Effect of fortification with multiple micronutrients and n-3 fatty acids on growth and cognitive performance in Indian schoolchildren: the CHAMPION (Children's Health and Mental Performance Influenced by Optimal Nutrition) Study

A multi-sectoral community development intervention has a positive impact on diet quality and growth in school-age children in rural Nepal

Poor diet quality (diet diversity and animal-source food [ASF] consumption) during childhood negatively affects growth, development, behaviour and physiologic function in later life. Relatively less is known about the impact of poor diet on the growth of school-age children compared to children <5 years of age, especially in low/middle-income countries. A better understanding of delivery strategies for effective interventions to improve diet and hence growth in school-age children is needed. A 36-month longitudinal controlled impact evaluation in rural Nepal assessed the nutrition and growth of children <5 years of age in families assigned via community clusters to full package intervention (community development, training in nutrition [during pregnancy and for children <5 years] and livestock husbandry), partial package (training only) or control (no inputs). Concurrent data were collected prospectively (baseline plus additional four rounds) on school-age children (5-8 years at baseline) in these households; the present study analysed findings in the cohort of school-age children seen at all five study visits (n = 341). Diet quality improved more in the full package school-age children compared to those in partial package or control households. full package children consumed more ASF (β +0.40 [CI 0.07,0.73], p < 0.05), more diverse diets (β +0.93 [CI 0.55,1.31], p < 0.001) and had better head circumference z-scores (β +0.21 [CI 0.07,0.35], p < 0.01) than control children. In conclusion, a multi-sectoral community development intervention was associated with improvements in diet and growth of school-age children in rural Nepal even though the intervention focused on the diet of children <5 years of age. The diet and growth of school-age children can be favourably influenced by community-level interventions, even indirectly.

Weekly iron-folic acid supplementation and its impact on children and adolescents iron status, mental health and school performance: a systematic review and meta-analysis in sub-Saharan Africa

OBJECTIVE

This systematic review and meta-analysis aimed to comprehensively assess the impact of weekly iron-folic acid supplementation (WIFAS) on the nutrition, health and educational outcomes of children and adolescents in sub-Saharan Africa.

DESIGN

A systematic review and meta-analysis was used.

DATA SOURCES

Five databases, namely, MEDLINE, Scopus, Web of Science, Cochrane Library and Google Scholar, were systematically searched for relevant articles up to 23 August 2023.

ELIGIBILITY CRITERIA

It was focused on randomised controlled trials involving children and adolescents in sub-Saharan Africa, exploring the effects of iron supplementation on various outcomes, such as serum ferritin and haemoglobin levels, anaemia, mental health and school performance.

DATA EXTRACTION AND SYNTHESIS

The Joanna Briggs Institute Critical Appraisal tools were used for quality assessment, with two independent reviewers thoroughly evaluating each paper. Using the Cochrane risk of bias tool, we evaluated the certainty of evidence such as the risk of bias, inconsistency, indirectness, imprecision and publication bias.

RESULTS

A systematic review of 10 articles revealed that WIFAS significantly increased serum ferritin levels in adolescent girls (Hedge's g=0.53, 95% CI 0.28 to 0.78; heterogeneity I2=41.21%, p<0.001) and haemoglobin levels in school-aged children (Hedge's g=0.37, 95% CI 0.01 to 0.73; heterogeneity I2=91.62%, p<0.001). The analysis further demonstrated a substantial reduction in the risk of anaemia by 20% (risk ratio=0.8, 95% CI 0.69 to 0.93; heterogeneity I2=28.12%, p<0.001).

CONCLUSION

WIFAS proved effective in enhancing serum ferritin and haemoglobin concentrations and lowering the risk of anaemia in school-aged children and adolescents compared with a placebo. Similarly, there are not enough studies to examine the effects of WIFAS on school performance. However, information regarding mental health problems, mortality and potential side effects remains insufficient.

PROSPERO REGISTRATION NUMBER

CRD42023397898.

New Perspectives on the Associations between Blood Fatty Acids, Growth Parameters, and Cognitive Development in Global Child Populations

Malnutrition is prevalent in low-middle-income countries (LMICs), but it is usually clinically diagnosed through abnormal anthropometric parameters characteristic of protein energy malnutrition (PEM). In doing so, other contributors or byproducts of malnutrition, notably essential fatty acid deficiency (EFAD), are overlooked. Previous research performed mainly in high-income countries (HICs) shows that deficiencies in essential fatty acids (EFAs) and their n-3 and n-6 polyunsaturated fatty acid (PUFA) byproducts (also known as highly unsaturated fatty acids or HUFAs) lead to both abnormal linear growth and impaired cognitive development. These adverse developmental outcomes remain an important public health issue in LMICs. To identify EFAD before severe malnutrition develops, clinicians should perform blood fatty acid panels to measure levels of fatty acids associated with EFAD, notably Mead acid and HUFAs. This review demonstrates the importance of measuring endogenous fatty acid levels for measuring fatty acid intake in various child populations in LMICs. Featured topics include a comparison of fatty acid levels between global child populations, the relationships between growth and cognition and PUFAs and the possible mechanisms driving these relationships, and the potential importance of EFAD and HUFA scores as biomarkers of overall health and normal development.

Effectiveness of Fish Oil-DHA Supplementation for Cognitive Function in Thai Children: A Randomized, Doubled-Blind, Two-Dose, Placebo-Controlled Clinical Trial

The effects of fish oil (FO) or omega-3 supplementation on cognition has been the subject of several previous clinical trials. However, the effect of different doses taken chronically on cognition in children has not been well studied. In order to address this gap in our knowledge, we conducted a randomized, double-blind, placebo-controlled clinical trial. A total of one hundred and twenty healthy, cognitively normal Thai children aged 6–12 years old consumed daily low dose FO (260 mg Docosahexaenoic acid (DHA)), high dose FO (520 mg DHA), or placebo (Soybean oil) for 12 weeks. Cognitive function was assessed using a computerized cognitive battery, including the Go/NoGo, N-Back, and Digit Span tests as well as concurrent event-related potentials (ERPs), which together measured attention, processing speed, inhibition, and memory at baseline and 12 weeks. We hypothesized that compared to placebo, the two FO groups would show improved cognitive performance and shorter ERP latencies. In total, 42, 39, and 39 participants completed each of the test (FO-A, FO-B) and placebo groups (P) allocations, respectively, and were analyzed (120 in total across the three groups). No significant differences were observed between reaction times (RTs), accuracy, or error rates for all three of the cognitive tests. The ERP measurement and analysis of brain activity during the cognitive tests showed an increase in ERP amplitude. For all cognitive tests, there was a dose-response effect of FO on ERP amplitudes. These findings indicate that fish oil intake leads to a consistent improvement in attention and cognitive processing ability measured by changes in brain activity during working and long-term memory processes. This is the first study to directly quantify such an effect through simultaneous measurement of manual and mental activity during cognitive tasks following chronic FO use in children.

Effects of Foods Fortified with Zinc, Alone or Cofortified with Multiple Micronutrients, on Health and Functional Outcomes: A Systematic Review and Meta-Analysis

Seventeen per cent of the world's population is estimated to be at risk of inadequate zinc intake, which could in part be addressed by zinc fortification of widely consumed foods. We conducted a review of efficacy and effectiveness studies to ascertain the effect of zinc fortification [postharvest fortification of an industrially produced food or beverage; alone or with multiple micronutrients (MMN)] on a range of health outcomes. Previous reviews have required that the effect of zinc be isolated; because zinc is always cofortified with MMN in existing fortification programs, we did not impose this condition. Outcomes assessed were zinc-related biomarkers (plasma or serum, hair or urine zinc concentrations, comet assay, plasma fatty acid concentrations, and the proportion of and total zinc absorbed in the intestine from the diet), child anthropometry, morbidity, mortality, cognition, plasma or serum iron and copper concentrations, and for observational studies, a change in consumption of the food vehicle. Fifty-nine studies were included in the review; 54 in meta-analyses, totaling 73 comparisons. Zinc fortification with and without MMN increased plasma zinc concentrations (efficacy, n = 27: 4.68 μg/dL; 95% CI: 2.62-6.75; effectiveness, n = 13: 6.28 μg/dL; 95% CI: 5.03-7.77 μg/dL) and reduced the prevalence of zinc deficiency (efficacy, n = 11: OR: 0.76, 95% CI: 0.60-0.96; effectiveness, n = 10: OR: 0.45, 95% CI: 0.31-0.64). There were statistically significant increases in child weight (efficacy, n = 11: 0.43 kg, 95% CI: 0.11-0.75 kg), improvements in short-term auditory memory (efficacy, n = 3: 0.32 point, 95% CI: 0.13-0.50 point), and decreased incidence of diarrhea (efficacy, n = 3: RR: 0.79, 95% CI: 0.68-0.92) and fever (efficacy, n = 2: RR: 0.85, 95% CI: 0.74-0.97). However, these effects cannot be solely attributed to zinc. Our review found that zinc fortification with or without MMN reduced the prevalence of zinc deficiency and may provide health and functional benefits, including a reduced incidence of diarrhea.

