The intervention, administered 5 days a week for 85 feeding days, provided ∼8.625 mg Fe from each serving of IFLs and 2.625 mg from NIFLs. Blood samples collected at baseline, midpoint (42 feeding days), and endpoint (85 feeding days) assessed key Fe and inflammation biomarkers. Statistical analyses were filtered for inflammation. RESULTS Although all groups experienced a decline in Fe status over time, the IFL group exhibited a significantly reduced decline in serum ferritin (sFer -7.2 μg/L), and total body iron (TBI -0.48 mg/kg) level compared with NIFL (sFer -14.3 μg/L and TBI -1.36 mg/kg) and usual intake group (sFer -12.8 μg/L and TBI -1.33 mg/kg). Additionally, those in the IFL group had a 57% reduced risk of developing clinical ID (sFer <15 μg/L) compared with the usual intake group. CONCLUSIONS Our findings suggest that incorporating IFLs into the diet can help mitigate a decline in sFer, indicating a positive impact on the body Fe status of adolescent girls. This research underscores the potential role of fortified foods in addressing ID and IDA in vulnerable populations, emphasizing the significance of food-based interventions in public health. TRIAL REGISTRATION NUMBER This trial was registered at the clinicaltrials.gov on May 24, 2018 (https://clinicaltrials.gov/study/NCT03516734?locStr=Bangladesh&country=Bangladesh&distance=50&cond=Anemia&intr=Iron%20fortified%20lentils&rank=1) as NCT03516734.
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Affiliation(s)
- Fakir Md Yunus
- College of Pharmacy and Nutrition, The University of Saskatchewan, Saskatoon, SK, Canada; Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Chowdhury Jalal
- Evaluation and Strategic Research, Nutrition International, Ottawa, ON, Canada
| | - Anupom Das
- Civil Surgeon Office, Ministry of Health and Family Welfare, Jashore, Bangladesh
| | - Kaosar Afsana
- James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Rajib Podder
- College of Agriculture and Bio-resources, The University of Saskatchewan, Saskatoon, SK, Canada
| | - Albert Vandenberg
- College of Agriculture and Bio-resources, The University of Saskatchewan, Saskatoon, SK, Canada
| | - Diane M DellaValle
- Department of Health and Human Performance, King's College, Wilkes-Barre, PA, United States.
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Lowe NM. Fortification or biofortification: complimentary strategies or duplication of effort? Proc Nutr Soc 2024:1-10. [PMID: 38197143 DOI: 10.1017/s0029665124000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Micronutrient deficiencies continue to be a global concern, with the most common deficiencies being vitamin A, iron, zinc and B vitamins (folate and B12). Addressing this requires strategies that are scalable and equitable such that they reach all members of a population irrespective of socioeconomic status and geography. Fortification and biofortification offer potential large-scale solutions, however each have strengths and limitations depending on the context, particularly the cultural and political factors that may create barriers or opportunities for effectiveness. Planning how to target scarce resources for maximum impact requires an in-depth knowledge and understanding of local food systems and market dynamics, alongside strong government policy and legislative support. A food fortification programme was launched in Pakistan in 2016, supported by UK Aid and designed to address the high prevalence of vitamin A, iron and zinc deficiency, particularly in women and children. In the same year, the first zinc biofortified variety of wheat, Zincol-2016, was released in Pakistan, supported and developed through the HarvestPlus programme in collaboration with the Pakistan National Agriculture Research Centre. This review explores the challenges faced by fortification and biofortification, initiated independently, (but around the same time) in Pakistan.
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Affiliation(s)
- Nicola Mary Lowe
- Centre for Global Development, University of Central Lancashire, PrestonPR1 2HE, UK
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Latunde-Dada GO. Iron Intake and Human Health. Nutrients 2024; 16:206. [PMID: 38257099 PMCID: PMC10819490 DOI: 10.3390/nu16020206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
Iron deficiency anemia (IDA) is a global nutritional disorder affecting large population groups in varying magnitudes in different countries [...].
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Affiliation(s)
- Gladys O Latunde-Dada
- Department of Nutritional Sciences, School of Life Course and Population Sciences, King's College London, London SE1 9NH, UK
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Bjørklund G, Semenova Y, Hangan T, Pen JJ, Aaseth J, Peana M. Perspectives on Iron Deficiency as a Cause of Human Disease in Global Public Health. Curr Med Chem 2024; 31:1428-1440. [PMID: 38572614 DOI: 10.2174/0929867330666230324154606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 11/23/2022] [Accepted: 12/13/2022] [Indexed: 04/05/2024]
Abstract
Iron (Fe) is a necessary trace element in numerous pathways of human metabolism. Therefore, Fe deficiency is capable of causing multiple health problems. Apart from the well-known microcytic anemia, lack of Fe can cause severe psychomotor disorders in children, pregnant women, and adults in general. Iron deficiency is a global health issue, mainly caused by dietary deficiency but aggravated by inflammatory conditions. The challenges related to this deficiency need to be addressed on national and international levels. This review aims to summarize briefly the disease burden caused by Fe deficiency in the context of global public health and aspires to offer some hands-on guidelines.
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Affiliation(s)
- Geir Bjørklund
- Department of Research, Council for Nutritional and Environmental Medicine (CONEM), Mo i Rana, Norway
| | - Yuliya Semenova
- Department of Surgery, Nazarbayev University School of Medicine, Astana, Kazakhstan
| | - Tony Hangan
- Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania
| | - Joeri J Pen
- Department of Nutrition, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Diabetes Clinic, Department of Internal Medicine, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jan Aaseth
- Research Department, Innlandet Hospital, Brumunddal, Norway
- Inland Norway University of Applied Sciences, Elverum, Norway
| | - Massimiliano Peana
- Department of Chemical, Physical, Mathematical and Natural Sciences, University of Sassari, Sassari, Italy
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Loechl CU, Datta-Mitra A, Fenlason L, Green R, Hackl L, Itzkowitz L, Koso-Thomas M, Moorthy D, Owino VO, Pachón H, Stoffel N, Zimmerman MB, Raiten DJ. Approaches to Address the Anemia Challenge. J Nutr 2023; 153 Suppl 1:S42-S59. [PMID: 37714779 PMCID: PMC10797550 DOI: 10.1016/j.tjnut.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 09/17/2023] Open
Abstract
Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.
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Affiliation(s)
- Cornelia U Loechl
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Ananya Datta-Mitra
- Department of Pathology and Laboratory Medicine, University of California, Davis, Davis, CA, United States
| | - Lindy Fenlason
- Bureau for Global Health, USAID, Washington, DC, United States
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, Davis, CA, United States
| | - Laura Hackl
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, United States
| | - Laura Itzkowitz
- Bureau for Global Health, USAID, Washington, DC, United States
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, Unites States
| | - Denish Moorthy
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, United States.
| | | | - Helena Pachón
- Food Fortification Initiative, Emory University, Atlanta, GA, United States
| | - Nicole Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Zu¨rich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Michael B Zimmerman
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, Unites States
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Jalal CS, De-Regil LM, Pike V, Mithra P. Fortification of condiments and seasonings with iron for preventing anaemia and improving health. Cochrane Database Syst Rev 2023; 9:CD009604. [PMID: 37665781 PMCID: PMC10472972 DOI: 10.1002/14651858.cd009604.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
BACKGROUND Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well-being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used. OBJECTIVES To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health-related outcomes in the general population. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non-randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before-after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co-morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used. DATA COLLECTION AND ANALYSIS Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence. MAIN RESULTS Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper-middle- and lower-middle-income countries. Three studies were controlled before-after studies, one was non-randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a "seasoning powder". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta-analysis. Six trials compared iron-fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low-certainty of evidence). We are uncertain about whether consuming iron-fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI -0.62 to 13.41; 2808 participants; 5 studies; very low-certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate-certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low-certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low-certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low-certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low-certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low -certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials. AUTHORS' CONCLUSIONS We are uncertain whether consuming iron-fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron-fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear.
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Affiliation(s)
| | - Luz Maria De-Regil
- Department of Nutrition and Food Safety, World Health Organisation, Geneva, Switzerland
| | - Vanessa Pike
- Global Technical Services, Nutrition International, Ottawa, Canada
- Canadian Foodgrains Bank, Winnipeg, Canada
| | - Prasanna Mithra
- Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
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Venugopal G, Khan ZH, Dash R, Tulsian V, Agrawal S, Rout S, Mahajan P, Ramadass B. Predictive association of gut microbiome and NLR in anemic low middle-income population of Odisha- a cross-sectional study. Front Nutr 2023; 10:1200688. [PMID: 37528994 PMCID: PMC10390256 DOI: 10.3389/fnut.2023.1200688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/27/2023] [Indexed: 08/03/2023] Open
Abstract
Background Iron is abundant on earth but not readily available for colonizing bacteria due to its low solubility in the human body. Hosts and microbiota compete fiercely for iron. <15% Supplemented Iron is absorbed in the small bowel, and the remaining iron is a source of dysbiosis. The gut microbiome signatures to the level of predicting anemia among low-middle-income populations are unknown. The present study was conducted to identify gut microbiome signatures that have predictive potential in association with Neutrophil to lymphocytes ratio (NLR) and Mean corpuscular volume (MCV) in anemia. Methods One hundred and four participants between 10 and 70 years were recruited from Odisha's Low Middle-Income (LMI) rural population. Hematological parameters such as Hemoglobin (HGB), NLR, and MCV were measured, and NLR was categorized using percentiles. The microbiome signatures were analyzed from 61 anemic and 43 non-anemic participants using 16 s rRNA sequencing, followed by the Bioinformatics analysis performed to identify the diversity, correlations, and indicator species. The Multi-Layered Perceptron Neural Network (MLPNN) model were applied to predict anemia. Results Significant microbiome diversity among anemic participants was observed between the lower, middle, and upper Quartile NLR groups. For anemic participants with NLR in the lower quartile, alpha indices indicated bacterial overgrowth, and consistently, we identified R. faecis and B. uniformis were predominating. Using ROC analysis, R. faecis had better distinction (AUC = 0.803) to predict anemia with lower NLR. In contrast, E. biforme and H. parainfluenzae were indicators of the NLR in the middle and upper quartile, respectively. While in Non-anemic participants with low MCV, the bacterial alteration was inversely related to gender. Furthermore, our Multi-Layered Perceptron Neural Network (MLPNN) models also provided 89% accuracy in predicting Anemic or Non-Anemic from the top 20 OTUs, HGB level, NLR, MCV, and indicator species. Conclusion These findings strongly associate anemic hematological parameters and microbiome. Such predictive association between the gut microbiome and NLR could be further evaluated and utilized to design precision nutrition models and to predict Iron supplementation and dietary intervention responses in both community and clinical settings.
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Affiliation(s)
- Giriprasad Venugopal
- Center of Excellence for Clinical Microbiome Research (CCMR), All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Zaiba Hasan Khan
- Center of Excellence for Clinical Microbiome Research (CCMR), All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Rishikesh Dash
- Center of Excellence for Clinical Microbiome Research (CCMR), All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Vinay Tulsian
- Center of Excellence for Clinical Microbiome Research (CCMR), All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Siwani Agrawal
- Department of Biochemistry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sudeshna Rout
- Department of Biochemistry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Preetam Mahajan
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Balamurugan Ramadass
- Center of Excellence for Clinical Microbiome Research (CCMR), All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
- Department of Biochemistry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
- Adelaide Medical School Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
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Assakran BS, Khalid R, Bennasser T, Alsaif M, Alsawyan W, Alsaleem H, Alsalhi A. Prevalence and Risk Factors of Anemia in Patients After Bariatric Surgery in Qassim Region, King Fahad Specialist Hospital. Cureus 2023; 15:e40131. [PMID: 37435259 PMCID: PMC10332640 DOI: 10.7759/cureus.40131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction There is a high prevalence of obesity among the Saudi population. Anemia due to iron deficiency or an inflammatory state is often associated with obesity. Multiple nutritional deficiencies are associated with bariatric surgeries, with anemia being one of the commonest causes. Aim This study aimed to evaluate the prevalence of anemia after bariatric surgery among patients in the Qassim Region, Saudi Arabia. Patients and methods This retrospective cohort study was conducted at King Fahad Specialist Hospital Al-Qassim (Buraydah), Saudi Arabia. We reviewed data from patients' records who underwent bariatric surgeries from January 2018 to January 2021. By using a structured data collection form, we collected data such as demographic variables, surgery perioperative-related data, postoperative complications and interventions, type of transfusion required after surgery, postoperative medications and/or supplements and duration, and blood count indices. Results Of the 520 patients who underwent bariatric surgery, 61% were females, and 31.7% were aged between 26 to 35 years old. The most prominent type of bariatric surgery was sleeve gastrectomy (97.1%). The prevalence of anemia among patients who underwent bariatric surgery was 28.1%. Independent risk factors for anemia were female gender, microcytic red blood cells, and low normal hematocrit and hemoglobin (Hgb) levels. It is interesting to know that sleeve gastrectomy and elevated BMI levels are considered to be the protective factors for developing anemia postoperatively. Conclusion There was a high prevalence of anemia among bariatric patients postoperatively. Female gender with decreasing hematocrit and hemoglobin levels after the surgery might be more at the receiving end for developing anemia than the other patients. Further longitudinal studies are needed to establish the prevalence and risk factors for developing anemia among bariatric surgery patients.
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Affiliation(s)
| | - Renad Khalid
- College of Medicine, Qassim University, Buraydah, SAU
| | | | - Maha Alsaif
- College of Medicine, Qassim University, Buraydah, SAU
| | | | | | - Ahlam Alsalhi
- Family Medicine, Primary Health Care Al Muntazah, Buraydah, SAU
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Srivarathan S, Addepalli R, Adiamo OQ, Kodagoda GK, Phan ADT, Wright ORL, Sultanbawa Y, Osborne S, Netzel ME. Edible Halophytes with Functional Properties: In Vitro Protein Digestibility and Bioaccessibility and Intestinal Absorption of Minerals and Trace Elements from Australian Indigenous Halophytes. Molecules 2023; 28:molecules28104004. [PMID: 37241743 DOI: 10.3390/molecules28104004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/28/2023] Open
Abstract
Halophytes are considered emerging functional foods as they are high in protein, minerals, and trace elements, although studies investigating halophyte digestibility, bioaccessibility, and intestinal absorption are limited. Therefore, this study investigated the in vitro protein digestibility, bioaccessibility and intestinal absorption of minerals and trace elements in saltbush and samphire, two important Australian indigenous halophytes. The total amino acid contents of samphire and saltbush were 42.5 and 87.3 mg/g DW, and even though saltbush had a higher total protein content overall, the in vitro digestibility of samphire protein was higher than the saltbush protein. The in vitro bioaccessibility of Mg, Fe, and Zn was higher in freeze-dried halophyte powder compared to the halophyte test food, suggesting that the food matrix has a significant impact on mineral and trace element bioaccessibility. However, the samphire test food digesta had the highest intestinal Fe absorption rate, whereas the saltbush digesta exhibited the lowest (37.7 vs. 8.9 ng/mL ferritin). The present study provides crucial data about the digestive "fate" of halophyte protein, minerals, and trace elements and increases the understanding of these underutilized indigenous edible plants as future functional foods.
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Affiliation(s)
- Sukirtha Srivarathan
- ARC Industrial Transformation Training Centre for Uniquely Australian Foods, Queensland Alliance for Agriculture and Food Innovation (QAAFI), The University of Queensland, Indooroopilly, QLD 4068, Australia
- Department of Biosystems Technology, Faculty of Technology, University of Jaffna, Ariviyal Nagar, Kilinochchi 44000, Sri Lanka
| | - Rama Addepalli
- Commonwealth Scientific and Industrial Research Organization (CSIRO), Agriculture and Food, St Lucia, QLD 4067, Australia
| | - Oladipupo Qudus Adiamo
- ARC Industrial Transformation Training Centre for Uniquely Australian Foods, Queensland Alliance for Agriculture and Food Innovation (QAAFI), The University of Queensland, Indooroopilly, QLD 4068, Australia
| | - Gethmini Kavindya Kodagoda
- ARC Industrial Transformation Training Centre for Uniquely Australian Foods, Queensland Alliance for Agriculture and Food Innovation (QAAFI), The University of Queensland, Indooroopilly, QLD 4068, Australia
| | - Anh Dao Thi Phan
- ARC Industrial Transformation Training Centre for Uniquely Australian Foods, Queensland Alliance for Agriculture and Food Innovation (QAAFI), The University of Queensland, Indooroopilly, QLD 4068, Australia
| | - Olivia Renee Louise Wright
- ARC Industrial Transformation Training Centre for Uniquely Australian Foods, Queensland Alliance for Agriculture and Food Innovation (QAAFI), The University of Queensland, Indooroopilly, QLD 4068, Australia
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, QLD 4072, Australia
| | - Yasmina Sultanbawa
- ARC Industrial Transformation Training Centre for Uniquely Australian Foods, Queensland Alliance for Agriculture and Food Innovation (QAAFI), The University of Queensland, Indooroopilly, QLD 4068, Australia
| | - Simone Osborne
- Commonwealth Scientific and Industrial Research Organization (CSIRO), Agriculture and Food, St Lucia, QLD 4067, Australia
| | - Michael Erich Netzel
- ARC Industrial Transformation Training Centre for Uniquely Australian Foods, Queensland Alliance for Agriculture and Food Innovation (QAAFI), The University of Queensland, Indooroopilly, QLD 4068, Australia
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Diniz Largueza CB, Mocellin MC, Nunes JC, Ribas SA. Effect of intake of iron-fortified milk on levels of ferritin and hemoglobin in preschoolers: A systematic review and meta-analysis. Clin Nutr ESPEN 2023; 54:1-11. [PMID: 36963849 DOI: 10.1016/j.clnesp.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/21/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Abstract
BACKGROUND Food fortification is often the simplest way to increase iron intake on a broad and sustainable basis. It is one of the most cost-effective global development efforts. OBJECTIVE To systematize data from randomized and nonrandomized controlled trials investigating the effect of consumption of iron-fortified milk (IFM) on serum iron status in preschoolers. METHODS The trials were systematically searched in five electronic databases that evaluated the effect of iron-fortified milk (IFM) consumption on hemoglobin and ferritin in children aged 1-6 years. The randomized the meta-analysis model was used to calculate total and stratified effects. RESULTS Seven trials representing 1210 preschoolers showed a significant effect of IFM on hemoglobin [difference in means (MD) 0.33 g/dL (95% CI 0.23, 0.44; I2 = 3.85%, p (Q statistic) < 0.01)] and ferritin concentrations [effect size (SMD) 0.57 (95% CI 0.19, 0.95; I2 = 84.63%, p (Q statistic) < 0.01)]. In stratified analyses, hemoglobin showed an increase when subjects received iron with other co-interventions [MD 0.35 g/dL (95% CI 0.22, 0.48; I2 = 11.01%; p (Q statistic) = 0.36)]; and when the iron dose was above 5 mg/day [MD 0.34 g/dL (95% CI 0.23, 0.45; I2 = 2.33%; p (Q statistic) = 0.37)] and the intervention time was over 6 months [MD 0.39 g/dL (95% CI 0.18, 0.60; I2 = 37.90%; p (Q statistic) = 0.20)]. For ferritin, stratified analyses showed a larger effect size when they used dose higher than 5 mg/day [SMD 0.60 (95% CI 0.02, 1.18; I2 = 91.06, p (Q statistic) < 0.01)] and intervention was conducted longer than 6 months [SMD 0.96 (95% CI - 0.16, 1.76; I2 = 93.38%, p (Q statistic) < 0.01)]. CONCLUSIONS Our findings indicate that although milk iron fortification modestly increases serum hemoglobin levels or the effect size of serum ferritin of participants, it cannot be considered in the coadjuvant treatment for anemia. Register: CRD42020213604.
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Affiliation(s)
- Caroline Bekman Diniz Largueza
- Postgraduate Program in Food and Nutritional Security, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Michel Carlos Mocellin
- Fundamental Nutrition Department, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juliana Côrtes Nunes
- Post-graduate Program in Food and Nutritional Security, Food Science Department, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone Augusta Ribas
- Post-graduate Program in Food and Nutritional Security, Program in Food and Nutritional Security, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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11
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Adetola OY, Taylor JRN, Duodu KG. Can consumption of local micronutrient- and absorption enhancer-rich plant foods together with starchy staples improve bioavailable iron and zinc in diets of at-risk African populations? Int J Food Sci Nutr 2023; 74:188-208. [PMID: 36843328 DOI: 10.1080/09637486.2023.2182740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Iron and zinc deficiencies remain prevalent in developing countries, often due to monotonous starchy diets that are low in bioavailable minerals. This review addresses the question as to whether consumption of starchy staple foods in Africa together with micronutrient-dense and absorption enhancer-rich plant foods can enhance iron and zinc bioavailability in the diets of at-risk populations. While green leafy vegetables (GLVs) fortification of starchy staples can improve mineral contents, especially iron, it may not improve bioavailable iron and zinc, due to GLVs' high contents of mineral absorption inhibitors, notably polyphenols, phytate and calcium. Fruits, although low in minerals, could improve bioavailable iron and zinc in the staples because of their high ascorbic and citric acid and/or β-carotene contents, which can form soluble chelates with the minerals. More human studies are needed to establish whether such a technology or fortification strategy can improve bioavailable iron and zinc in African-type plant-based diets.
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Affiliation(s)
- Oluyimika Y Adetola
- Department of Consumer and Food Sciences, University of Pretoria, Hatfield, South Africa
| | - John R N Taylor
- Department of Consumer and Food Sciences, University of Pretoria, Hatfield, South Africa
| | - K G Duodu
- Department of Consumer and Food Sciences, University of Pretoria, Hatfield, South Africa
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12
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Wrottesley SV, Mates E, Brennan E, Bijalwan V, Menezes R, Ray S, Ali Z, Yarparvar A, Sharma D, Lelijveld N. Nutritional status of school-age children and adolescents in low- and middle-income countries across seven global regions: a synthesis of scoping reviews. Public Health Nutr 2023; 26:63-95. [PMID: 35156607 PMCID: PMC11077463 DOI: 10.1017/s1368980022000350] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 01/12/2022] [Accepted: 02/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To summarise available evidence on the nutritional status of school-age children and adolescents (5-19 years) from seven global regions and on interventions implemented to improve malnutrition in this population. SETTING Global. DESIGN Findings were compiled from seven scoping literature reviews, including data from low- and middle-income countries within the following UNICEF-defined global regions: East Asia and Pacific; Europe and Central Asia; South Asia; West and Central Africa; Eastern and Southern Africa; Middle East and North Africa and Latin America and the Caribbean. RESULTS A double burden of malnutrition was evident across the world regions reviewed: stunting, thinness, anaemia and other micronutrient deficiencies persisted, alongside rising overweight and obesity prevalence. Transitions towards diets increasingly high in energy-dense, processed and micronutrient-poor foods were observed. Evidence from intervention studies was limited, but suggested that providing multiple micronutrient-fortified foods or beverages at school may effectively target micronutrient deficiencies and facilitate weight gain in undernourished populations. Interventions to prevent or manage overweight and obesity were even more limited. There was minimal evidence of using novel technological approaches to engage school-age children and adolescents, or of involving them in designing interventions. CONCLUSION The limited data available on nutrition of school-age children and adolescents are neither standardised nor comparable. Consensus on methods for assessing nutritional status and its determinants for this age group is urgently needed to set targets and monitor progress. Additionally, strategies are required to ensure that nutritious, safe and sustainable diets are available, affordable and appealing.
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Affiliation(s)
- Stephanie V Wrottesley
- Emergency Nutrition Network (ENN), 2nd Floor, 69 High St, Marlborough House, Kidlington, OxfordshireOX5 2DN, UK
| | - Emily Mates
- Emergency Nutrition Network (ENN), 2nd Floor, 69 High St, Marlborough House, Kidlington, OxfordshireOX5 2DN, UK
| | - Eilise Brennan
- Emergency Nutrition Network (ENN), 2nd Floor, 69 High St, Marlborough House, Kidlington, OxfordshireOX5 2DN, UK
| | - Vasundhara Bijalwan
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Rachael Menezes
- Emergency Nutrition Network (ENN), 2nd Floor, 69 High St, Marlborough House, Kidlington, OxfordshireOX5 2DN, UK
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephanie Ray
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Zakari Ali
- Emergency Nutrition Network (ENN), 2nd Floor, 69 High St, Marlborough House, Kidlington, OxfordshireOX5 2DN, UK
- Nutrition Theme, MRC Unit The Gambia, London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | | | | | - Natasha Lelijveld
- Emergency Nutrition Network (ENN), 2nd Floor, 69 High St, Marlborough House, Kidlington, OxfordshireOX5 2DN, UK
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Tolerability of Oral Supplementation with Microencapsulated Ferric Saccharate Compared to Ferrous Sulphate in Healthy Premenopausal Woman: A Crossover, Randomized, Double-Blind Clinical Trial. Int J Mol Sci 2022; 23:ijms232012282. [PMID: 36293136 PMCID: PMC9603338 DOI: 10.3390/ijms232012282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022] Open
Abstract
A single-center, crossover, randomized, double-blind, and controlled clinical study was conducted to assess the tolerability profile, especially with regard to gastrointestinal complaints, of oral supplementation with AB-Fortis®, a microencapsulated ferric saccharate (MFS), as compared with conventional ferrous sulphate (FS) in healthy premenopausal women. A dose of 60 mg/day of elemental iron was used. The test products were administered for 14 consecutive days with a washout period of two menstrual episodes and a minimum of one month between the two intervention periods. The subjects completed simple-to-answer questionnaires daily for 14 days during both the intervention and the washout periods, capturing the symptoms associated with oral iron supplementation and overall health aspects. Following product consumption, the incidences of symptoms, numbers of complaints/symptoms, overall intensity, and total days with symptoms were found to be significantly higher for FS consumption as compared to MFS. The better tolerability profile of MFS over FS was further substantiated when both products were compared to a real-life setting (i.e., the washout period). Overall, the administration of both study products was safe with no serious or significant adverse events reported. In summary, the current study shows the better tolerability of the MFS preparation when compared to that of the FS, presenting MFS as a well-tolerated and safe option for improving iron nutrition.