Omega-3 polyunsaturated fatty acid intake and plasma fatty acids of school going Indian children - a cross-sectional study

Long-chain omega-3 polyunsaturated fatty acids (PUFA) such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) play an essential role in cognitive and behavioural changes among school going children. This study delineates the dietary omega-3 PUFA [alpha-Linolenic acid (ALA), DHA, and EPA] intake and plasma fatty acids levels among school-going children. This is a cross-sectional study purely observational in nature, wherein 625 apparently healthy boys and girls aged between 7 and 13 years were selected from five different schools of Hyderabad. Dietary information on omega-3 PUFA (ALA, DHA, and EPA) intake was collected using a food frequency questionnaire. Plasma fatty acid concentrations were measured in 34% of sub-sample using standard gas chromatography. The study revealed that the average dietary intakes of omega-3 PUFA, ALA, DHA, and EPA were 55.46, 15.82, 35.59, 4.06 mg/day, respectively. There was a significant difference in mean DHA intake among gender and age group [girls (38.64±1.45 mg/day), boys (31.80±1.38 mg/day) p < 0.001] and [7-10 years (31.75±1.38 mg/day), 11-13 years (38.07±1.40 mg/day) p < 0.01]. The mean plasma DHA and DPA levels of overall subjects were 0.98 nmol% and 0.18nmol% respectively which was comparable among different gender, age and BMI-for age groups. There was a positive correlation between dietary DHA intake and plasma DHA level [ρ=0.376 (p < 0.001)]. The current study demonstrated that the omega-3 PUFA intake in school going children was less and reinforces the importance of increasing the omega-3 PUFA intake through diet and supplements.

Effect of Omega-3 Long Chain Polyunsaturated Fatty Acids (n-3 LCPUFA) Supplementation on Cognition in Children and Adolescents: A Systematic Literature Review with a Focus on n-3 LCPUFA Blood Values and Dose of DHA and EPA

Omega-3 long chain polyunsaturated fatty acids (n-3 LCPUFA) supplementation in the cardiovascular field is effective if a certain Omega-3 index (O3I) is achieved or the daily n-3 LCPUFA dose is high enough. Whether this applies to studies on cognition in children and adolescents is unclear. The aims of the current review were to investigate whether: (1) a certain O3I level and (2) a minimum daily n-3 LCPUFA dose are required to improve cognition in 4-25 year olds. Web of Science and PubMed were searched. Inclusion criteria: placebo controlled randomized controlled trial; participants 4-25 years; supplementation with docosahexaenoic acid (DHA) and/or eicosapentaenoic acid (EPA); assessing cognition; in English and ≥10 participants per treatment arm. Thirty-three studies were included, 21 in typically developing participants, 12 in those with a disorder. A positive effect on cognitive measures was more likely in studies with an increase in O3I to >6%. Half of the studies in typically developing children with daily supplementation dose ≥450 mg DHA + EPA showed improved cognition. For children with a disorder no cut-off value was found. In conclusion, daily supplementation of ≥450 mg DHA + EPA per day and an increase in the O3I to >6% makes it more likely to show efficacy on cognition in children and adolescents.

Effects of oily fish intake on cognitive and socioemotional function in healthy 8-9-year-old children: the FiSK Junior randomized trial

BACKGROUND

Long-chain n-3 PUFAs (n-3 LCPUFAs) accrete in the brain during childhood and affect brain development. Randomized trials in children show inconsistent effects of n-3 LCPUFAs on cognitive and socioemotional function, and few have investigated effects of fish per se.

OBJECTIVES

We aimed to investigate the effects of oily fish consumption on overall and domain-specific cognitive and socioemotional scores and explore sex differences.

METHODS

Healthy 8-9-y-old children (n = 199) were randomly allocated to receive ∼300 g/wk oily fish or poultry (control) for 12 ± 2 wk. At baseline and endpoint, we assessed attention, processing speed, executive functions, memory, emotions, and behavior with a large battery of tests and questionnaires and analyzed erythrocyte fatty acid composition.

RESULTS

One hundred and ninety-seven (99%) children completed the trial. Children in the fish group consumed 375 (25th-75th percentile: 325-426) g/wk oily fish resulting in 2.3 (95% CI: 1.9, 2.6) fatty acid percentage points higher erythrocyte n-3 LCPUFA than in the poultry group. The overall cognitive performance score tended to improve by 0.17 (95% CI: -0.01, 0.35) points in children who received fish compared with poultry, supported by n-3 LCPUFA dose dependency. This was driven mainly by fewer errors [-1.9 (95% CI: -3.4, -0.3)] in an attention task and improved cognitive flexibility measured as faster reaction time [-51 ms (95% CI: -94, -7 ms)] in a complex relative to a simple task ("mixing cost"). The fish intervention furthermore reduced parent-rated Strength and Difficulties Questionnaire total difficulties by -0.89 (95% CI: -1.60, -0.18) points mainly due to a -0.63 (95% CI: -1.11, -0.16) points reduction in internalizing problems that was reflected in tendency to a decrease in the overall socioemotional problems score of -0.13 (95% CI: -0.26, 0.01) points. The overall effects were similar in boys and girls.

CONCLUSIONS

Oily fish dose-dependently improved cognitive function, especially attention and cognitive flexibility, and reduced socioemotional problems. The results support the importance of n-3 LCPUFAs for optimal brain function and fish intake recommendations in children.The trial was registered at www.clinicaltrials.gov as NCT02809508.

Effect of Omega-3 and Korean Red Ginseng on Children with Attention Deficit Hyperactivity Disorder: An Open-Label Pilot Study

Objective

The purpose of the present study was to evaluate the efficacy of omega-3 and Korean red ginseng on improving attention deficit hyperactivity disorder (ADHD) symptoms and cognitive function in children with ADHD.

Methods

A total of 40 children aged 6 to 12 years diagnosed with ADHD participated in this open-label trial. Participants received daily supplements containing 500 mg of omega-3 (eicosapentaenoic acid, 294 mg; docosahexaenoic acid, 206 mg) and 3 mg of Korean red ginseng extract (combination of ginsenoside Rg1, Rb1, and Rg3) for 12 weeks. No psychotropic drug was allowed during the study period. ADHD symptoms were assessed using the ADHD Rating Scale (ADHD-RS) and Clinical Global Impression-Severity (CGI-S) scale. Neuropsychological tests on sustained attention, short-term memory, and executive function were also assessed.

Results

After 12 weeks, participants showed significant improvements on ADHD-RS (31.12 ± 8.82 at baseline, 24.15 ± 11.45 at endpoint; p < 0.001) and CGI-S (3.38 ± 1.18 at baseline, 2.94 ± 1.00 at endpoint; p < 0.001). On the Continuous Performance Test, commission errors significantly decreased, while reaction time significantly increased. Immediate recall and delayed recall on both Auditory Verbal Learning Test and Complex Figure Test showed significant improvements. Scores of Color–Word Task from Stroop Color–Word Test also showed significant improvements after the treatment. The supplement was well tolerated.

Conclusion

The results of this pilot study suggest that the combination of omega-3 and Korean red ginseng may improve ADHD symptoms and cognitive function including attention, memory, and executive function in children with ADHD. Future randomized placebo-controlled trials with a larger sample is warranted.

Associations of dietary carbohydrate and fatty acid intakes with cognition among children

OBJECTIVE

To investigate the cross-sectional associations of dietary carbohydrate and fatty acid intakes with cognition in mid-childhood.

DESIGN

Dietary carbohydrate and fatty acid intakes were assessed using 4-d food records, and cognition was evaluated using the Raven's Coloured Progressive Matrices (RCPM) score. The cross-sectional associations of dietary carbohydrate and fatty acid intakes with cognition were investigated using linear regression analyses adjusted for age, sex, body fat percentage, household income, parental education and daily energy intake.

SETTING

The baseline examinations of the Physical Activity and Nutrition in Children study.

PARTICIPANTS

A population-based sample of 487 children (250 boys, 237 girls) aged 6-8 years living in the city of Kuopio, Finland.