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14
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Gasong LS, Damayanthi E, Marliyati SA, Martianto D. Formulation and Effect of Iron Fortified Instant Bose Corn on Addressing Anemia among Adolescent Girls in Kupang, Indonesia. Prev Nutr Food Sci 2022; 27:276-281. [PMID: 36313062 PMCID: PMC9585402 DOI: 10.3746/pnf.2022.27.3.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This study aimed to develop Fe-fortified instant Bose corn (IBC), a traditional Timorese food, as a strategy to address anemia among adolescent girls in Kupang, Indonesia. Instant corn and cowpea grits were made to shorten the preparation time with various times of soaking (IBC1=10 min; IBC2=15 min; IBC3=20 min) to select the best formula. The selected IBC was then fortified with NaFeEDTA·3H2O and nutrient content was evaluated. In the intervention study, a pre-post controlled trial was applied to 40 anemic adolescent girls aged 16∼19 years. Subjects with severe anemia (Hb=8.5∼10.4 g/dL) received the fortified selected IBC, whereas those with moderate anemia (Hb=10.5∼11.5 g/dL) received the unfortified selected IBC. A total of 100 g IBC were provided three times/week for 2 months. The hemoglobin and soluble transferrin receptor (sTfR) levels were measured at baseline and endline, respectively. IBC3 produced the highest acceptance level as compared to other formulas. The fortified IBC3 met 127.4% recommended dietary allowances for iron. Moreover, both fortified and unfortified IBC3 significantly increased the hemoglobin levels of adolescent girls with the higher improvement found in the group of fortified IBC3 (1.73±1.21 g/dL; P<0.05). However, the beneficial effects of the fortified IBC3 could not be observed on sTfR levels. Since the effect on Hb levels was significant with less effect, the intervention of IBC3 for only 2 months did not adequate to improve sTfR levels. Nevertheless, this study suggests that Fe-fortified IBC may be effective in preventing anemia among adolescent girls in Kupang, Indonesia.
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Affiliation(s)
- Ludia Simuruk Gasong
- Department of Food Technology, Kupang State Agricultural Polytechnic, Kupang 85148, Indonesia,
Correspondence to Ludia Simuruk Gasong, E-mail:
| | - Evy Damayanthi
- Department of Community Nutrition, Faculty of Human Ecology, IPB University, Bogor 16680, Indonesia
| | - Sri Anna Marliyati
- Department of Community Nutrition, Faculty of Human Ecology, IPB University, Bogor 16680, Indonesia
| | - Drajat Martianto
- Department of Community Nutrition, Faculty of Human Ecology, IPB University, Bogor 16680, Indonesia
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Ghosh S, Thomas T, Pullakhandam R, Nair KM, Sachdev HS, Kurpad AV. A proposed method for defining the required fortification level of micronutrients in foods: An example using iron. Eur J Clin Nutr 2022; 77:436-446. [PMID: 36076065 DOI: 10.1038/s41430-022-01204-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022]
Abstract
In 2006, the WHO published a framework for calculating the desired level of fortification of any micronutrient in any staple food vehicle, to reduce micronutrient malnutrition. This framework set the target median nutrient intake, of the population consuming the fortified food, at the 97.5th percentile of their nutrient requirement distribution; the Probability of Inadequacy (PIA) of the nutrient would then be 2.5%. We argue here that the targeted median nutrient intake should be at Estimated Average Requirement (50th percentile), since the intake distribution will then overlap the requirement distribution in a population that is in homeostasis, resulting in a PIA of 50%. It is also important to recognize that setting the target PIA at 2.5% may put a sizable proportion at risk of adverse consequences associated with exceeding the tolerable upper limit (TUL) of intake. This is a critical departure from the WHO framework. For a population with different age- and sex-groups, the pragmatic way to fix the fortification level for a staple food vehicle is by achieving a target PIA of 50% in the most deprived age- or sex-group of that population, subject to the condition that only a very small proportion of intakes exceed the TUL. The methods described here will aid precision in public health nutrition, to pragmatically determine the precise fortification level of a nutrient in a food vehicle, while balancing risks of inadequacy and excess intake.
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Affiliation(s)
- Santu Ghosh
- Department of Biostatistics, St John's Medical College, Bengaluru, India
| | - Tinku Thomas
- Department of Biostatistics, St John's Medical College, Bengaluru, India
| | - Raghu Pullakhandam
- Drug Safety Division, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Krishnapillai Madhavan Nair
- Former Senior Scientist, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Harshpal S Sachdev
- Senior Consultant Paediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi, India.
| | - Anura V Kurpad
- Department of Physiology, St John's Medical College, Bengaluru, India.
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16
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Knowledge, Attitudes, and Practices Toward Iron-Deficiency Anemia Among Jordanian Women. TOP CLIN NUTR 2022. [DOI: 10.1097/tin.0000000000000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Kunnath AK, Mathew S, Mothadaka MP, Rao RCN. Iron-Enriched Fish Powder Improved Haemoglobin Levels in Adolescent Girls of West Jaintia Hills District of Meghalaya, India. Biol Trace Elem Res 2022; 200:2017-2024. [PMID: 34269974 DOI: 10.1007/s12011-021-02820-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022]
Abstract
This study was carried out to assess the efficacy of sodium iron EDTA (NaFeEDTA) salt-enriched fish powder in addressing iron deficiency in adolescent anaemic girls. This was a 60-day randomised double-blinded, controlled intervention trial involving 123 girls age ranging from 10 to 19 years in three villages of West Jaintia Hills District of State of Meghalaya in India using soup made out of sodium iron EDTA (NaFeEDTA)-enriched fish powder (250 mg/100 g). The influence of the iron-enriched powder on blood haemoglobin levels and serum iron was determined. The research also analysed the food consumed by the study subjects during the study period and it was found that there were no significant differences between the iron-enriched and control groups. The results indicated that the girls predominantly consumed cereals with little fruits, vegetables and meat. On an average, 100 ml of soup prepared out of 10 g of fish powder per day was consumed that theoretically provided about 25 mg of iron each day. Following intervention, all the participants in the group that consumed soup made out of NaFeEDTA-enriched fish powder had significantly higher haemoglobin levels and serum iron and a lower prevalence of anaemia than the control group. The effects of NaFeEDTA salt-enriched fish powder were statistically significant and it can be inferred that NaFeEDTA-enriched fish powder was highly effective in controlling iron deficiency and reducing the prevalence of iron-deficiency anaemia among the adolescent girls.
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Affiliation(s)
- Asha Kurukkan Kunnath
- ICAR-Central Institute of Fisheries Technology, CIFT Junction, Matsyapuri PO, Cochin, 682029, India.
| | - Suseela Mathew
- ICAR-Central Institute of Fisheries Technology, CIFT Junction, Matsyapuri PO, Cochin, 682029, India
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18
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Baxter JAB, Carducci B, Kamali M, Zlotkin SH, Bhutta ZA. Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status. Cochrane Database Syst Rev 2022; 4:CD013463. [PMID: 35446435 PMCID: PMC9022669 DOI: 10.1002/14651858.cd013463.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low-resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large-scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double-fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. OBJECTIVES: To assess the effect of double-fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. SELECTION CRITERIA All prospective randomised controlled trials (RCTs), including cluster-randomised controlled trials (cRCTs), and controlled before-after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. DATA COLLECTION AND ANALYSIS Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). MAIN RESULTS: We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low-certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD -96.86 μg/L, 95% CI -164.99 to -28.73; 7 studies, 1594 participants; low-certainty evidence), although both salts increased mean urinary iodine concentration above the cut-off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI -0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD -17.27 µg/L, 95% CI -49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD -3.94 µg/L, 95% CI -20.65 to 12.77; 5 studies, 1419 participants; low-certainty evidence) or transferrin receptor concentration (MD -4.68 mg/L, 95% CI -11.67 to 2.31; 5 studies, 1256 participants; low-certainty evidence) compared to IS. However, DFS may reduce zinc protoporphyrin concentration (MD -27.26 µmol/mol, 95% CI -47.49 to -7.03; 3 studies, 921 participants; low-certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low-certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate-certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low-certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. AUTHORS' CONCLUSIONS Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free-living population (non-research population), where there could be an added cost to purchase double-fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status.
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Affiliation(s)
- Jo-Anna B Baxter
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
| | - Bianca Carducci
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Mahdis Kamali
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Offord Centre for Child Studies, Hamilton, Canada
| | - Stanley H Zlotkin
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Munk School of Global Affairs and Public Policy, University of Toronto, Toronto, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Centre of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
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Ensuring the Efficacious Iron Fortification of Foods: A Tale of Two Barriers. Nutrients 2022; 14:nu14081609. [PMID: 35458169 PMCID: PMC9031268 DOI: 10.3390/nu14081609] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Iron fortification of foods has always been a challenge. This is because iron fortification compounds vary widely in relative absorption; because many foods undergo unacceptable changes in color or flavor from the addition of iron; and because many of the iron-fortified foods contain potent inhibitors of iron absorption. These technical barriers have largely been overcome, and efficacious iron-fortified foods, that maintain or improve the iron status of women or children in long-term feeding studies, can be designed. Commercially fortified infant foods are efficacious, and other commercial iron-fortified foods targeted at women and children will provide a useful amount of iron provided the fortification level is adjusted according to the relative absorption of the iron compound. Technologies for the large-scale fortification of wheat and maize flour are also well established, and iron fortification of rice, using the recently developed extruded premix technique, is showing great promise. However, some important knowledge gaps still remain, and further research and development is needed in relation to iron (and iodine)-fortified salt and iron-fortified liquid milk. The usefulness of less-soluble iron compounds, such as ferrous fumarate, to fortify foods for infants and young children in low- and middle-income countries (LMICs) also needs further investigation. A more formidable barrier to efficacious iron-fortified food has been reported in recent years. This is the infection-initiated inflammation barrier, which inhibits iron absorption in response to infection. This barrier is particularly important in LMICs where infections such as malaria and HIV are widespread, and gastrointestinal infections are common due to poor quality water supplies and sanitation. Another source of inflammation in such countries is the high prevalence of obesity in women. Most countries in sub-Saharan Africa have high inflammation which not only decreases the efficacy of iron-fortified and iron-biofortified foods but complicates the monitoring of large-scale iron fortification programs. This is because iron deficiency anemia cannot be differentiated from the more prominent anemia of inflammation and because inflammation confounds the measurement of iron status. There is an urgent need to better quantify the impact of inflammation on the efficacy of iron-fortified foods. However, at present, in LMICs with high inflammation exposure, infection control, cleaner water, improved sanitation, and a decrease in obesity prevalence will undoubtedly have a greater impact on iron status and anemia than the iron fortification of foods.
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Barbosa BST, Garcia-Rojas EE. Double emulsions as delivery systems for iron: Stability kinetics and improved bioaccessibility in infants and adults. Curr Res Food Sci 2022; 5:718-725. [PMID: 35497774 PMCID: PMC9046948 DOI: 10.1016/j.crfs.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/25/2022] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Iron deficiency is one of the main causes of anemia in the world, especially in children and women, so food fortification through microencapsulation is a viable alternative to combat this deficiency. The present work aimed to encapsulate iron in a water-in-oil-in-water double emulsion (W1/O/W2), which was formed with whey protein isolate and polyglycerol polyricinoleate as the emulsifying agents, tara gum as a thickening agent, and sucrose as an osmotic active substance. The double emulsion formed with 12% whey protein isolate, 0.8% tara gum, and 2% sucrose presented high encapsulation efficiency (96.95 ± 1.00%) and good stability (up to 7 days). Additionally, after the in vitro gastrointestinal simulations, the bioaccessibility was high for adults (49.54 ± 5.50%) and infants (39.71 ± 2.33%). Finally, the study show that double emulsions can form stable systems with high iron bioaccessibility even in infant gastric systems, which indicates the possibility of using double emulsions to fortify food with iron. Stable double emulsions were obtained using WPI and PGPR as emulsifiers. Tara gum ensured an increase in the general stability of the emulsion. High bioaccessibility of iron were obtained for adults and infants. Emulsions are presented as a potential alternative to be used in iron-fortified food.
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Affiliation(s)
- Bruno Sérgio Toledo Barbosa
- Programa de Pós-graduação em Ciência e Tecnologia de Alimentos (PPGCTA), Universidade Federal Rural de Rio de Janeiro (UFRRJ), Rodovia BR 465, Km 7, Seropédica, RJ, 23890-000, Brazil
| | - Edwin Elard Garcia-Rojas
- Programa de Pós-graduação em Ciência e Tecnologia de Alimentos (PPGCTA), Universidade Federal Rural de Rio de Janeiro (UFRRJ), Rodovia BR 465, Km 7, Seropédica, RJ, 23890-000, Brazil
- Laboratório de Engenharia e Tecnologia Agroindustrial (LETA), Universidade Federal Fluminense (UFF), Av. Dos Trabalhadores, 420, 27255-125, Volta Redonda, RJ, Brazil
- Corresponding author. Programa de Pós-graduação em Ciência e Tecnologia de Alimentos (PPGCTA), Universidade Federal Rural de Rio de Janeiro (UFRRJ), Rodovia BR 465, Km 7, Seropédica, RJ, 23890-000, Brazil.
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21
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Nuzzo D, Picone P, Lozano Sanchez J, Borras-Linares I, Guiducci A, Muscolino E, Giacomazza D, Sanfilippo T, Guggino R, Bulone D, Dispenza C, San Biagio PL, Lapasin R. Recovery from Food Waste-Biscuit Doughs Enriched with Pomegranate Peel Powder as a Model of Fortified Aliment. BIOLOGY 2022; 11:biology11030416. [PMID: 35336790 PMCID: PMC8945212 DOI: 10.3390/biology11030416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 01/02/2023]
Abstract
The aim of the present work is the characterization of biscuit doughs enriched with pomegranate peel powder (PPP) at 3 (PPP3) and 5 (PPP5) wt% in the prospect of developing a fortified aliment as a support of the therapy of chronic inflammatory diseases of the intestinal tract. The total phenolic content of the powder was preliminarily evaluated. Then, the main compounds present in the PPP were identified by HPLC-ESI-TOF-MS analysis, being mainly hydrolysable tannins. The PPP was then treated at 180 °C for 20 min to mimic the baking treatment, and its water-soluble fraction (PPPwsf) was then added in the Caco-2 cell culture as a model of the intestinal epithelial barrier to verify its dose-dependent toxicity, ability in counteracting the oxidative stress, and anti-inflammatory action. Rheological experiments were performed to predict the macroscopic behavior of the PPP-added doughs during lamination and biscuit baking. SEM investigations gave their contribution to the microscopic comprehension of the dough structure. Finally, a consumer panel composed by thirty volunteers was enrolled to express its opinion on the sensory agreeableness of the biscuits prepared with two different concentrations of PPP compared with the reference dough. The discussion is focused on the biological effects of the main components found in the PPP.
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Affiliation(s)
- Domenico Nuzzo
- Istituto per la Ricerca e l’Innovazione Biomedica, Consiglio Nazionale delle Ricerche, 90146 Palermo, Italy;
- Correspondence: (D.N.); (D.G.); (C.D.)
| | - Pasquale Picone
- Istituto per la Ricerca e l’Innovazione Biomedica, Consiglio Nazionale delle Ricerche, 90146 Palermo, Italy;
| | - Jesus Lozano Sanchez
- Department of Food Science and Nutrition, University of Granada, 18071 Granada, Spain;
- Center of Research and Development of Functional Food, Health Science Technological Park, 18100 Granada, Spain;
| | - Isabel Borras-Linares
- Center of Research and Development of Functional Food, Health Science Technological Park, 18100 Granada, Spain;
| | - Alessandro Guiducci
- IEMEST-Istituto Euro-Mediterraneo di Scienza e Tecnologia, 90139 Palermo, Italy;
| | - Emanuela Muscolino
- Dipartimento di Ingegneria, Università degli Studi di Palermo, 90128 Palermo, Italy;
| | - Daniela Giacomazza
- Istituto di Biofisica, Consiglio Nazionale delle Ricerche, 90146 Palermo, Italy; (D.B.); (P.L.S.B.)
- Correspondence: (D.N.); (D.G.); (C.D.)
| | - Tiziana Sanfilippo
- Anestesia e Rianimazione, Presidio Ospedaliero “Salvatore Cimino”, 90141 Palermo, Italy; (T.S.); (R.G.)
- Ambulatorio di Nutrizione Clinica, ASP Palermo, 90141 Palermo, Italy
| | - Rossella Guggino
- Anestesia e Rianimazione, Presidio Ospedaliero “Salvatore Cimino”, 90141 Palermo, Italy; (T.S.); (R.G.)
- Ambulatorio di Nutrizione Clinica, ASP Palermo, 90141 Palermo, Italy
| | - Donatella Bulone
- Istituto di Biofisica, Consiglio Nazionale delle Ricerche, 90146 Palermo, Italy; (D.B.); (P.L.S.B.)
| | - Clelia Dispenza
- Dipartimento di Ingegneria, Università degli Studi di Palermo, 90128 Palermo, Italy;
- Istituto di Biofisica, Consiglio Nazionale delle Ricerche, 90146 Palermo, Italy; (D.B.); (P.L.S.B.)
- Correspondence: (D.N.); (D.G.); (C.D.)
| | - Pier Luigi San Biagio
- Istituto di Biofisica, Consiglio Nazionale delle Ricerche, 90146 Palermo, Italy; (D.B.); (P.L.S.B.)
| | - Romano Lapasin
- Dipartimento di Ingegneria e Architettura, Università degli Studi di Trieste, 34127 Trieste, Italy;
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22
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Micronutrient's deficiency in India: a systematic review and meta-analysis. J Nutr Sci 2022; 10:e110. [PMID: 35059191 PMCID: PMC8727714 DOI: 10.1017/jns.2021.102] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 02/02/2023] Open
Abstract
India is coming to grips with a stage of nutrition transition. According to the Food Safety and Standards Authority of India (FSSAI), preventable micronutrient deficiency is arising public health precedence in India. However, the foremost public health concern is the lack of national prevalence data. The present study was carried out to estimate the pooled age-wise prevalence of six preventable micronutrient deficiencies (vitamin A, vitamin B12, vitamin D, iron, iodine and folic acid) in India. A systematic review was carried out on PubMed and Global Index Medicus databases using the Boolean search strategy. Statistical analyses were done using R software, version 3.6. 2. PRISMA guidelines were strictly adhered to during the review. A preliminary literature search yielded 4302 articles; however, 270 original research articles were found eligible to be included in quantitative synthesis. The estimated overall prevalence was 17 % [95 % confidence interval (CI) 0⋅07, 0⋅26] for iodine deficiency, 37 % (95 % CI 0⋅27, 0⋅46) for folic acid deficiency, 54 % (95 % CI 0⋅49, 0⋅59) for iron deficiency, 53 % (95 % CI 0⋅41, 0⋅64) for vitamin B12 deficiency, 19 % (95 % CI 0⋅09, 0⋅29) for vitamin A deficiency and 61 % (95 % CI 0⋅07, 0⋅26) for vitamin D with high heterogeneity. We classified the population into infants (0–5 years), adolescents (<18 years), adults (>18 years) and pregnant women. Iron deficiency was most prevalent (61 %) in pregnant women. The results of the present study reinforce the data on micronutrient deficiency in India and warrant the immediate need for further active public health interventions to address these deficiencies. The study is registered with PROSPERO (CRD42020205043).
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23
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Harrison OA, Hays NP, Ansong RS, Datoghe D, Vuvor F, Steiner‐Asiedu M. Effect of iron-fortified infant cereal on nutritional status of infants in Ghana. Food Sci Nutr 2022; 10:286-294. [PMID: 35035929 PMCID: PMC8751428 DOI: 10.1002/fsn3.2669] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 01/07/2023] Open
Abstract
Iron deficiency anemia is prevalent among infants in Ghana. This study evaluated the effect of micronutrient-fortified infant cereal on the nutritional status of infants in the La Nkwantanang Municipality of the Greater Accra Region of Ghana, located in western Africa. In this double-blind, controlled trial, infants aged 6-18 months were cluster-randomized to receive either micronutrient-fortified infant cereal containing 3.75 mg iron as ferrous fumarate/50 g cereal (INT; n = 107) or the same cereal without iron (CTL; n = 101) to complement other foods and breast milk. The intervention phase lasted six months followed by a two-month post-intervention phase (with no further study product feeding). Hemoglobin and anthropometry were assessed every 2 months for the 8-month study period. After the 6-month intervention phase, adjusted mean ± standard error change in hemoglobin from baseline in INT and CTL was 1.97 ± 0.19 and 1.16 ± 0.21 g/dl, respectively (p < .01 for each); the increase in hemoglobin was significantly larger in INT versus CTL (increase 0.68 ± 0.30 g/dl; p = .02). Prevalence of anemia declined to a significantly greater extent in INT (84.1% to 42.8%) compared to CTL (89.1% to 62.8%; p = .006). There was no significant difference between groups in weight gain (p = .41) or height gain (p = .21) over the study period. In infants aged 6-18 months, micronutrient-fortified infant cereal consumed for 6 months promoted greater reductions in iron-deficiency anemia, which is a significant public health concern not only in Ghana but also in many developing countries globally.
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Affiliation(s)
| | | | - Richard S. Ansong
- Department of Nutrition and Food ScienceUniversity of GhanaLegon‐AccraGhana
| | - Dominic Datoghe
- Department of Nutrition and Food ScienceUniversity of GhanaLegon‐AccraGhana
| | - Frederick Vuvor
- Department of Nutrition and Food ScienceUniversity of GhanaLegon‐AccraGhana
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da Silva Lopes K, Yamaji N, Rahman MO, Suto M, Takemoto Y, Garcia-Casal MN, Ota E. Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews. Cochrane Database Syst Rev 2021; 9:CD013092. [PMID: 34564844 PMCID: PMC8464655 DOI: 10.1002/14651858.cd013092.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling). OBJECTIVES To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle. METHODS In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting). MAIN RESULTS We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus). AUTHORS' CONCLUSIONS Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.
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Affiliation(s)
| | - Noyuri Yamaji
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Md Obaidur Rahman
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Maiko Suto
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - Yo Takemoto
- Department of Obstetrics and Gynaecology, School of Medicine, Juntendo University, Tokyo, Japan
| | | | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University , Tokyo, Japan
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Abstract
OBJECTIVE To characterise the prevalence and persistence of anaemia among Samoan children over a 2-3-year period. DESIGN Data were from two consecutive waves (2015 and 2017-2018) of the Ola Tuputupua'e 'Growing up' study. Anaemia (Hb < 11·0 or 11·5 g/dl for 2-4 and ≥ 5 years old, respectively) was considered 'transient' when it occurred at only one wave or 'persistent' if it was present at two consecutive waves. Child, maternal and household correlates of anaemia were examined using log-binomial and modified Poisson regressions. SETTING Eleven Samoan villages. PARTICIPANTS Mother-child pairs (n 257) recruited in 2015 and reassessed in 2017-2018. RESULTS Anaemia prevalence was 33·9 % in 2015 and 28·0 % in 2017-2018; 35·6 % of cases identified in 2015 were persistent. Risk of anaemia at only one wave was lower among children who were older in 2015 (age 4 v. 2 years, adjusted relative risk (aRR) = 0·54, (95 % CI 0·35, 0·84), P = 0·007), had older mothers (≥ 40 v. 18-29 years, aRR = 0·61, (95 % CI 0·39, 0·95), P = 0·029) and had higher daily sodium intake (for every 100 mg/d, aRR = 0·97, (95 % CI 0·95, 0·99), P = 0·003) than children with no anaemia. Children whose anaemia persisted were more likely to have had a mother with anaemia (aRR = 2·13, (95 % CI 1·17, 3·89), P = 0·013) and had higher daily dietary iron intake (for every 10 mg/d, aRR = 4·69, (95 % CI 1·33, 16·49), P = 0·016) than those with no anaemia. CONCLUSIONS Alongside broadly targeted prevention efforts, which are warranted given the moderate-high anaemia prevalence observed, specific attention should be paid to children with risk factors for persistent anaemia. Routine screening of children whose mothers have anaemia should be encouraged.
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Brzezińska J, Szewczyk A, Brzezicha J, Prokopowicz M, Grembecka M. Evaluation of Physicochemical Properties of Beetroot-Based Dietary Supplements. Foods 2021; 10:foods10081693. [PMID: 34441471 PMCID: PMC8393586 DOI: 10.3390/foods10081693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/11/2021] [Accepted: 07/17/2021] [Indexed: 12/19/2022] Open
Abstract
In the European Union, no specific requirements for the physicochemical parameters of dietary supplements have been established, contrary to the United States of America. This research aimed to assess the selected physical parameters of 31 commercially available beetroot-based dietary supplements in the form of tablets and capsules following the United States Pharmacopoeia (USP) guidelines and the Food and Drug Administration (FDA) recommendations. There was also estimated zinc and iron content by atomic absorption spectroscopy with flame detection. Results showed that nine products did not meet the USP requirements. Seven supplements needed more than 30 min to disintegrate. Two products in the form of tablets did not pass the friability test because of cracking. The hardness values varied significantly between manufacturers, demonstrating values from 59.1 to 455.8 N. The iron-enriched supplements differed significantly in iron content compared with the manufacturers’ declaration (84.91–140.69%). Inappropriate quality of dietary supplements, which may constitute a potential risk to consumers, can be related to the lack of specific regulations in Europe; hence, similar to the USA requirements should be considered in the European Union. The work emphasizes the need to better control the quality of dietary supplements before they are introduced to the European market.