RESULTS

A higher dietary intake of fructose (standardised regression coefficient, β = 0·24, P < 0·001), total fibre (β = 0·16, P = 0·02) and soluble fibre (β = 0·15, P = 0·02) was associated with a higher RCPM score in boys. Other dietary carbohydrates and fatty acids, including total carbohydrates, glucose, sucrose, starch, insoluble fibre, total fat, SFAs, MUFAs, PUFAs, palmitic acid (C16), stearic acid (C18), linoleic acid (C18:2), α-linoleic acid (C18:3), arachidonic acid (C20:4), EPA (C20:5n-3) and DHA (C22:6n-6), were not associated with the RCPM score in boys. Dietary carbohydrates or fatty acids were not associated with the RCPM score in girls.

CONCLUSIONS

Higher dietary fructose and fibre intakes were associated with better cognition in boys, but not in girls. Dietary fatty acids were not related to cognition in boys or in girls.

Food fortification with multiple micronutrients: impact on health outcomes in general population

BACKGROUND

Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

OBJECTIVES

To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

SEARCH METHODS

We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

MAIN RESULTS

We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

AUTHORS' CONCLUSIONS

The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

Comprehensive school-based health programs to improve child and adolescent health: Evidence from Zambia

BACKGROUND

While school-aged children in low- and middle-income countries remain highly exposed to acute infections, programs targeting this age group remain limited in scale and scope. In this paper, we evaluate the impact of a new and comprehensive primary school-based health intervention program on student-reported morbidity and anthropometric outcomes in Lusaka, Zambia.

METHODS

A prospective matched control study identified 12 classes in 7 schools for the intervention and 12 classes in 7 matched schools as controls. Teachers in intervention schools were trained to deliver health lessons and to refer sick students to care. In addition, vitamin A and deworming medication were biannually administered to intervention students. The primary study outcome was student-reported morbidity. Secondary outcomes were weight, height, health knowledge, and absenteeism. Multivariable linear and logistic regression models were used to estimate program impact.

RESULTS

380 students ages 4-16 were enrolled in the study in 2015, and 97% were followed up at endline in 2016. The intervention decreased the adjusted odds of self-reported acute illnesses by 38% (95% CI: 0.48, 0.77) and the adjusted odds of stunting by 52% (95% CI: 0.26, 0.87). It also increased health knowledge by 0.53 standard deviations (95% CI: 0.24, 0.81). No impact was found on weight (adjusted mean difference β = 0.17, 95% CI: - 1.11, 1.44) and student absenteeism (adjusted odds ratio (aOR) = 0.89, 95% CI: 0.60, 1.33).

CONCLUSION

The results presented in this paper suggest that comprehensive school-based health programs may offer a highly effective way to improve students' health knowledge as well as their health status. Given their low cost, a more general adoption and implementation of such programs seems recommendable.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03607084.

Effect of 1 Year Krill Oil Supplementation on Cognitive Achievement of Dutch Adolescents: A Double-Blind Randomized Controlled Trial

Long-chain polyunsaturated fatty acids (LCPUFA) are important for brain development and function, maybe especially during adolescence. Observational studies have demonstrated an association between fish consumption (a source of LCPUFA) and cognition in adolescents, but intervention trials are lacking. The goal of the current study was to investigate the effect of one year of krill oil (a source of LCPUFA) supplementation on the cognitive performance of adolescents with a low Omega-3 Index (O3I ≤ 5%). A double-blind, randomized, and placebo-controlled supplementation trial with repeated measurements (baseline (T0), three months (T1), six months (T2), and 12 months (T3)) in adolescents (267 randomized) was executed. Participants were randomized to 400 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) per day in Cohort I or placebo and 800 mg EPA + DHA per day in Cohort II or placebo. O3I was monitored by a finger prick at all time points. At T0, T2, and T3, participants executed a neurocognitive test battery. Covariate corrected mixed models were run with either condition (krill or placebo) or O3I as predictors. Krill oil supplementation led to a small but significant increase in mean O3I, but few participants increased to the intended O3I range (8–11%). There was no significant effect of supplementation on the neurocognitive tests, nor a relationship between O3I and neurocognitive test scores. The increase in O3I was small in most participants, probably due to non-compliance. Possibly the increase in O3I was too small to demonstrate an effect. More research on the influence of LCPUFAs on cognition in adolescents is needed.

Exploring correlations between neuropsychological measures and domain-specific consistency in associations with n-3 LCPUFA status in 8-9 year-old boys and girls

Long-chain n-3 polyunsaturated fatty acids (n-3 LCPUFA) have in some studies been associated with cognitive and socioemotional outcomes in children, but results are inconsistent possibly due to the use of different tests and potential gender-specific effects. The objective of this cross-sectional study was to explore overall patterns in neuropsychological scores as well as correlations between scores within specific domains, and to examine potential gender differences and consistency in associations with n-3 LCPUFA status. In 199 Danish 8–9 year-old children, we performed a large battery of tests and questionnaires on attention, processing speed, executive functions, memory, and socioemotional traits, and measured erythrocyte fatty acid composition. Principal component analyses (PCA) showed that most of the variation in both cognitive performance and socioemotional traits was explained by overall performance, followed by speed-accuracy trade off and externalizing vs. internalizing problems, respectively. Boys had higher speed, lower attention and higher externalizing problem scores than girls. Measures of performance within both processing speed and attention domains correlated moderately, whereas no correlations were found for measures of executive functions apart from some weak correlations for impulsivity. Parent-rated scores for both externalizing and internalizing problems correlated strongly, whereas correlations with child-rated scores were weak. Scores within specific domains did not consistently associate with n-3 LCPUFA, except for processing speed measures which all pointed to faster processing with increased n-3 LCPUFA status. Gender differences in the associations were observed for attention and impulsivity. Child- but not parent-rated internalizing and social problems tended to associate directly with n-3 LCPUFA, supported by increased internalizing problems measured by the PCA component. In conclusion, measures of speed and attention seem to represent these domains in general, whereas single measures of more complex cognitive functions should be interpreted with caution. One approach could be to use multiple tests and create multivariate scores to guide interpretations. Furthermore, the results indicate a need to consider both parent- and child-rated socioemotional scores and gender differences in neuropsychological functions e.g. in investigations of n-3 LCPUFA effects.

Whole blood n-3 fatty acids are associated with executive function in 2-6-year-old Northern Ghanaian children

Several studies demonstrate the importance of essential fatty acids (EFAs), and the long chain polyunsaturated FA docosahexaenoic acid (DHA), on cognition and brain development. The objective of this study was to investigate the relationship between whole-blood FAs and executive function in children from Northern Ghana. A total of 307, 2-to-6-year-old children attempted the dimensional change card sort (DCCS) task to assess executive function, and dried blood spot samples were collected and analyzed for FA content. Significant differences in mean % total whole-blood fatty acids were observed between children who could not follow directions on the DCCS test (49.8% of the sample) and those who could (50.2% of the sample). Positive associations with DCCS performance were observed for DHA (β=0.25, P=.06), total n-3 (β=0.17, P=.06) and dihomo-gamma-linolenic acid (DGLA; β=0.60, P=.06). Children with the highest levels of total n-3 and DHA were three and four times, respectively, more likely to pass at least one condition of the DCCS test of executive function than those with the lowest DHA levels. The results of this study indicate an association between n-3 FAs and high-level cognitive processes in children two to six years of age, providing impetus for further studies into possible interventions to improve EFA status of children in developing countries.

Fatty fish intake and cognitive function: FINS-KIDS, a randomized controlled trial in preschool children

BACKGROUND

Marine resources including fatty fish are important sources of n-3 long chain polyunsaturated fatty acids (n-3 LC-PUFAs), which are important for brain development. To our knowledge, this is the first randomized controlled trial (RCT) investigating the impact of fatty fish on cognition in preschool children. The purpose of the trial was to investigate whether an increased intake of fatty fish compared to meat improves cognitive function in children 4-6 years old.

METHODS

The children (n = 232) in this two-armed RCT, Fish Intervention Studies-KIDS (FINS-KIDS) were recruited from 13 kindergartens in Bergen, Norway. They were randomly assigned to lunch meals with fatty fish (herring/mackerel) or meat (chicken/lamb/beef) three times a week for 16 weeks. The fish and meat were weighed before and after the meals to record the exact consumption (dietary compliance). The primary outcome was cognitive function measured by the Wechsler Preschool and Primary Scale of Intelligence, 3rd edition (WPPSI-III) and fine-motor coordination measured by the 9-Hole Peg Test (9-HPT) at pre- and post-intervention. Biological samples (blood, urine, hair), and questionnaires to the caregivers were included at both time points. Linear mixed effect models with a random intercept for kindergarten were used to analyze changes from pre- to post-intervention in the primary outcome variables.

RESULTS

There were 218 children included in the trial (105 in the fish, and 113 in the meat group). The children consumed a mean (standard deviation) of 2070 (978) g fish or 2675 (850) g meat from the study meals (p < 0.0001). The fish group had a significant increase of red blood cell n-3 LC-PUFAs. The intervention had no effect on the WPPSI-III scores (mean change total raw score; fish group 17.7, 95% confidence interval (CI) 14.8-20.7 vs meat group 17.8, 95% CI 15.0-20.6, p = 0.97) in the main analyses. In the sub-analyses, adjusting for dietary compliance, the fish group showed a higher improvement on total raw score (20.4, 95% CI 17.5-23.3) compared to the meat group (15.2, 95% CI 12.4-18.0, p = 0.0060); docosahexaenoic acid mediated this effect.

CONCLUSIONS

There was no beneficial effect of fatty fish compared to meat on cognitive functioning in the preschool children. When considering dietary compliance, we found a beneficial effect of fatty fish on cognitive scores.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02331667 December 17, 2014.

n-3 Fatty Acid Supplementation in Mothers, Preterm Infants, and Term Infants and Childhood Psychomotor and Visual Development: A Systematic Review and Meta-Analysis

Background

Epidemiologic studies link maternal seafood and n-3 (ω-3) polyunsaturated fatty acid (PUFA) consumption with improved childhood cognitive development; trials show mixed results.

Objective

We investigated effects of n-3 PUFA supplementation on child cognitive and visual outcomes.

Methods

We systematically reviewed and meta-analyzed randomized controlled trials of n-3 PUFA supplementation in mothers or infants (age ≤2 y) and evaluated standardized measures of cognitive or visual development up to age 18 y. Of 6286 abstracts and 669 full-text articles, 38 trials with 53 intervention arms were included. Data were extracted independently in duplicate. Findings were pooled using random-effects meta-analysis across supplementation periods (maternal, preterm, term infant); we also explored subgroup analyses stratified by supplementation period. Heterogeneity was explored using I2, stratified analysis, and meta-regression. Cognitive development was assessed by Bayley Scales of Infant Development mental and psychomotor developmental indexes (MDI, PDI) and intelligence quotient (IQ); visual acuity was assessed by electrophysiological or behavioral measures.

Results

The 38 trials (mothers: n = 13; preterm infants: n = 7; term infants: n = 18) included 5541 participants. When we explored effects during different periods of supplementation, n-3 PUFA supplementation improved MDI in preterm infants (3.33; 95% CI: 0.72, 5.93), without statistically significant effects on PDI or IQ in different intervention period subgroups. Visual acuity [measured as the logarithm of the minimum angle of resolution (logMAR)] was improved by supplementation in preterm (-0.08 logMAR; 95% CI: -0.14, -0.01 logMAR) and term infants (-0.08 logMAR; 95% CI: -0.11, -0.05 logMAR), with a nonsignificant trend for maternal supplementation (-0.02 logMAR; 95% CI: -0.04, 0.00 logMAR). In main analyses pooling all supplementation periods, compared with placebo, n-3 PUFA supplementation improved MDI (n = 21 trials; 0.91; 95% CI: 0.005, 1.81; P = 0.049), PDI (n = 21 trials; 1.06 higher index; 95% CI: 0.10, 2.03; P = 0.031), and visual acuity (n = 24; -0.063 logMAR; 95% CI: -0.084, -0.041 logMAR; P < 0.001) but not IQ (n = 7; 0.20; 95% CI: -1.56, 1.96, P = 0.83), although few studies assessed this endpoint. Potential publication bias was identified for MDI (Eggers P = 0.005), but not other endpoints. Significant differences in findings were not identified by world region, race, maternal education, age at outcome assessment, supplementation duration, DHA or EPA dose, DHA:AA ratio, or study quality score (P-interaction > 0.05 each).

Conclusions

n-3 PUFA supplementation improves childhood psychomotor and visual development, without significant effects on global IQ later in childhood, although the latter conclusion is based on fewer studies.

A Randomized, Double-Blind Study Assessing Changes in Cognitive Function in Indian School Children Receiving a Combination of Bacopa monnieri and Micronutrient Supplementation vs. Placebo

Several studies have indicated a chronic cognitive enhancing effect of Bacopa monnieri across different ages and cognitive impairment associated with vitamin and mineral deficiencies in children. Therefore, we investigated the effects of 4-month supplementation with a combination of B. monnieri extract and multiple micronutrients on cognitive functions in Indian school children aged 7–12 years. This was a randomized, double-blind, parallel design, single-center study in which 300 children were randomized to receive a beverage either fortified with B. monnieri and multiple micronutrients (“fortified”) or a non-fortified isocaloric equivalent (“control”) twice-daily for 4 months. Cognitive function was assessed by the Cambridge Neuropsychological Automated Test Battery (CANTAB) administered at baseline, Day 60 and Day 121. The primary endpoint was change in short-term memory (working memory) from baseline in subjects receiving “fortified” vs. “control” beverages after 4 months. Secondary endpoints included sustained attention, episodic memory, and executive function. The “fortified” beverage did not significantly improve short-term memory or any of the secondary outcomes tested relative to the “control” beverage. However, the spatial working memory “strategy” score showed significant improvement on Day 60 (difference between groups in change from baseline: −0.55; p < 0.05), but not on Day 121 due to the active intervention. Study products were well-tolerated. Reasons for these unexpected findings are discussed.

School Children's Intestinal Parasite and Nutritional Status One Year after Complementary School Garden, Nutrition, Water, Sanitation, and Hygiene Interventions in Burkina Faso

The potential health benefits of combined agricultural, nutrition, water, sanitation, and hygiene (WASH) interventions are poorly understood. We aimed to determine whether complementary school garden, nutrition, and WASH interventions reduce intestinal parasites and improve school children's nutritional status in two regions of Burkina Faso. A cluster-randomized controlled trial was conducted in the Plateau Central and Center-Ouest regions of Burkina Faso. A total of 360 randomly selected children, aged 8-15 years, had complete baseline and end-line survey data. Mixed regression models were used to assess the impact of the interventions, controlling for baseline characteristics. The prevalence of intestinal parasitic infections decreased both in intervention and control schools, but the decrease was significantly higher in the intervention schools related to the control schools (odds ratio [OR] of the intervention effect = 0.2, 95% confidence interval [CI] = 0.1-0.5). Indices of undernutrition did not decrease at end-line in intervention schools. Safe handwashing practices before eating and the use of latrines at schools were significantly higher in the intervention schools than in the control schools at end-line (OR = 6.9, 95% CI = 1.4-34.4, and OR = 14.9, 95% CI = 1.4-153.9, respectively). Parameters of water quality remained unchanged. A combination of agricultural, nutritional, and WASH-related interventions embedded in the social-ecological systems and delivered through the school platform improved several child health outcomes, including intestinal parasitic infections and some WASH-related behaviors. Sustained interventions with stronger household and community-based components are, however, needed to improve school children's health in the long-term.

The Impact of Nutritional Interventions beyond the First 2 Years of Life on Linear Growth: A Systematic Review and Meta-Analysis

A large body of evidence suggests that the first 1000 d from conception is a critical window in which interventions to address malnutrition will be most effective, but little is known about the impact on linear growth of nutritional interventions in children ≥2 y of age. The aim of this analysis was to evaluate the effectiveness of several nutrition-based interventions, specifically iron, zinc, calcium, iodine, vitamin A, multiple (≥2) micronutrients, protein, and food, at improving growth in children ≥2 y of age. A systematic search of MEDLINE and EMBASE retrieved 7794 articles. A total of 69 studies met prespecified inclusion criteria. Baseline height-for-age z score, age, nutrient dose, and study duration were examined as potential sources of heterogeneity. Zinc (mean effect size: 0.15; 95% CI: 0.06, 0.24), vitamin A (0.05; 95% CI: 0.01, 0.09), multiple micronutrients (0.26; 95% CI: 0.13, 0.39), and protein (0.68; 95% CI: 0.30, 1.05) had significant positive effects on linear growth, with baseline height-for-age z score as a significant inverse predictor of the effect size. Iron, calcium, iodine, and food-based interventions had no significant effect on growth. Age at baseline, study duration, and dose were not related to effect size for any nutrient examined. These findings suggest that zinc, vitamin A, multiple micronutrients, and protein interventions delivered after 24 mo of age can have a positive effect on linear growth, especially in populations that have experienced growth failure.