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Affiliation(s)
- Joanna Brzezińska
- Department of Bromatology, Faculty of Pharmacy, Medical University of Gdańsk, Gen. J. Hallera Avenue 107, 80-416 Gdańsk, Poland; (J.B.); (J.B.)
| | - Adrian Szewczyk
- Department of Physical Chemistry, Faculty of Pharmacy, Medical University of Gdańsk, Gen. J. Hallera Avenue 107, 80-416 Gdańsk, Poland; (A.S.); (M.P.)
| | - Justyna Brzezicha
- Department of Bromatology, Faculty of Pharmacy, Medical University of Gdańsk, Gen. J. Hallera Avenue 107, 80-416 Gdańsk, Poland; (J.B.); (J.B.)
| | - Magdalena Prokopowicz
- Department of Physical Chemistry, Faculty of Pharmacy, Medical University of Gdańsk, Gen. J. Hallera Avenue 107, 80-416 Gdańsk, Poland; (A.S.); (M.P.)
| | - Małgorzata Grembecka
- Department of Bromatology, Faculty of Pharmacy, Medical University of Gdańsk, Gen. J. Hallera Avenue 107, 80-416 Gdańsk, Poland; (J.B.); (J.B.)
- Correspondence:
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Bjørklund G, Peana M, Pivina L, Dosa A, Aaseth J, Semenova Y, Chirumbolo S, Medici S, Dadar M, Costea DO. Iron Deficiency in Obesity and after Bariatric Surgery. Biomolecules 2021; 11:biom11050613. [PMID: 33918997 PMCID: PMC8142987 DOI: 10.3390/biom11050613] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/10/2021] [Accepted: 04/16/2021] [Indexed: 02/06/2023] Open
Abstract
Iron deficiency (ID) is particularly frequent in obese patients due to increased circulating levels of acute-phase reactant hepcidin and adiposity-associated inflammation. Inflammation in obese subjects is closely related to ID. It induces reduced iron absorption correlated to the inhibition of duodenal ferroportin expression, parallel to the increased concentrations of hepcidin. Obese subjects often get decreased inflammatory response after bariatric surgery, accompanied by decreased serum hepcidin and therefore improved iron absorption. Bariatric surgery can induce the mitigation or resolution of obesity-associated complications, such as hypertension, insulin resistance, diabetes mellitus, and hyperlipidemia, adjusting many parameters in the metabolism. However, gastric bypass surgery and sleeve gastrectomy can induce malabsorption and may accentuate ID. The present review explores the burden and characteristics of ID and anemia in obese patients after bariatric surgery, accounting for gastric bypass technique (Roux-en-Y gastric bypass-RYGB) and sleeve gastrectomy (SG). After bariatric surgery, obese subjects' iron status should be monitored, and they should be motivated to use adequate and recommended iron supplementation.
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Affiliation(s)
- Geir Bjørklund
- Council for Nutritional and Environmental Medicine, Toften 24, 8610 Mo i Rana, Norway
- Correspondence: (G.B.); (M.P.)
| | - Massimiliano Peana
- Department of Chemistry and Pharmacy, University of Sassari, Via Vienna 2, 07100 Sassari, Italy;
- Correspondence: (G.B.); (M.P.)
| | - Lyudmila Pivina
- Department of Neurology, Ophthalmology and Otolaryngology, Semey Medical University, 071400 Semey, Kazakhstan; (L.P.); (Y.S.)
- CONEM Kazakhstan Environmental Health and Safety Research Group, Semey Medical University, 071400 Semey, Kazakhstan
| | - Alexandru Dosa
- Faculty of Medicine, Ovidius University of Constanta, 900470 Constanta, Romania; (A.D.); (D.-O.C.)
| | - Jan Aaseth
- Research Department, Innlandet Hospital Trust, 2380 Brumunddal, Norway;
| | - Yuliya Semenova
- Department of Neurology, Ophthalmology and Otolaryngology, Semey Medical University, 071400 Semey, Kazakhstan; (L.P.); (Y.S.)
- CONEM Kazakhstan Environmental Health and Safety Research Group, Semey Medical University, 071400 Semey, Kazakhstan
| | - Salvatore Chirumbolo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy;
- CONEM Scientific Secretary, 37134 Verona, Italy
| | - Serenella Medici
- Department of Chemistry and Pharmacy, University of Sassari, Via Vienna 2, 07100 Sassari, Italy;
| | - Maryam Dadar
- Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Karaj 31975/148, Iran;
| | - Daniel-Ovidiu Costea
- Faculty of Medicine, Ovidius University of Constanta, 900470 Constanta, Romania; (A.D.); (D.-O.C.)
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Dewi NU, Mahmudiono T. Effectiveness of Food Fortification in Improving Nutritional Status of Mothers and Children in Indonesia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042133. [PMID: 33671696 PMCID: PMC7926461 DOI: 10.3390/ijerph18042133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 11/16/2022]
Abstract
Food fortification programs have been conducted in several countries to overcome micronutrient deficiency and related problems with various degrees of effectiveness. Available information regarding the success of food fortification programs in some developing countries, including Indonesia, is still limited. Thus, this study conducts a systematic review of the effects of food fortification of mothers and children using biochemical and anthropometric measures focusing on linear growth. Three databases were used in the literature search, namely PubMed, Science Direct and Google Scholar. Fifteen articles were included for analysis from 517 studies found consisting of Indonesian and English articles published from 2000 to June 2020. Fortification of iron, vitamin A, and iodine can increase the level of hemoglobin, serum ferritin, and serum retinol and median urine iodine excretion, especially in toddlers and schoolchildren. However, multinutrient fortification interventions were associated with various effects on hemoglobin, serum ferritin, and serum retinol but a positive association was found with linear growth indicators in the form of body length for age. The effectiveness of food fortification in reducing the prevalence of stunting still needs more and stronger evidence through studies with large sample size and longer duration.
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Affiliation(s)
- Nikmah Utami Dewi
- Department of Nutrition, Faculty of Public Health, University of Tadulako, Palu 94148, Indonesia
- Correspondence: (N.U.D.); (T.M.)
| | - Trias Mahmudiono
- Department of Nutrition, Faculty of Public Health, University of Airlangga, Surabaya 60115, Indonesia
- Correspondence: (N.U.D.); (T.M.)
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29
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Drewnowski A, Garrett GS, Kansagra R, Khan N, Kupka R, Kurpad AV, Mannar V, Martorell R, Zimmermann MB. Key Considerations for Policymakers-Iodized Salt as a Vehicle for Iron Fortification: Current Evidence, Challenges, and Knowledge Gaps. J Nutr 2021; 151:64S-73S. [PMID: 33582786 PMCID: PMC7882367 DOI: 10.1093/jn/nxaa377] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/27/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022] Open
Abstract
Could DFS help prevent iron deficiency and anemia? Studies in controlled settings (efficacy) demonstrate that double-fortified salt (DFS; iron added to iodized salt) reduces the prevalence of anemia and iron deficiency anemia. Studies in program settings (effectiveness) are limited and reported differing levels of DFS coverage, resulting in mixed evidence of impact on anemia. What iron formulations are available and how do they affect iodized salt? Ferrous sulfate and encapsulated ferrous fumarate (both with various enhancers and/or coating materials) are the main iron formulations currently in use for DFS. Adding iron to iodized salt may lead to adverse changes in the product, specifically discoloration and losses in iodine content. These changes are greatest when the iodized salt used in DFS production is of low quality (e.g., contain impurities, has high moisture, and is of large crystal size). DFS requires iodized salt of the highest quality and a high-quality iron formulation in order to minimize adverse sensory changes and iodine losses. Appropriate packaging of iodized salt is also important to prevent losses. What is known about the minimum requirements to manufacture DFS? DFS producers must use high-quality refined iodized salt meeting the minimum standards for DFS production (which is higher than standards for salt intended for iodization alone), and an iron formulation for which there are rigid quality-assurance measures to ensure consistent quality and blending techniques. The actual proportion of iodized salt meeting the stringent requirements necessary for DFS production is unclear, but likely to be low in many countries, especially those with fragmented salt industries and a low proportion of industrially produced salt. What are the financial implications of adding iron to iodized salt? As a result of higher input costs both for input salt and the iron compound, DFS is more expensive to produce than iodized salt and thus has a higher production cost. Various grades of iodized salt are produced and consumed in different sectors of the market. Experience in India indicates that, on average, producing DFS costs 31-40 US dollars/metric ton or 0.03-0.04 US dollars/kg more than high-quality refined iodized salt. The exact impact of this production-level cost difference on profit margins and consumer price is specific to the conditions of different salt markets. Factors such as transport costs, customary wholesale and retail mark-ups, and taxes all vary greatly and need to be assessed on a case by case basis. Is DFS in alignment with salt-reduction efforts? The WHO has long recognized that salt iodization is an important public health intervention to achieve optimal iodine nutrition and is compatible with salt-reduction goals. Fortification of salt (with any nutrient) should not be used to justify or encourage an increase in salt intake to the public. Any effort to expand salt fortification to other nutrients should be done in close consultation with WHO and those working on salt reduction. What has been the experience with DFS delivery under different platforms? To date, DFS has been introduced into the retail market and in social safety net (primarily in India) programs, but sensory changes in DFS have been raised as concerns. The higher price for DFS has limited expansion in the retail market. In social safety net programs where the cost of DFS is subsidized for beneficiaries, programs must consider long-term resourcing for sustainability. Overall: The optimal production and delivery of DFS are still under development, as many challenges need to be overcome. There is a beneficial impact on hemoglobin in efficacy trials. Thus, if those conditions can be replicated in programs or the technology can be adapted to better fit current production and delivery realities, DFS may provide an effective contribution in countries that need additional food-fortification vehicles to improve iron intake.
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Affiliation(s)
- Adam Drewnowski
- Center for Public Health Nutrition, University of Washington, Seattle, WA, USA
| | - Greg S Garrett
- ThinkWell, Geneva, Switzerland
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | | | - Noor Khan
- Nutrition International, Ottawa, Canada
| | - Roland Kupka
- United Nations Children's Fund (UNICEF) Headquarters, New York, NY, USA
| | - Anura V Kurpad
- Department of Physiology, St. John's Medical College, St. John's National Academy of Health Sciences, Bangalore, India
| | - Venkatesh Mannar
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada
| | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michael B Zimmermann
- Department of Health Science and Technology, Laboratory of Human Nutrition, Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
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Hurrell RF. Iron Fortification Practices and Implications for Iron Addition to Salt. J Nutr 2021; 151:3S-14S. [PMID: 33582781 PMCID: PMC7882371 DOI: 10.1093/jn/nxaa175] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/31/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
This introductory article provides an in-depth technical background for iron fortification, and thus introduces a series of articles in this supplement designed to present the current evidence on the fortification of salt with both iodine and iron, that is, double-fortified salt (DFS). This article reviews our current knowledge of the causes and consequences of iron deficiency and anemia and then, with the aim of assisting the comparison between DFS and other common iron-fortified staple foods, discusses the factors influencing the efficacy of iron-fortified foods. This includes the dietary and physiological factors influencing iron absorption; the choice of an iron compound and the fortification technology that will ensure the necessary iron absorption with no sensory changes; encapsulation of iron fortification compounds to prevent unacceptable sensory changes; the addition of iron absorption enhancers; the estimation of the iron fortification level for each vehicle based on iron requirements and consumption patterns; and the iron status biomarkers that are needed to demonstrate improved iron status in populations regularly consuming the iron-fortified food. The supplement is designed to provide a summary of evidence to date that can help advise policy makers considering DFS as an intervention to address the difficult public health issue of iron deficiency anemia, while at the same time using DFS to target iodine deficiency.
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Hurrell RF. The Potential of Iodine and Iron Double-Fortified Salt Compared with Iron-Fortified Staple Foods to Increase Population Iron Status. J Nutr 2021; 151:47S-63S. [PMID: 33582784 PMCID: PMC7882360 DOI: 10.1093/jn/nxaa204] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/10/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022] Open
Abstract
The potential of double-fortified salt (DFS) to improve population iron status is compared with the potential of iron-fortified wheat flour, maize flour, rice grains, and milk products. The potential for a positive impact on iron status is based on reported efficacy studies, consumption patterns, the extent of industrialization, and whether there are remaining technical issues with the fortification technologies. Efficacy studies with DFS, and with iron-fortified wheat flour, maize flour, and rice, have all reported good potential to improve population iron status. Iron-fortified milk powder has shown good impact in young children. When these foods are industrially fortified in modern, automated facilities, with high-level quality control and assurance practices, high-quality raw materials, and a wide population coverage, all vehicles have good potential to improve iron status. Relative to other fortification vehicles, fortification practices with wheat flour are the most advanced and iron-fortified wheat flour has the highest potential for impact in the short- to medium-term in countries where wheat flour is consumed as a staple. Liquid milk has the least potential, mainly because an acceptable iron fortification technology has not yet been developed. Maize is still predominantly milled in small-scale local mills and, although the extruded rice premix technology holds great promise, it is still under development. Salt has a proven record as an excellent vehicle for iodine fortification and has demonstrated good potential for iron fortification. However, technical issues remain with DFS and further studies are needed to better understand and avoid color formation and iron-catalyzed iodine losses in both high- and low-quality salts under different storage conditions. There is currently a risk that the introduction of DFS may jeopardize the success of existing salt iodization programs because the addition of iron may increase iodine losses and cause unacceptable color formation.
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Affiliation(s)
- Richard F Hurrell
- Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland
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Field MS, Mithra P, Peña-Rosas JP. Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations. Cochrane Database Syst Rev 2021; 1:CD011302. [PMID: 33461239 PMCID: PMC8407500 DOI: 10.1002/14651858.cd011302.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Anaemia is a condition where the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. OBJECTIVES To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health-related outcomes in populations over two years of age. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. SELECTION CRITERIA We included cluster- or individually-randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. MAIN RESULTS Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta-analyses. Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low-certainty evidence). It is uncertain whether iron-fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low-certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low-certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C-reactive protein (CRP) (mean difference (MD) 0.04, 95% CI -0.02 to 0.11; 2 studies, 558 participants; moderate-certainty evidence). Iron-fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low-certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate-certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI -0.39 to 5.45; 4 studies, 532 participants; very low-certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. AUTHORS' CONCLUSIONS Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron-fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom.
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Affiliation(s)
- Martha S Field
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Prasanna Mithra
- Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
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Lemoine A, Tounian P. Childhood anemia and iron deficiency in sub-Saharan Africa – risk factors and prevention: A review. Arch Pediatr 2020; 27:490-496. [DOI: 10.1016/j.arcped.2020.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 04/15/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
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A scoping review of literature describing the nutritional status and diets of adolescents in Côte d'Ivoire. Public Health Nutr 2020; 24:5261-5276. [PMID: 32883396 DOI: 10.1017/s1368980020002621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adolescents living in resource-limited settings remain a neglected population regarding their nutritional health. We reviewed what studies on nutrition have been conducted for adolescents living in Côte d'Ivoire. DESIGN A scoping literature review, searching for any quantitative studies published from 1 January 2000 to 1 May 2019, referenced in PubMed and grey literature, related to adolescent nutritional status and diet, written in English or French. SETTING Côte d'Ivoire, West Africa. SUBJECTS Adolescent girls and boys (aged 10-19 years). RESULTS We used three search strategies to explore studies related to (1) diet and nutritional practices, (2) anthropometry and (3) micronutrient intakes/status. Each identified 285, 108 and 84 titles and abstracts, respectively, resulting in 384 full-text articles to review. Finally, after adding five relevant studies from the grey literature, thirty articles were included. Two-thirds were cross-sectional observation studies. The main topics were anaemia and parasitic diseases. Among seven intervention studies, most focused on micronutrient supplementation or deworming. No studies on macronutrients or food supplementation were found. Overall, studies showed a high prevalence of undernutrition, along with emerging overweight and obesity. Anaemia and Fe deficiency were highly prevalent, with Fe supplementation showing modest improvements. Malaria and gut parasite infections remain a major burden, affecting adolescents' nutritional status. CONCLUSIONS Few specific relevant studies have been published regarding adolescent nutrition in Côte d'Ivoire, and most studies being focused on younger children. There are knowledge gaps about many nutritional aspects in this population, which urgently need to be addressed.
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Speich C, Wegmüller R, Brittenham GM, Zeder C, Cercamondi CI, Buhl D, Prentice AM, Zimmermann MB, Moretti D. Measurement of long-term iron absorption and loss during iron supplementation using a stable isotope of iron ( 57 Fe). Br J Haematol 2020; 192:179-189. [PMID: 32862453 DOI: 10.1111/bjh.17039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/19/2020] [Indexed: 12/12/2022]
Abstract
We report the first measurements of long-term iron absorption and loss during iron supplementation in African children using a stable isotope of iron (57 Fe). After uniform labelling of body iron with 57 Fe, iron absorption is proportional to the rate of decrease in the 57 Fe tracer concentration, while iron loss is proportional to the rate of decrease in the 57 Fe tracer amount. Anaemic Gambian toddlers were given 2 mg 57 Fe orally to equilibrate with total body iron over 8-11 months. After assignment to the positive control arm of the HIGH study, 22 toddlers consumed a micronutrient powder containing 12 mg iron for 12 weeks followed by 12 weeks without iron supplementation. Their daily iron absorption increased 3·8-fold during the iron supplementation period compared to the control period [median (interquartile range, IQR): 1·00 (0·82; 1·28) mg/day vs. 0·26 (0·22; 0·35) mg/day; P = 0·001]. Unexpectedly, during the supplementation period, daily iron loss also increased by 3·4-fold [0·75 (0·55; 0·87) mg/day vs. 0·22 (0·19; 0·29) mg/day; P = 0·005]. Consequently, most (~72%) of the absorbed iron was lost during supplementation. Long-term studies of iron absorption and loss are a promising and accurate method for assessing and quantifying long-term iron balance and may provide a reference method for evaluating iron intervention programs in vulnerable population groups. This study was registered as ISRCTN 0720906.
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Affiliation(s)
- Cornelia Speich
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
| | - Rita Wegmüller
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland.,MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, USA
| | - Christophe Zeder
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
| | - Colin I Cercamondi
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
| | - Daniela Buhl
- Department of Laboratory Medicine, Cantonal Hospital Luzern, Luzern, Switzerland
| | - Andrew M Prentice
- MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zürich, Zurich, Switzerland
| | - 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
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Moorthy D, Merrill R, Namaste S, Iannotti L. The Impact of Nutrition-Specific and Nutrition-Sensitive Interventions on Hemoglobin Concentrations and Anemia: A Meta-review of Systematic Reviews. Adv Nutr 2020; 11:1631-1645. [PMID: 32845972 PMCID: PMC7666908 DOI: 10.1093/advances/nmaa070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/12/2020] [Accepted: 05/21/2020] [Indexed: 11/14/2022] Open
Abstract
Anemia is a multifactorial condition arising from inadequate nutrition, infection, chronic disease, and genetic-related etiologies. Our aim was to assess the impact of nutrition-sensitive and nutrition-specific interventions on hemoglobin (Hb) concentrations and anemia to inform the prioritization and scale-up of interventions to address the multiple causes of anemia. We performed a meta-review synthesis of information by searching multiple databases for reviews published between 1990 and 2017 and used standard methods for conducting a meta-review of reviews, including double independent screening, extraction, and quality assessment. Quantitative pooling and narrative syntheses were used to summarize information. Hb concentration and anemia outcomes were pooled in specific population groups (children aged <5 y, school-age children, and pregnant women). Methodological quality of the systematic reviews was assessed using Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria. Of the 15,444 records screened, we identified 118 systematic reviews that met inclusion criteria. Reviews focused on nutrition-specific interventions (96%). Daily and intermittent iron supplementation, micronutrient powders, malaria treatment, use of insecticide-treated nets (ITNs), and delayed cord clamping were associated with increased Hb concentration in children aged <5 y. Among children older than 5 y, daily and intermittent iron supplementation and deworming, and in pregnant women, daily iron-folic acid supplementation, use of ITNs, and delayed cord clamping, were associated with increased Hb concentration. Similar results were obtained for the reduced risk of anemia outcome. This meta-review suggests the importance of nutrition-specific interventions for anemia and highlights the lack of evidence to understand the influence of nutrition-sensitive and multifaceted interventions on the condition.
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Affiliation(s)
| | - Rebecca Merrill
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sorrel Namaste
- The Demographic and Health Survey Program, ICF, Rockville, MD, USA
| | - Lora Iannotti
- Brown School, Institute for Public Health, Washington University in St Louis, MO, USA
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Khoja KK, Aslam MF, Sharp PA, Latunde-Dada GO. In vitro bioaccessibility and bioavailability of iron from fenugreek, baobab and moringa. Food Chem 2020; 335:127671. [PMID: 32745843 DOI: 10.1016/j.foodchem.2020.127671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/10/2020] [Accepted: 07/23/2020] [Indexed: 11/27/2022]
Abstract
Iron deficiency anaemia (IDA) is a common nutritional disorder worldwide. Sustainable food-based approaches are being advocated to use high and bioavailable dietary iron sources to prevent iron deficiency. The study investigated the bioaccessibility and bioavailability of iron from some plant products. Total iron levels in the samples were measured by inductively coupled plasma optical emission spectrometry (ICP-OES). Fractionation of the iron from the digested extracts was carried out by centrifugation and ultrafiltration. Iron bioavailability was determined using an in vitro simulated peptic-pancreatic digestion, followed by measurement of ferritin in Caco-2 cells. The highest amount of bioaccessible iron was obtained from moringa leaves (9.88% ± 0.45 and 8.44 ± 0.01 mg/100 g), but the highest percentage bioavailability was from baobab fruit pulp (99.7% ± 0.13 and 1.74 ± 0.01 mg/100 g) respectively. All the plant products, except for baobab, significantly inhibited iron uptake from FeSO4 and FAC, with fenugreek sprout being the most inhibitory.
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Affiliation(s)
- Kholoud K Khoja
- Department of Nutritional Sciences, School of Life Course Sciences, King's College London, Franklin-Wilkins-Building, 150 Stamford Street, London SE1 9NH, UK
| | - Mohamad F Aslam
- Department of Nutritional Sciences, School of Life Course Sciences, King's College London, Franklin-Wilkins-Building, 150 Stamford Street, London SE1 9NH, UK
| | - Paul A Sharp
- Department of Nutritional Sciences, School of Life Course Sciences, King's College London, Franklin-Wilkins-Building, 150 Stamford Street, London SE1 9NH, UK
| | - Gladys O Latunde-Dada
- Department of Nutritional Sciences, School of Life Course Sciences, King's College London, Franklin-Wilkins-Building, 150 Stamford Street, London SE1 9NH, UK.
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Field MS, Mithra P, Estevez D, Peña-Rosas JP. Wheat flour fortification with iron for reducing anaemia and improving iron status in populations. Cochrane Database Syst Rev 2020; 7:CD011302. [PMID: 32677706 PMCID: PMC9503748 DOI: 10.1002/14651858.cd011302.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Anaemia is a condition where the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body's physiologic needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. OBJECTIVES To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health-related outcomes in populations over two years of age. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 4 September 2019. SELECTION CRITERIA We included cluster- or individually randomised controlled trials (RCT) carried out among the general population from any country aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. Trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat were included. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risk of bias. We followed Cochrane methods in this review. MAIN RESULTS Our search identified 3048 records, after removing duplicates. We included nine trials, involving 3166 participants, carried out in Bangladesh, Brazil, India, Kuwait, Phillipines, Sri Lanka and South Africa. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, two trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial employed various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta-analyses. Seven studies compared wheat flour fortified with iron alone versus unfortified wheat flour, three studies compared wheat flour fortified with iron in combination with other micronutrients versus unfortified wheat flour and two studies compared wheat flour fortified with iron in combination with other micronutrients versus fortified wheat flour with the same micronutrients (but not iron). No studies included a 'no intervention' comparison arm. None of the included trials reported any other adverse side effects (including constipation, nausea, vomiting, heartburn or diarrhoea). Wheat flour fortified with iron alone versus unfortified wheat flour (no micronutrients added) Wheat flour fortification with iron alone may have little or no effect on anaemia (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.61 to 1.07; 5 studies; 2200 participants; low-certainty evidence). It probably makes little or no difference on iron deficiency (RR 0.43, 95% CI 0.17 to 1.07; 3 studies; 633 participants; moderate-certainty evidence) and we are uncertain about whether wheat flour fortified with iron increases haemoglobin concentrations by an average 3.30 (g/L) (95% CI 0.86 to 5.74; 7 studies; 2355 participants; very low-certainty evidence). No trials reported data on adverse effects in children, except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to risk of Infection or inflammation at individual level as measured by C-reactive protein (CRP) (moderate-certainty evidence). Wheat flour fortified with iron in combination with other micronutrients versus unfortified wheat flour (no micronutrients added) Wheat flour fortified with iron, in combination with other micronutrients, may or may not decrease anaemia (RR 0.95, 95% CI 0.69 to 1.31; 2 studies; 322 participants; low-certainty evidence). It makes little or no difference to average risk of iron deficiency (RR 0.74, 95% CI 0.54 to 1.00; 3 studies; 387 participants; moderate-certainty evidence) and may or may not increase average haemoglobin concentrations (mean difference (MD) 3.29, 95% CI -0.78 to 7.36; 3 studies; 384 participants; low-certainty evidence). No trials reported data on adverse effects in children. Wheat flour fortified with iron in combination with other micronutrients versus fortified wheat flour with same micronutrients (but not iron) Given the very low certainty of the evidence, the review authors are uncertain about the effects of wheat flour fortified with iron in combination with other micronutrients versus fortified wheat flour with same micronutrients (but not iron) in reducing anaemia (RR 0.24, 95% CI 0.08 to 0.71; 1 study; 127 participants; very low-certainty evidence) and in reducing iron deficiency (RR 0.42, 95% CI 0.18 to 0.97; 1 study; 127 participants; very low-certainty evidence). The intervention may make little or no difference to the average haemoglobin concentration (MD 0.81, 95% CI -1.28 to 2.89; 2 studies; 488 participants; low-certainty evidence). No trials reported data on the adverse effects in children. Eight out of nine trials reported source of funding with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. AUTHORS' CONCLUSIONS Eating food items containing wheat flour fortified with iron alone may have little or no effect on anaemia and probably makes little or no difference in iron deficiency. We are uncertain on whether the intervention with wheat flour fortified with iron increases haemoglobin concentrations improve blood haemoglobin concentrations. Consuming food items prepared from wheat flour fortified with iron, in combination with other micronutrients, has little or no effect on anaemia, makes little or no difference to iron deficiency and may or may not improve haemoglobin concentrations. In comparison to fortified flour with micronutrients but no iron, wheat flour fortified with iron with other micronutrients, the effects on anaemia and iron deficiency are uncertain as certainty of the evidence has been assessed as very low. The intervention may make little or no difference to the average haemoglobin concentrations in the population. None of the included trials reported any other adverse side effects. The effects of this intervention on other health outcomes are unclear.