N-3 Polyunsaturated Fatty Acids through the Lifespan: Implication for Psychopathology

OBJECTIVE

The impact of lifetime dietary habits and their role in physical, mental, and social well-being has been the focus of considerable recent research. Omega-3 polyunsaturated fatty acids as a dietary constituent have been under the spotlight for decades. Omega-3 polyunsaturated fatty acids constitute key regulating factors of neurotransmission, neurogenesis, and neuroinflammation and are thereby fundamental for development, functioning, and aging of the CNS. Of note is the fact that these processes are altered in various psychiatric disorders, including attention deficit hyperactivity disorder, depression, and Alzheimer's disease.

DESIGN

Relevant literature was identified through a search of MEDLINE via PubMed using the following words, "n-3 PUFAs," "EPA," and "DHA" in combination with "stress," "cognition," "ADHD," "anxiety," "depression," "bipolar disorder," "schizophrenia," and "Alzheimer." The principal focus was on the role of omega-3 polyunsaturated fatty acids throughout the lifespan and their implication for psychopathologies. Recommendations for future investigation on the potential clinical value of omega-3 polyunsaturated fatty acids were examined.

RESULTS

The inconsistent and inconclusive results from randomized clinical trials limits the usage of omega-3 polyunsaturated fatty acids in clinical practice. However, a body of literature demonstrates an inverse correlation between omega-3 polyunsaturated fatty acid levels and quality of life/ psychiatric diseases. Specifically, older healthy adults showing low habitual intake of omega-3 polyunsaturated fatty acids benefit most from consuming them, showing improved age-related cognitive decline.

CONCLUSIONS

Although further studies are required, there is an exciting and growing body of research suggesting that omega-3 polyunsaturated fatty acids may have a potential clinical value in the prevention and treatment of psychopathologies.

Effects of wheat-flour biscuits fortified with iron and EDTA, alone and in combination, on blood lead concentration, iron status, and cognition in children: a double-blind randomized controlled trial

BACKGROUND

Lead is a common neurotoxicant and its absorption may be increased in iron deficiency (ID). Thus, iron fortification to prevent ID in populations is a promising lead mitigation strategy. Two common fortificants are ferrous sulfate (FeSO₄) and ferric sodium EDTA (NaFeEDTA). EDTA can chelate iron and lead.

OBJECTIVES

Our study objective was to determine the effects of iron and EDTA, alone and in combination, on blood lead (BPb) concentration, iron status, and cognition.

DESIGN

In this 2 × 2 factorial, double-blind placebo-controlled trial, 457 lead-exposed Moroccan children were stratified by school and grade and randomly assigned to consume biscuits (6 d/wk at school) containing 1) ∼8 mg Fe as FeSO₄, 2) ∼8 mg Fe as NaFeEDTA that contained ∼41 mg EDTA, 3) ∼41 mg EDTA as sodium EDTA (Na₂EDTA), or 4) placebo for 28 wk. The primary outcome was BPb concentration; secondary outcomes were iron status and cognitive outcomes from subtests of the Kaufman Assessment Battery for Children and the Hopkins Verbal Learning Test. These outcomes were measured at baseline and endpoint. All data were analyzed by intention-to-treat.

RESULTS

The adjusted geometric mean BPb concentration at baseline was 4.3 μg/dL (95% CI: 4.2, 4.3 μg/dL), and at endpoint these values were 3.3 μg/dL (95% CI: 3.1, 3.5 μg/dL) for FeSO₄, 2.9 μg/dL (95% CI: 2.7, 3.0 μg/dL) for NaFeEDTA, 3.3 μg/dL (95% CI: 3.1, 3.5 μg/dL) for EDTA, and 3.7 μg/dL (95% CI: 3.5, 3.9 μg/dL) for placebo. We found an effect of iron (P = 0.009) and EDTA (P = 0.012) for reduced BPb concentrations at endpoint, but no iron × EDTA interaction. Iron fortification improved iron status, but there were no positive effects of iron or EDTA on cognitive test scores.

CONCLUSIONS

Food fortification with iron and EDTA additively reduces BPb concentrations. Our findings suggest that NaFeEDTA should be the iron fortificant of choice in lead-exposed populations. This trial was registered at clinicaltrials.gov as NCT01573013.

Long-chain omega-3 fatty acids and optimization of cognitive performance

Low consumption of the omega-3 fatty acids, eicosapentaenoic and docosahexaenonic acids, is linked to delayed brain development and, in late life, increased risk for Alzheimer's disease. The current review focuses on cognitive functioning during midlife and summarizes available scientific evidence relevant to the hypothesis that adequate dietary consumption of the long-chain omega-3 fatty acids is necessary for optimal cognitive performance. Taken together, the findings suggest that raising the currently low consumption among healthy adults may improve some aspects of cognitive performance. Nonetheless, evidence from randomized clinical trials is comparatively sparse and leaves unclear: (a) whether such effects are clinically significant, (b) whether effects of eicosapentaenoic acid and DHA differ, (c) which dimensions of cognitive function are affected, (d) the dose-response relationships, or (e) the time course of the response. Clarification of these issues through both laboratory and clinical investigations is a priority given the broad implications for public health, as well as for military personnel and other positions of high performance demand and responsibility.

Docosahexaenoic Acid and Cognition throughout the Lifespan

Docosahexaenoic acid (DHA) is the predominant omega-3 (n-3) polyunsaturated fatty acid (PUFA) found in the brain and can affect neurological function by modulating signal transduction pathways, neurotransmission, neurogenesis, myelination, membrane receptor function, synaptic plasticity, neuroinflammation, membrane integrity and membrane organization. DHA is rapidly accumulated in the brain during gestation and early infancy, and the availability of DHA via transfer from maternal stores impacts the degree of DHA incorporation into neural tissues. The consumption of DHA leads to many positive physiological and behavioral effects, including those on cognition. Advanced cognitive function is uniquely human, and the optimal development and aging of cognitive abilities has profound impacts on quality of life, productivity, and advancement of society in general. However, the modern diet typically lacks appreciable amounts of DHA. Therefore, in modern populations, maintaining optimal levels of DHA in the brain throughout the lifespan likely requires obtaining preformed DHA via dietary or supplemental sources. In this review, we examine the role of DHA in optimal cognition during development, adulthood, and aging with a focus on human evidence and putative mechanisms of action.

Docosahexaenoic Acid and Cognition throughout the Lifespan

Docosahexaenoic acid (DHA) is the predominant omega-3 (n-3) polyunsaturated fatty acid (PUFA) found in the brain and can affect neurological function by modulating signal transduction pathways, neurotransmission, neurogenesis, myelination, membrane receptor function, synaptic plasticity, neuroinflammation, membrane integrity and membrane organization. DHA is rapidly accumulated in the brain during gestation and early infancy, and the availability of DHA via transfer from maternal stores impacts the degree of DHA incorporation into neural tissues. The consumption of DHA leads to many positive physiological and behavioral effects, including those on cognition. Advanced cognitive function is uniquely human, and the optimal development and aging of cognitive abilities has profound impacts on quality of life, productivity, and advancement of society in general. However, the modern diet typically lacks appreciable amounts of DHA. Therefore, in modern populations, maintaining optimal levels of DHA in the brain throughout the lifespan likely requires obtaining preformed DHA via dietary or supplemental sources. In this review, we examine the role of DHA in optimal cognition during development, adulthood, and aging with a focus on human evidence and putative mechanisms of action.

A combined supplementation of vitamin B12and omega-3 fatty acids across two generations improves cardiometabolic variables in rats

Our earlier studies indicate that micronutrients (vitamin B₁₂, folic acid) and omega-3 fatty acids especially docosahexaenoic acid (DHA) are interlinked in one carbon cycle.

Diet-induced changes in iron and n-3 fatty acid status and associations with cognitive performance in 8-11-year-old Danish children: secondary analyses of the Optimal Well-Being, Development and Health for Danish Children through a Healthy New Nordic Diet School Meal Study

Fe and n-3 long-chain PUFA (n-3 LCPUFA) have both been associated with cognition, but evidence remains inconclusive in well-nourished school-aged children. In the Optimal Well-Being, Development and Health for Danish Children through a Healthy New Nordic Diet (OPUS) School Meal Study, the 3-month intervention increased reading performance, inattention, impulsivity and dietary intake of fish and Fe. This study investigated whether the intervention influenced n-3 LCPUFA and Fe status and, if so, explored how these changes correlated with the changes in cognitive performance. The study was a cluster-randomised cross-over trial comparing school meals with packed lunch (control). At baseline and after each treatment, we measured serum ferritin, whole-blood n-3 LCPUFA and Hb, and performance in reading, mathematics and d2-test of attention. Data were analysed using mixed models (n 726) and principal component analysis of test performances (n 644), which showed two main patterns: 'school performance' and 'reading comprehension'. The latter indicated that children with good reading comprehension were also more inattentive and impulsive (i.e. higher d2-test error%). The intervention improved 'school performance' (P=0·015), 'reading comprehension' (P=0·043) and EPA+DHA status 0·21 (95% CI 0·15, 0·27) w/w % (P<0·001), but it did not affect serum ferritin or Hb. At baseline, having small Fe stores was associated with poorer 'school performance' in girls, but with better 'reading comprehension' in both boys and girls. Both baseline EPA+DHA status and the intervention-induced increase in EPA+DHA status was positively associated with 'school performance', suggesting that n-3 LCPUFA could potentially explain approximately 20 % of the intervention effect. These exploratory associations indicate that increased fish intake might explain some of the increase in reading performance and inattention in the study.

Reduced Symptoms of Inattention after Dietary Omega-3 Fatty Acid Supplementation in Boys with and without Attention Deficit/Hyperactivity Disorder

Attention deficit/hyperactivity disorder (ADHD) is one of the most common child psychiatric disorders, and is often treated with stimulant medication. Nonpharmacological treatments include dietary supplementation with omega-3 fatty acids, although their effectiveness remains to be shown conclusively. In this study, we investigated the effects of dietary omega-3 fatty acid supplementation on ADHD symptoms and cognitive control in young boys with and without ADHD. A total of 40 boys with ADHD, aged 8-14 years, and 39 matched, typically developing controls participated in a 16-week double-blind randomized placebo-controlled trial. Participants consumed 10 g of margarine daily, enriched with either 650 mg of eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) each or placebo. Baseline and follow-up assessments addressed ADHD symptoms, fMRI of cognitive control, urine homovanillic acid, and cheek cell phospholipid sampling. EPA/DHA supplementation improved parent-rated attention in both children with ADHD and typically developing children. Phospholipid DHA level at follow-up was higher for children receiving EPA/DHA supplements than placebo. There was no effect of EPA/DHA supplementation on cognitive control or on fMRI measures of brain activity. This study shows that dietary supplementation with omega-3 fatty acids reduces symptoms of ADHD, both for individuals with ADHD and typically developing children. This effect does not appear to be mediated by cognitive control systems in the brain, as no effect of supplementation was found here. Nonetheless, this study offers support that omega-3 supplementation may be an effective augmentation for pharmacological treatments of ADHD (NCT01554462: The Effects of EPA/DHA Supplementation on Cognitive Control in Children with ADHD; http://clinicaltrials.gov/show/NCT01554462).

The Long Term Impact of Micronutrient Supplementation during Infancy on Cognition and Executive Function Performance in Pre-School Children

Brain growth and development are critically dependent on several micronutrients. During early development cellular activity may be sensitive to micronutrient deficiencies, however the evidence from human studies is equivocal. The objective of this study was to examine the long-term cognitive and social-emotional effects of multiple micronutrient supplementation compared with iron supplementation alone, administered during infancy. This study was a follow-up to an initial randomized, double-blind controlled trial (RCT) in 2010 in which 902 infants, aged 6–17 months, from Lima, Peru, were given daily supplements of either iron (Fe) or multiple micronutrients (MMN) including zinc (451 in each group). The supplementation period for both groups was six months. In 2012, a subsample of 184 children from the original cohort (now aged 36–48 months) was randomly selected to participate in a follow-up trial and was assessed for intelligence, working memory, inhibition, and executive function. The tests showed no significant differences between the supplementation groups though there were some gender differences, with girls displaying higher scores than boys across both groups on the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) Verbal IQ sentences subtest, the Day-Night cognitive test and on the Brief Infant-Toddler Social Emotional Assessment (BITSEA) social competency, and boys scoring higher than girls in problem behaviour. The results indicate that MMN supplementation had no long term additional effects on cognitive function compared with iron supplementation alone. The timing of supplement administration for maximum impact on a child’s cognitive development requires further investigation.

The effects of regular consumption of a multiple micronutrient fortified milk beverage on the micronutrient status of school children and on their mental and physical performance

Multiple micronutrient deficiencies exist in school going children in India and bridging the gap between nutrient intake and requirements is an effective way to combat the deficiencies. This study aimed to test the effect of a multi-micronutrient fortified malt and cocoa based milk beverage on the micronutrient status, cognition, physical performance and nutritional deficiencies of 7-10 years old south Indian children. A randomized, double blind placebo controlled study design was used with normal healthy children from low to middle income families, aged 7-10 years randomly assigned to receive either a multi-micronutrient fortified or an unfortified milk based control drink. The drinks were provided 6 days/week for 5 months. Assessments included anthropometry, blood biochemistry, physical performance and cognition at baseline and endline. The baseline characteristics of the study groups were similar. The changes in body weight and height were similar between the groups at the end of the study. Levels of vitamin B12, red cell folate and vitamin B2 significantly improved in the intervention group, while vitamin D, selenium and body iron showed no difference. The Hemoglobin (Hb) and serum ferritin levels of the control group decreased at endline, while those in the intervention group maintained their levels. The serum transferrin receptor levels increased in both the groups. The prevalence of iron deficiency and Vitamin B2 deficiency were significantly lower in the intervention group at endline. Overall improvement in cognitive and physical performance was seen in both the groups at endline, with no significant differences between the groups. The micronutrient fortified milk based drink was efficacious in improving the micronutrient status of Vitamin B2, Vitamin B12 and red cell folate and in preventing a decline in Hb level compared to an unfortified milk based drink. It also reduced anemia and the risk of deficiencies of iron, and B12, in apparently healthy children. ClinicalTrials.gov IdentifierNCT01415557. Clinical Trial RegistryIndia - REF/2012/12/004332.

Prenatal nutritional deficiency reprogrammed postnatal gene expression in mammal brains: implications for schizophrenia

BACKGROUND

Epidemiological studies have identified prenatal exposure to famine as a risk factor for schizophrenia, and animal models of prenatal malnutrition display structural and functional brain abnormalities implicated in schizophrenia.

METHODS

The offspring of the RLP50 rat, a recently developed animal model of prenatal famine malnutrition exposure, was used to investigate the changes of gene expression and epigenetic modifications in the brain regions. Microarray gene expression analysis was carried out in the prefrontal cortex and the hippocampus from 8 RLP50 offspring rats and 8 controls. MBD-seq was used to test the changes in DNA methylation in hippocampus depending on prenatal malnutrition exposure.

RESULTS

In the prefrontal cortex, offspring of RLP50 exhibit differences in neurotransmitters and olfactory-associated gene expression. In the hippocampus, the differentially-expressed genes are related to synaptic function and transcription regulation. DNA methylome profiling of the hippocampus also shows widespread but systematic epigenetic changes; in most cases (87%) this involves hypermethylation. Remarkably, genes encoded for the plasma membrane are significantly enriched for changes in both gene expression and DNA methylome profiling screens (p = 2.37×10(-9) and 5.36×10(-9), respectively). Interestingly, Mecp2 and Slc2a1, two genes associated with cognitive impairment, show significant down-regulation, and Slc2a1 is hypermethylated in the hippocampus of the RLP50 offspring.

CONCLUSIONS

Collectively, our results indicate that prenatal exposure to malnutrition leads to the reprogramming of postnatal brain gene expression and that the epigenetic modifications contribute to the reprogramming. The process may impair learning and memory ability and result in higher susceptibility to schizophrenia.

Omega-3 supplementation during the first 5 years of life and later academic performance: a randomised controlled trial

BACKGROUND/OBJECTIVES

Consumption of oily fish more than once per week has been shown to improve cognitive outcomes in children. However, it is unknown whether similar benefits can be achieved by long-term omega-3 fatty acid supplementation. The objective was to investigate the effect of omega-3 fatty acid supplementation during the first 5 years of life on subsequent academic performance in children by conducting a secondary analysis of the CAPS (Childhood Asthma Prevention Study).