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Affiliation(s)
- Martha S Field
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Prasanna Mithra
- Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Diana Estevez
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
| | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
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Ekoe T, Bianpambe OI, Nguefack F, Pondi DM, Kana‐Sop MM, Hays NP, Medoua G, Koki PN. Efficacy of an iron-fortified infant cereal to reduce the risk of iron deficiency anemia in young children in East Cameroon. Food Sci Nutr 2020; 8:3566-3577. [PMID: 32724619 PMCID: PMC7382166 DOI: 10.1002/fsn3.1639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 03/02/2020] [Accepted: 04/24/2020] [Indexed: 01/02/2023] Open
Abstract
Complementary foods in Africa are often poor sources of bioavailable iron. We assessed the efficacy of iron-fortified wheat-based infant cereal (IC) to reduce the risk of iron deficiency anemia in children aged 18-59 months in Cameroon. A 6-month double-blind, cluster-randomized controlled trial was conducted in 2017 among anemic (hemoglobin 7-11 g/dl) but otherwise healthy children. In conjunction with usual diet, children received two 50 g servings/day of a standard, micronutrient-fortified IC (providing 3.75 mg iron/serving; n = 106) or the same IC without iron fortification (n = 99). Anthropometric measurements, blood sampling, and systematic deworming were performed in all children at baseline (pre-intervention), 3, and 6 months. Mean hemoglobin, ferritin adjusted for C-reactive protein (CRP), serum iron, transferrin saturation, prevalence of anemia, iron deficiency, and iron deficiency anemia as well as anthropometrics were compared between the groups at baseline, 3, and 6 months. Compared to the control group, children consuming the iron-fortified IC had significantly higher baseline-adjusted mean hemoglobin (10.0 ± 1.8 vs. 9.7 ± 1.4 g/dl, respectively; p = .023), ferritin adjusted for CRP (16.1 ± 8.3 vs. 9.5 ± 7.5 μg/L, p < .001), serum iron (14.5 ± 3.9 vs. 11.2 ± 4.4 μg/dl; p < .001), and transferrin saturation (19.0 ± 17.4 vs. 10.7 ± 12.5%; p ˂ .001) at 6 months. The prevalence of anemia, iron deficiency, and iron deficiency anemia at 6 months decreased by a larger extent in the iron-fortified group versus controls (all p < .01). In addition, at 6 months, children in the iron-fortified group demonstrated higher weight-for-age z-scores (p = .016) compared to the control group. Wheat-based IC fortified with 7.5 mg ferrous fumarate administered daily for 6 months improved iron and nutritional status and decreased the prevalence of iron deficiency anemia in children aged 18-59 months in Salapoumbé, Cameroon.
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Affiliation(s)
- Tetanye Ekoe
- Faculty of Medicine and Biomedical SciencesUniversity of Yaoundé IYaoundéCameroon
| | | | - Felicitee Nguefack
- Faculty of Medicine and Biomedical SciencesUniversity of Yaoundé IYaoundéCameroon
| | - Daniel M. Pondi
- Faculty of Medicine and Biomedical SciencesUniversity of Yaoundé IYaoundéCameroon
| | | | | | - Gabriel Medoua
- Food and Nutrition Research CenterInstitute for Medical Research and Study of Medicinal PlantsYaoundéCameroon
| | - Paul N. Koki
- Faculty of Medicine and Biomedical SciencesUniversity of Yaoundé IYaoundéCameroon
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Mithra P, Khatib MN, Sinha AP, Kumar N, Holla R, Unnikrishnan B, Vijayamma R, Nair NS, Gaidhane A, Quazi Zahiruddin S. Interventions for Addressing Anemia Among Children and Adolescents: An Overview of Systematic Reviews. Front Pediatr 2020; 8:549549. [PMID: 33665173 PMCID: PMC7921152 DOI: 10.3389/fped.2020.549549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 12/18/2020] [Indexed: 01/08/2023] Open
Abstract
Context: Anemia is a public health problem that can lead to growth, cognitive, and motor impairments. Objective: To collate evidence on interventions for addressing childhood and adolescent anemia. Methods: In this overview of systematic reviews, we included Cochrane as well as non-Cochrane systematic reviews (SRs) irrespective of language and publication status. Two sets of review authors independently screened articles for eligibility and extracted data from relevant SRs. We present data in a tabular format and summarize results based on outcome reported, age of participants, and type of interventions. We also adopt a "measurement for change" approach to assess the utility of measurement for development of interventions in childhood and adolescent anemia. Results: Our search yielded 2,601 records of which 31 SRs were found eligible for inclusion. Results were favorable for fortification and supplementation with clear reduction in the risk of anemia and increase in hemoglobin levels across all age groups. Other interventions reported by the SRs were inconclusive and suggest further research. Conclusions: Current evidence suggests that fortification or supplementation with iron and micronutrients leads to better reduction in the risk of anemia and improvements in hemoglobin levels among children and adolescents. Results of this overview can help decision makers in informing selection of interventions to address childhood and adolescent anemia. Review Registration: PROSPERO CRD42016053687.
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Affiliation(s)
- Prasanna Mithra
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Mahalaqua Nazli Khatib
- Division of Evidence Synthesis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India
| | - Anju Pradhan Sinha
- Division of Reproductive, Maternal and Child Health, Indian Council of Medical Research, New Delhi, India
| | - Nithin Kumar
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Ramesh Holla
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Bhaskaran Unnikrishnan
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Ratheebhai Vijayamma
- Manipal Institute of Communication, Manipal Academy of Higher Education, Manipal, India
| | - N Sreekumaran Nair
- Medical Biometrics & Informatics (Biostatistics), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Abhay Gaidhane
- Department of Community Medicine, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India
| | - Syed Quazi Zahiruddin
- Department of Community Medicine, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India
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Henare SJ, Nur Singh N, Ellis AM, Moughan PJ, Thompson AK, Walczyk T. Iron bioavailability of a casein-based iron fortificant compared with that of ferrous sulfate in whole milk: a randomized trial with a crossover design in adult women. Am J Clin Nutr 2019; 110:1362-1369. [PMID: 31573611 PMCID: PMC6885464 DOI: 10.1093/ajcn/nqz237] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/27/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A highly soluble iron-casein complex has been developed for food fortification purposes with the aim to provide high iron bioavailability. OBJECTIVE We aimed to determine the iron bioavailability of the iron-casein complex relative to that of ferrous sulfate (control) when given with whole milk in healthy young women. METHODS A randomized comparator-controlled trial with a crossover design was conducted using the erythrocyte incorporation dual stable isotope (57Fe, 58Fe) technique. Iron absorption from the iron-casein complex was compared with that from ferrous sulfate in 21 healthy women aged 20-38 y with normal iron status. RESULTS Fractional iron absorption (geometric mean; -SD, +SD) from the iron-casein complex (3.4%; 1.4%, 5.4%) and from ferrous sulfate (3.9%; 1.7%, 6.1%) were not statistically different (P > 0.05). The relative bioavailability value of the iron-casein complex to ferrous sulfate was determined to be 0.87 (-1 SD, +1 SD: -0.90, +2.64). CONCLUSIONS The iron-casein complex has iron bioavailability comparable to that of ferrous sulfate in healthy young women. This trial was registered at www.anzctr.org.au as ACTRN12615000690550.
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Affiliation(s)
- Sharon J Henare
- School of Health Sciences, Massey University, Palmerston North, New Zealand,Riddet Institute, Massey University, Palmerston North, New Zealand,Address correspondence to SJH (e-mail: )
| | - Nadia Nur Singh
- NutriTrace@NUS, Department of Chemistry, Faculty of Science, National University of Singapore, Singapore
| | - Ashling M Ellis
- Riddet Institute, Massey University, Palmerston North, New Zealand,School of Food and Advanced Technology, Massey University, Palmerston North, New Zealand
| | - Paul J Moughan
- Riddet Institute, Massey University, Palmerston North, New Zealand
| | - Abby K Thompson
- Riddet Institute, Massey University, Palmerston North, New Zealand,Food HQ, The Factory, Palmerston North, New Zealand
| | - Thomas Walczyk
- NutriTrace@NUS, Department of Chemistry, Faculty of Science, National University of Singapore, Singapore
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Peña‐Rosas JP, Mithra P, Unnikrishnan B, Kumar N, De‐Regil LM, Nair NS, Garcia‐Casal MN, Solon JA. Fortification of rice with vitamins and minerals for addressing micronutrient malnutrition. Cochrane Database Syst Rev 2019; 2019:CD009902. [PMID: 31684687 PMCID: PMC6814158 DOI: 10.1002/14651858.cd009902.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Rice fortification with vitamins and minerals has the potential to increase the nutrition in rice-consuming countries where micronutrient deficiencies exist. Globally, 490 million metric tonnes of rice are consumed annually. It is the dominant staple food crop of around three billion people. OBJECTIVES To determine the benefits and harms of rice fortification with vitamins and minerals (iron, vitamin A, zinc or folic acid) on micronutrient status and health-related outcomes in the general population. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and 16 other databases all up to 10 December 2018. We searched ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (ICTRP) on 10 December 2018. SELECTION CRITERIA We included randomised and quasi-randomised trials (with either individual or cluster randomisation) and controlled before-and-after studies. Participants were populations older than two years of age (including pregnant women) from any country. The intervention was rice fortified with at least one micronutrient or a combination of several micronutrients (iron, folic acid, zinc, vitamin A or other vitamins and minerals) compared with unfortified rice or no intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently screened studies and extracted data. MAIN RESULTS We included 17 studies (10,483 participants) and identified two ongoing studies. Twelve included studies were randomised-controlled trials (RCTs), with 2238 participants after adjusting for clustering in two cluster-RCTs, and five were non-randomised studies (NRS) with four controlled before-and-after studies and one cross-sectional study with a control (8245 participants). Four studies were conducted in India, three in Thailand, two in the Philippines, two in Brazil, one each in Bangladesh, Burundi, Cambodia, Indonesia, Mexico and the USA. Two studies involved non-pregnant, non-lactating women and 10 involved pre-school or school-age children. All 17 studies reported fortification with iron. Of these, six studies fortified rice with iron only; 11 studies had other micronutrients added (iron, zinc and vitamin A, and folic acid). One study had one arm each with vitamin A alone and carotenoid alone. Elemental iron content ranged from 0.2 to 112.8 mg/100 g uncooked rice given for a period varying from two weeks to 48 months. Thirteen studies did not clearly describe either sequence generation or allocation concealment. Eleven studies had a low attrition rate. There was no indication of selective reporting in the studies. We considered two RCTs at low overall risk of bias and 10 at high overall risk of bias. One RCT was at high or unclear risk of bias for most of the domains. All controlled before-and-after studies had a high risk or unclear risk of bias in most domains. The included studies were funded by Government, private and non-governmental organisations, along with other academic institutions. The source of funding does not appear to have altered the results. We used the NRS in the qualitative synthesis but we excluded them from the quantitative analysis and review conclusions since they provided mostly contextual information and limited quantitative information. Rice fortified with iron alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) Fortification of rice with iron (alone or in combination with other micronutrients) may make little or no difference in the risk of having anaemia (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.54 to 0.97; I2 = 74%; 7 studies, 1634 participants; low-certainty evidence) and may reduce the risk of iron deficiency (RR 0.66, 95% CI 0.51 to 0.84; 8 studies, 1733 participants; low-certainty evidence). Rice fortification may increase mean haemoglobin (mean difference (MD) 1.83, 95% CI 0.66 to 3.00; I2 = 54%; 11 studies, 2163 participants; low-certainty evidence) and it may make little or no difference to vitamin A deficiency (with vitamin A as one of the micronutrients in the fortification arm) (RR 0.68, 95% CI 0.36 to 1.29; I2 = 37%; 4 studies, 927 participants; low-certainty evidence). One study reported that fortification of rice (with folic acid as one of the micronutrients) may improve serum or plasma folate (nmol/L) (MD 4.30, 95% CI 2.00 to 6.60; 215 participants; low-certainty evidence). One study reported that fortification of rice with iron alone or with other micronutrients may slightly increase hookworm infection (RR 1.78, 95% CI 1.18 to 2.70; 785 participants; low-certainty evidence). We are uncertain about the effect of fortified rice on diarrhoea (RR 3.52, 95% CI 0.18 to 67.39; 1 study, 258 participants; very low-certainty evidence). Rice fortified with vitamin A alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) One study had one arm providing fortified rice with vitamin A only versus unfortified rice. Fortification of rice with vitamin A (in combination with other micronutrients) may increase mean haemoglobin (MD 10.00, 95% CI 8.79 to 11.21; 1 study, 74 participants; low-certainty evidence). Rice fortified with vitamin A may slightly improve serum retinol concentration (MD 0.17, 95% CI 0.13 to 0.21; 1 study, 74 participants; low-certainty evidence). No studies contributed data to the comparisons of rice fortification versus no intervention. The studies involving folic acid and zinc also involved iron in the fortification arms and hence we reported them as part of the first comparison. AUTHORS' CONCLUSIONS Fortification of rice with iron alone or in combination with other micronutrients may make little or no difference in the risk of having anaemia or presenting iron deficiency and we are uncertain about an increase in mean haemoglobin concentrations in the general population older than 2 years of age. Fortification of rice with iron and other micronutrients such as vitamin A or folic acid may make little or no difference in the risk of having vitamin A deficiency or on the serum folate concentration. There is limited evidence on any adverse effects of rice fortification.