SUBJECTS/METHODS

A total of 616 infants with a family history of asthma were randomised to receive tuna fish oil (high in long-chain omega-3 fatty acids, active) or Sunola oil (low in omega-3 fatty acids, control) from the time breastfeeding ceased or at the age of 6 months until the age of 5 years. Academic performance was measured by a nationally standardised assessment of literacy and numeracy (National Assessment Program Literacy and Numeracy (NAPLAN)) in school years 3, 5, 7 and 9. Plasma omega-3 fatty acid levels were measured at regular intervals until 8 years of age. Between-group differences in test scores, adjusted for maternal age, birth weight and maternal education, were estimated using mixed-model regression.

RESULTS

Among 239 children, there were no significant differences in NAPLAN scores between active and control groups. However, at 8 years, the proportion of omega-3 fatty acid in plasma was positively associated with the NAPLAN score (0.13 s.d. unit increase in score per 1% absolute increase in plasma omega-3 fatty acid (95% CI 0.03, 0.23)).

CONCLUSIONS

Our findings do not support the practice of supplementing omega-3 fatty acids in the diet of young children to improve academic outcomes. Further exploration is needed to understand the association between plasma omega-3 fatty acid levels at 8 years and academic performance.

Does consumption of LC omega-3 PUFA enhance cognitive performance in healthy school-aged children and throughout adulthood? Evidence from clinical trials

Long-chain (LC) omega-3 PUFA derived from marine sources may play an important role in cognitive performance throughout all life stages. Docosahexaenoic acid (DHA), the dominant omega-3 in the brain, is a major component of neuronal cell membranes and affects various neurological pathways and processess. Despite its critical role in brain function, human’s capacity to synthesize DHA de novo is limited and its consumption through the diet is important. However, many individuals do not or rarely consume seafood. The aim of this review is to critically evaluate the current evidence from randomised controlled trials (RCT) in healthy school-aged children, younger and older adults to determine whether consumption of LC omega-3 PUFA improves cognitive performance and to make recommendations for future research. Current evidence suggests that consumption of LC omega-3 PUFA, particularly DHA, may enhance cognitive performance relating to learning, cognitive development, memory and speed of performing cognitive tasks. Those who habitually consume diets low in DHA, children with low literacy ability and malnourished and older adults with age-related cognitive decline and mild cognitive impairment seem to benefit most. However, study design limitations in many RCTs hamper firm conclusions. The measurement of a uniform biomarker, e.g., % DHA in red blood cells, is essential to establish baseline DHA-status, to determine targets for cognitive performance and to facilitate dosage recommendations. It is recommended that future studies be at least 16 weeks in duration, account for potential interaction effects of gender, age and apolipoprotein E genotype, include vegan/vegetarian populations, include measures of speed of cognitive performance and include brain imaging technologies as supportive information on working mechanisms of LC omega-3 PUFA.

Dietary lipids are differentially associated with hippocampal-dependent relational memory in prepubescent children

BACKGROUND

Studies in rodents and older humans have shown that the hippocampus-a brain structure critical to relational/associative memory-has remarkable plasticity as a result of lifestyle factors (eg, exercise). However, the effect of dietary intake on hippocampal-dependent memory during childhood has remained unexamined.

OBJECTIVE

We investigated the cross-sectional relation of dietary components characteristic of the Western diet, including saturated fatty acids (SFAs), omega-3 (n-3) fatty acids, and refined sugar, with hippocampal-dependent relational memory in prepubescent children.

DESIGN

Participants aged 7-9 y (n = 52) reported their dietary intake by using the Youth-Adolescent Food-Frequency Questionnaire and completed memory tasks designed to assess relational (hippocampal-dependent) and item (hippocampal-independent) memory. Performance on the memory tasks was assessed with both direct (accuracy) and indirect (eye movement) measures.

RESULTS

Partial correlations adjusted for body mass index showed a positive relation between relational memory accuracy and intake of omega-3 fatty acids and a negative relation of both relational and item memory accuracy with intake of SFAs. Potential confounding factors of age, sex, intelligence quotient, socioeconomic status, pubertal timing, and aerobic fitness (maximal oxygen volume) were not significantly related to any of the dietary intake measures. Eye movement measures of relational memory (preferential viewing to the target stimulus) showed a negative relation with intake of added sugar.

CONCLUSIONS

SFA intake was negatively associated with both forms of memory, whereas omega-3 fatty acid intake was selectively positively associated with hippocampal-dependent relational memory. These findings are among the first to show a link between habitual dietary intake and cognitive health as pertaining to hippocampal function in childhood. The Fitness Improves Thinking Kids (FITKids) and FITKids2 trials were registered at www.clinicaltrials.gov as NCT01334359 and NCT01619826, respectively.

Clinical significance of neuropsychological improvement after supplementation with omega-3 in 8-12 years old malnourished Mexican children: a randomized, double-blind, placebo and treatment clinical trial

It has been shown that supplementation with omega-3 improves cognitive performance, especially in infants and toddlers, but it is unknown whether these results are effective in older malnourished children. The aims of this study, therefore, were to investigate the omega-3 supplementation effects in 8- to 12-year-old children and to know which neuropsychological functions improve after three months of intervention in a sample of Mexican children with mild to moderate malnutrition. This study was a randomized, double-blind, treatment and placebo study of 59 children aged 8-12 years who were individually allocated to 2 groups. The duration of the intervention lasted 3 months. Neuropsychological performance was measured at baseline and at 3 months. Results show that more than 50% of children in the treatment group had greater improvement in 11 of the 18 neuropsychological variables studied. Processing speed, visual-motor coordination, perceptual integration, attention and executive function showed improvement in more than 70% of the omega-3 supplemented children. This trial was registered at clinicaltrials.gov as NCT01199120.

The relationship of docosahexaenoic acid (DHA) with learning and behavior in healthy children: a review

Childhood is a period of brain growth and maturation. The long chain omega-3 fatty acid, docosahexaenoic acid (DHA), is a major lipid in the brain recognized as essential for normal brain function. In animals, low brain DHA results in impaired learning and behavior. In infants, DHA is important for optimal visual and cognitive development. The usual intake of DHA among toddlers and children is low and some studies show improvements in cognition and behavior as the result of supplementation with polyunsaturated fatty acids including DHA. The purpose of this review was to identify and evaluate current knowledge regarding the relationship of DHA with measures of learning and behavior in healthy school-age children. A systematic search of the literature identified 15 relevant publications for review. The search found studies which were diverse in purpose and design and without consistent conclusions regarding the treatment effect of DHA intake or biomarker status on specific cognitive tests. However, studies of brain activity reported benefits of DHA supplementation and over half of the studies reported a favorable role for DHA or long chain omega-3 fatty acids in at least one area of cognition or behavior. Studies also suggested an important role for DHA in school performance.

Micronutrient supply and health outcomes in children

PURPOSE OF REVIEW

Multiple micronutrient deficiencies are still common worldwide and often occur at an early age, negatively affecting both physical and cognitive development. Even though specific effects of a variety of different micronutrients have been studied extensively, it is understood that a combination of multiple micronutrients may be more beneficial in most instances, as deficiencies usually do not occur in isolation. The aim of this review was to summarize the most recent evidence of the effects of micronutrient interventions on growth, mental, and physical performance as well as morbidity in children.

RECENT FINDINGS

For growth, cognitive or motor function, and morbidity, it appears that providing sufficient amounts of micronutrients especially to the most vulnerable and deficient groups of children can make a difference, but also that the intervention has to be planned carefully. However, findings are still variable, more particularly with reference to morbidity. Two reports of increased diagnoses of infection with micronutrient supplementation are also of concern.

SUMMARY

There are still difficulties in coming to a universal conclusion about benefit in all populations, because reports vary in study design, population, and so on. Although micronutrients have a role in depleted groups, it is also important to not only consider the group of children targeted, but also the regime of administration.

Micronutrient deficiency and cognitive and physical performance in Indian children

Several micronutrient deficiencies affect functional, particularly cognition and physical performance of children. Identifying and preventing sub-clinical deficiencies may be important so that adverse effects on functional performance by these deficiencies, particularly of iron and the B vitamins, are prevented. There is also the potential for childhood micronutrient deficiencies to have long-term effects that affect health and productivity in adulthood. This is especially relevant in a developing country such as India, which faces the dual burden of malnutrition and where the prevalence of these deficiencies is high. This review highlights the extent of micronutrient deficiencies in Indian children and focuses on the effect of deficiencies of the B vitamins and iron on cognitive and physical performance in children. Most studies on multiple micronutrient supplementation or fortification in Indian school children show modest effects on cognitive and physical performance, and it is relevant to point out that these studies have largely been conducted on urban children with mild deficiency at most; children with moderate or severe deficiency have not been studied. However, diets of rural children indicate large deficits in micronutrient intake, particularly of folic acid, riboflavin and iron, and their consequences have not been studied. With the limited evidence available, a short term but economical solution to ensure adequate micronutrient intakes could be through the fortification of staple cereals taken throughout the day. As increasing household incomes translate into an increase in food expenditure and diet diversification, it may become necessary to define upper limits of intake for nutrients in India, particularly as many commercial foods are fortified.

Influence of micronutrient status and socioeconomic gradient on growth indices of 2-18-year-old Indian girls

Micronutrient deficiencies are common consequences of the plant-based diet in children from developing countries which may affect their linear and ponderal growth. The aim of the study was to investigate the association between micronutrient status and growth indices in Indian girls. In cross-sectional studies (2006-2010), data on weight, height and diet were collected on 1302 girls (2-18 years) from Pune city, India. Fasting hemoglobin was measured on 1118 girls and serum zinc was measured on 695 girls. Height-for-age Z-scores (HAZ) and body mass index for age Z-score (BMIZ) were computed using contemporary Indian references. HAZ >-1 was observed in 54% girls, and 18.1% were short (HAZ <-2). BMIZ was within the reference range (-2<BMIZ<2) in majority (82.4%) of the girls. Average HAZ and BMIZ were significantly higher in higher socioeconomic (HSE) than in middle (MSE) and lower (LSE) socioeconomic groups (p<0.05). Girls in all age groups had calcium, zinc, iron and vitamin intakes of <50% of Indian recommended dietary intakes. Mean nutrient intakes were significantly higher in HSE than in MSE and LSE girls (p<0.05). Girls with short stature (HAZ <-2) had significantly lower intakes of calcium, zinc, iron, β-carotene, riboflavin, niacin, folate and ascorbic acid (p<0.05). Higher levels of serum zinc and hemoglobin were observed in girls with HAZ >-1 than in short girls even after adjusting for socioeconomic status (SES). The mean serum zinc level of thin girls (BMIZ <-2) was significantly lower than those of both normal and overweight girls after adjusting for SES. Micronutrient sufficiency is of paramount importance for adequate growth in Indian girls.

Effects of iron and n-3 fatty acid supplementation, alone and in combination, on cognition in school children: a randomized, double-blind, placebo-controlled intervention in South Africa

BACKGROUND

Little is known about the combined effects of iron and n-3 (omega-3) fatty acid (FA) supplementation on cognitive performance. The provision of either DHA/EPA or iron alone in rats with combined iron and n-3 FA deficiency has been reported to exacerbate cognitive deficits associated with deficiency.

OBJECTIVE

We investigated the effects of iron and DHA/EPA supplementation, alone and in combination, in children with poor iron and n-3 FA status.

DESIGN

In a 2-by-2 factorial trial, children with iron deficiency (ID) (n = 321; aged 6-11 y) were allocated to receive 1) iron (50 mg) plus DHA/EPA (420/80 mg), 2) iron plus placebo, 3) placebo plus a mixture of DHA and EPA (DHA/EPA), or 4) placebo plus placebo as oral supplements (4/wk) for 8.5 mo. Cognition was assessed at baseline and endpoint by using the Hopkins Verbal Learning Test (HVLT) and subscales of the Kaufman Assessment Battery for Children.

RESULTS

Both iron and DHA/EPA significantly increased weight-for-age z scores. Iron increased the number of words recalled at HVLT recall 2 (intervention effect: 0.90; 95% CI: 0.18, 1.62), and in anemic children, iron increased scores in the Atlantis Delayed test (1.51; 95% CI: 0.03, 2.99) and HVLT recall 2 (2.02; 95% CI: 0.55, 3.49). DHA/EPA showed no benefit in any of the cognitive tests but decreased Atlantis test scores (-2.48; 95% CI: -3.99, -0.96) in children who were anemic at baseline and decreased Atlantis delayed scores (-0.9; 95% CI: -1.45, -0.36) in girls with ID, whereas boys tended to perform better.

CONCLUSIONS

In children with poor iron and n-3 FA status, iron supplementation improved verbal and nonverbal learning and memory, particularly in children with anemia. In contrast, DHA/EPA supplementation had no benefits on cognition and impaired working memory in anemic children and long-term memory and retrieval in girls with ID.

Multiple micronutrient-fortified rice affects physical performance and plasma vitamin B-12 and homocysteine concentrations of Indian school children

Fortifying rice with multiple micronutrients could be a promising strategy for combat micronutrient deficiencies in developing countries. We determined the efficacy of extruded rice grains fortified with multiple micronutrients on the prevalence of anemia, micronutrient status, and physical and cognitive performance in 6- to 12-y-old, low-income school children in Bangalore, India. In a randomized, double-blind, controlled trial, 258 children were assigned to 1 of 3 intervention groups to receive rice-based lunch meals fortified with multiple micronutrients with either low-iron (6.25 mg) or high-iron (12.5 mg) concentrations or identical meals with unfortified rice. The meals were provided 6 d/wk for 6 mo. Anthropometric, biochemical, physical performance, and cognitive assessments were taken at baseline and endpoint. At baseline, study groups were comparable, with 61% of the children being anemic. However, only <10% were deficient in iron, vitamin A, and zinc. After 6 mo, plasma vitamin B-12 and homocysteine concentrations (both P < 0.001) as well as physical performance (P < 0.05) significantly improved in the intervention arms. No between-group differences were observed in hemoglobin concentration, anemia, and deficiencies of other micronutrients or cognitive function after 6 mo, but paired analyses revealed a small reduction in anemia prevalence in children in the low-iron group. The fortified rice was efficacious in improving vitamin B-12 status and physical performance in Indian school children.

Vitamins and neural and cognitive developmental outcomes in children

The role of vitamin status in the development of the brain and the subsequent functioning of the brain was considered. There are data with a range of vitamins, from animal studies and human studies in developing countries, suggesting that a clinical deficiency during the critical period when the brain is developing causes permanent damage. To date there is, however, with the exception of cases of clinical deficiency such as those that might be associated with a vegan diet, little evidence that variations in the diet of those living in industrialised countries have a lasting developmental influence. Similarly, later in life clinical deficiencies of various vitamins disrupt cognition although there is to date limited evidence that variations in the intake of single vitamins in industrialised societies influence functioning. It may well be, however, unreasonable to expect that vitamins examined in isolation will be associated with differences in cognitive functioning. The output of the brain reflects millions of metabolic processes, each potentially susceptible to any of a range of vitamins. A diet poor in one respect is likely to be poor in other respects as well. As such, the preliminary reports in double-blind placebo-controlled trials that aspects of cognition and behaviour respond to supplementation with multi-micronutrients may indicate the way forward.

The effect of a 1-year multiple micronutrient or n-3 fatty acid fortified food intervention on morbidity in Indian school children

BACKGROUND/OBJECTIVES

Few studies have shown that supplementation with micronutrients (MNs) or n-3 fatty acids may have health benefits such as reduced morbidity in schoolchildren. The effect of a combination of these nutrients has never been investigated. This study aimed to determine the effect of a combination of two different doses of MN and n-3 fatty acids on morbidity in schoolchildren in Bangalore, India.

SUBJECTS/METHODS

In all 598 children (6-10 years) received foods fortified with either high (100% recommended dietary allowance) or low (15% recommended dietary allowance) MN, combined with either high (900 mg α-linolenic acid (ALA) plus 100 mg docosahexaenoic acid) or low (140 mg ALA) n-3 fatty acids for 1 year. Morbidity was measured by weekly self-reports using a structured questionnaire. Poisson regression analyses of episodes/child/year and duration/episode adjusted for age and sex were performed on clusters of symptoms, including upper and lower respiratory tract infections (URTI and LRTI), gastrointestinal complaints (GI) and general symptoms of illness to observe MN and n-3 fatty acid treatment effects.

RESULTS

Children consuming high n-3 fatty acids had significantly fewer episodes of URTI/child/year (relative risk (RR)=0.88, 95% confidence interval (CI): 0.79, 0.97) and significantly shorter duration/episode of URTI (RR=0.81, 95% CI: 0.78, 0.85), LRTI (RR=0.91, 95% CI: 0.85, 0.97), GI complaints (RR=0.79, 95% CI: 0.74, 0.85) and general symptoms (RR=0.90, 95% CI: 0.82, 0.98) compared with children who received low n-3 fatty acid intervention. The high MN intervention reduced the duration of general symptoms (RR=0.89, 95% CI: 0.82, 0.98).

CONCLUSION

Although n-3 fatty acids may be beneficial for reducing illness in Indian schoolchildren, more research is needed to confirm presence of combined effect with MN.