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Affiliation(s)
- Juan Pablo Peña‐Rosas
- World Health OrganizationEvidence and Programme Guidance, Department of Nutrition for Health and Development20 Avenue AppiaGenevaGESwitzerland1211
| | - Prasanna Mithra
- Kasturba Medical College, Mangalore, Manipal Academy of Higher EducationDepartment of Community MedicineManipalKarnatakaIndia
| | - Bhaskaran Unnikrishnan
- Kasturba Medical College, Mangalore, Manipal Academy of Higher EducationDepartment of Community MedicineManipalKarnatakaIndia
| | - Nithin Kumar
- Kasturba Medical College, Mangalore, Manipal Academy of Higher EducationDepartment of Community MedicineManipalKarnatakaIndia
| | - Luz Maria De‐Regil
- Nutrition InternationalGlobal Technical Services180 Elgin Street, Suite 1000OttawaONCanadaK2P 2K3
| | - N Sreekumaran Nair
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) (Institution of National Importance Under Ministry of Health and Family Welfare, Government of India)Department of Medical Biometrics & Informatics (Biostatistics)4th Floor, Administrative BlockDhanvantri NagarPuducherryIndia605006
| | - Maria N Garcia‐Casal
- World Health OrganizationEvidence and Programme Guidance, Department of Nutrition for Health and Development20 Avenue AppiaGenevaGESwitzerland1211
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Systematic review and meta-analysis of the effect of iron-fortified flour on iron status of populations worldwide. Public Health Nutr 2019; 22:3465-3484. [DOI: 10.1017/s1368980019002179] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
AbstractObjective:Assess the effectiveness of iron-fortified flour on iron status.Design:Systematic review and meta-analysis.Setting:Argentina, Australia, Azerbaijan, Bangladesh, Brazil, Cameroon, Chile, China, Costa Rica, Côte d’Ivoire, Denmark, India, Iran, Jordan, Kazakhstan, Kenya, Kuwait, Mongolia, Morocco, Norway, South Africa, Sri Lanka, Tajikistan, Thailand, UK, USA, Uzbekistan, Venezuela, Vietnam, and Zambia.Participants:Fifty-two articles (ninety-four trials) were examined. The main target groups were women, children, and infants/toddlers. The effects of different types of iron-fortified flour (wheat, maize, rice, soy, and beans) on iron status were examined.Results:A random effects analysis of before–after studies showed that iron-fortified flour led to significant increases of mean haemoglobin level (3·360 g/l; 95 % CI: 0·980, 5·730) and mean serum ferritin level (4·518 µg/l; 95 % CI: 2·367, 6·669); significant decreases of anaemia (−6·7 %; 95 % CI: −9·8 %, −3·6 %) and iron deficiency (ID) (−10·4 %; 95 % CI: −14·3 %, −6·5 %); but had no significant effect on iron deficiency anaemia (IDA). A random effects analysis of controlled trials indicated that iron-fortified flour led to significant increases of mean haemoglobin level (2·630 g/l; 95 % CI: 1·310, 3·950) and mean ferritin level (8·544 µg/l; 95 % CI: 6·767, 10·320); and significant decreases of anaemia (−8·1 %; 95 % CI: −11·7 %, −4·4 %), ID (−12·0 %; 95 % CI: −18·9 %, −5·1 %), and IDA (−20·9 %; 95 % CI: −38·4 %, −3·4 %).Conclusions:Flour fortification with iron is an effective public health strategy that improves iron status of populations worldwide.
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Childhood iron deficiency anemia leads to recurrent respiratory tract infections and gastroenteritis. Sci Rep 2019; 9:12637. [PMID: 31477792 PMCID: PMC6718651 DOI: 10.1038/s41598-019-49122-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/20/2019] [Indexed: 12/03/2022] Open
Abstract
Anemia affects approximately 30% of children all over the world. Acute respiratory tract infections (ARTI), urinary tract infections (UTI) and gastroenteritis (GE) are common infectious entities in children. Here, we assessed the association between anemia and development of recurrent ARTI, UTI, and GE in children. This was a case-control study in hospitalized 2–5 years old children in Professorial Pediatric Unit at Teaching Hospital Anuradhapura, Sri Lanka. An 18-month follow up was done to assess the risk factors for the development of recurrent ARTI, GE, UTI, and control presented without infections. Further, 6-month follow up done after 3-month iron supplementation to assess the occurrence of recurrences. Blood Hb concentration was measured using Drabking’s reagent. Logistic regression was used to find the risk factors for the development of recurrences. In ARTI, 121/165 (73.3%), GE, 88/124 (71%), UTI 46/96 (47.9%) and control 40/100 (40%) were having anemia. Initial ARTI group, recurrent ARTI was 24 (14.5%, p = 0.03); initial GE group: recurrent GE was 14 (11.3%, p = 0.03), recurrent ARTI was 11 (8.9%, p = 0.04); initial UTI group, development of; recurrent UTI was 8 (8.3%, p = 0.04); control, recurrent ARTI was 11 (11%, p = 0.03). Following 3-month iron supplementation reduction of recurrences was significant: initial ARTI recurrent ARTI in 90%, recurrent GE in 77.7%; initial GE recurrent GE in 83.3%, recurrent ARTI in 80%; initial UTI recurrent ARTI in 71.4% and control recurrent ARTI in 88.8%. Iron deficiency is a major type of anemia and anemic children are more prone to develop recurrent ARTI and GE. Once iron deficiency being corrected the rate of recurrent ARTI and GE was reduced. This would be a boost for policy developers to implement strategies at the community level to prevent iron deficiency in children to reduce ARTI and GE recurrences.
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Neufeld LM, Larson LM, Kurpad A, Mburu S, Martorell R, Brown KH. Hemoglobin concentration and anemia diagnosis in venous and capillary blood: biological basis and policy implications. Ann N Y Acad Sci 2019; 1450:172-189. [PMID: 31231815 PMCID: PMC7496102 DOI: 10.1111/nyas.14139] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 11/28/2022]
Abstract
Anemia is an important public health challenge and accurate prevalence estimates are needed for program planning and tracking progress. While venous blood assessed by automated hematology analyzers is considered gold standard, most population‐based surveys use point‐of‐care diagnostics and capillary blood to estimate population prevalence of anemia. Several factors influence hemoglobin (Hb) concentration, including human and analytic error, analysis method, and type of instrument, but it is unclear whether biological variability exists between venous and capillary blood. The objective of this paper was to systematically review sources of Hb variability and the potential biological basis for venous and capillary differences. We use data from a recent survey in the state of Uttar Pradesh, India, to illustrate the implications on anemia prevalence estimates. Significant differences in Hb concentration between capillary and venous blood samples are common. Most but not all find capillary Hb concentration to be higher than venous. Instrument/method variability and human error play an important role, but cannot fully explain these differences. A normative guide to data collection, analysis, and anemia diagnosis is needed to ensure consistent and appropriate interpretation. Further research is needed to fully understand the biological implications of venous and capillary Hb variability.
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Affiliation(s)
| | - Leila M Larson
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland.,Department of Medicine, the University of Melbourne, Melbourne, Victoria, Australia
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Larson LM, Kubes JN, Ramírez‐Luzuriaga MJ, Khishen S, H. Shankar A, Prado EL. Effects of increased hemoglobin on child growth, development, and disease: a systematic review and meta‐analysis. Ann N Y Acad Sci 2019; 1450:83-104. [DOI: 10.1111/nyas.14105] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/24/2019] [Accepted: 04/03/2019] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Maria J. Ramírez‐Luzuriaga
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate SchoolEmory University Atlanta Georgia
| | - Sarah Khishen
- Department of Public Health SciencesUniversity of California – Davis Davis California
| | - Anuraj H. Shankar
- Eijkman‐Oxford Clinical Research UnitEijkman Institute for Molecular Biology Jakarta Indonesia
- The Centre for Tropical Medicine and Global Health, Nuffield Department of MedicineUniversity of Oxford Oxford United Kingdom
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Keats EC, Neufeld LM, Garrett GS, Mbuya MNN, Bhutta ZA. Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis. Am J Clin Nutr 2019; 109:1696-1708. [PMID: 30997493 PMCID: PMC6537942 DOI: 10.1093/ajcn/nqz023] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/25/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Micronutrient malnutrition is highly prevalent in low- and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of large-scale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts. OBJECTIVES The aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs. METHODS All applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs. RESULTS LSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential. CONCLUSIONS Measurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.
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Affiliation(s)
- Emily C Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Greg S Garrett
- Global Alliance for Improved Nutrition, Geneva, Switzerland
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada,Address correspondence to ZAB (e-mail: )
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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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Campos Ponce M, Polman K, Roos N, Wieringa FT, Berger J, Doak CM. What Approaches are Most Effective at Addressing Micronutrient Deficiency in Children 0-5 Years? A Review of Systematic Reviews. Matern Child Health J 2019; 23:4-17. [PMID: 29868936 PMCID: PMC6373288 DOI: 10.1007/s10995-018-2527-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Introduction Even though micronutrient deficiency is still a major public health problem, it is still unclear which interventions are most effective in improving micronutrient status. This review therefore aims to summarize the evidence published in systematic reviews on intervention strategies that aim at improving micronutrient status in children under the age of five. Methods We searched the literature and included systematic reviews that reported on micronutrient status as a primary outcome for children of 0-5 years old, had a focus on low or middle income countries. Subsequently, papers were reviewed and selected by two authors. Results We included 4235 reviews in this systematic review. We found that (single or multiple) micronutrient deficiencies in pre-school children improved after providing (single or multiple) micronutrients. However home fortification did not always lead to significant increase in serum vitamin A, serum ferritin, hemoglobin or zinc. Commercial fortification did improve iron status. Cord clamping reduced the risk of anemia in infants up to 6 months and, in helminth endemic areas, anthelminthic treatment increased serum ferritin levels, hemoglobin and improved height for age z-scores. Anti-malaria treatment improved ferritin levels. Discussion Based on our results the clearest recommendations are: delayed cord clamping is an effective intervention for reducing anemia in early life. In helminth endemic areas iron status can be improved by anthelminthic treatment. Anti-malaria treatment can improve ferritin. In deficient populations, single iron, vitamin A and multimicronutrient supplementation can improve iron, vitamin A and multimicronutrient status respectively. While the impact of home-fortification on multimicronutrient status remains questionable, commercial iron fortification may improve iron status.
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Affiliation(s)
- M Campos Ponce
- Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands.
| | - K Polman
- Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - N Roos
- Department of Human Nutrition, University of Copenhagen, Copenhagen, Denmark
| | - F T Wieringa
- French National Research Institute for Sustainable Development (IRD), Montpellier, France
| | - J Berger
- French National Research Institute for Sustainable Development (IRD), Montpellier, France
| | - C M Doak
- Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands
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Maximising benefits and minimising adverse effects of micronutrient interventions in low- and middle-income countries. Proc Nutr Soc 2019; 78:540-546. [PMID: 30853033 DOI: 10.1017/s0029665119000557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Micronutrient deficiencies are widespread and disproportionately affect women and children in low- and middle-income countries (LMIC). Among various interventions, food fortification and supplementation with micronutrients have been proven to be cost-effective. The aim of the present paper is to review existing literature to assess risks of excessive intake in LMIC to then highlight programmatic changes required to maximise benefits of micronutrient interventions while minimising risks of adverse effects. While very few LMIC have national food consumption surveys that can inform fortification programmes, many more are implementing mandatory fortification programmes. The risks of inadequate micronutrient intakes were common, but risks of excessive intakes were also present for iodine, vitamin A, folic acid and iron. Excessive salt consumption, high concentrations of iodine in ground-water and excessive levels of iodisation were linked with excessive iodine intake. For vitamin A, overlapping interventions were the main risk for excessive intake; whereas for iron, contamination with iron from soil and screw-wares of millers and high iron concentration in drinking-water increased the risk of excessive intake, which could be further exacerbated with fortification. Before implementing micronutrient interventions, adherence to the basic principles of documenting evidence confirming that the deficiency in question exists and that fortification will correct this deficiency is needed. This can be supported with dietary intake assessments and biochemical screening that help diagnose nutrient deficiencies. Targeting micronutrient interventions, although programmatically challenging, should be considered whenever possible. Moreover, closer monitoring of appropriate fortification of foods and overlapping interventions is needed.
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