1
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Hess SY, Smith TJ, Sitthideth D, Arnold CD, Tan X, Jones KS, Brown KH, Alayon S, Kounnavong S. Risk factors for anaemia among women and their young children hospitalised with suspected thiamine deficiency in northern Lao PDR. Matern Child Nutr 2024; 20:e13565. [PMID: 37803889 PMCID: PMC10749997 DOI: 10.1111/mcn.13565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/17/2023] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
Anaemia among women and young children remains a major public health concern. This secondary study describes the anaemia prevalence among young hospitalised children and their mothers in northern Lao People's Democratic Republic and explores possible nutritional causes and risk factors for anaemia. Hospitalised children (ages 21 days to <18 months) with clinical symptoms suggestive of thiamine deficiency disorders were eligible along with their mothers. Venous blood was collected for determination of haemoglobin, ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), erythrocyte glutathione reductase activation coefficient (EGRac), thiamine diphosphate (ThDP) and acute phase proteins. Risk factors for anaemia were modelled using minimally adjusted logistic regression controlling for age. Haemoglobin results were available for 436 women (mean ± SD age 24.7 ± 6.4 years; 1.6% pregnant) and 427 children (4.3 ± 3.5 months; 60.3% male). Anaemia prevalence (Hb < 120 g/L for nonpregnant women and <110 g/L for pregnant women and children) was 30.7% among women and 55.2% among children. In bivariate analyses, biomarkers significantly associated with anaemia in women were ferritin, sTfR, RBP, EGRac and ThDP. Other risk factors for women were lower BMI, mid-upper arm circumference < 23.5 cm, lower education, lower socioeconomic index, food insecurity, Hmong ethnicity, not/rarely having attended antenatal care, not having taken antenatal iron-containing supplements and not meeting minimum dietary diversity. Risk factors for anaemia among children were older age, male sex, stunting, sTfR, ThDP and alpha-1-acid-glycoprotein. Anaemia was common among women and their hospitalised children and was associated with micronutrient deficiencies and socioeconomic, dietary and health care-seeking risk factors, suggesting that multiple strategies are required to prevent anaemia among women and children.
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Affiliation(s)
- Sonja Y. Hess
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Taryn J. Smith
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Dalaphone Sitthideth
- Lao Tropical and Public Health InstituteVientianeLao People's Democratic Republic
| | - Charles D. Arnold
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Xiuping Tan
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Kerry S. Jones
- Nutritional Biomarker Laboratory, MRC Epidemiology UnitUniversity of CambridgeCambridgeUK
| | - Kenneth H. Brown
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Silvia Alayon
- USAID Advancing NutritionArlingtonVirginiaUSA
- Save the ChildrenWashingtonWashington, D.C.USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health InstituteVientianeLao People's Democratic Republic
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2
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Williams AM, Brown KH, Allen LH, Dary O, Moorthy D, Suchdev PS. Improving Anemia Assessment in Clinical and Public Health Settings. J Nutr 2023; 153 Suppl 1:S29-S41. [PMID: 37778891 PMCID: PMC11002965 DOI: 10.1016/j.tjnut.2023.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/28/2023] [Accepted: 05/10/2023] [Indexed: 10/03/2023] Open
Abstract
We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.
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Affiliation(s)
- Anne M Williams
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand; Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States.
| | - Kenneth H Brown
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA, United States
| | - Lindsay H Allen
- United States Department of Agriculture, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA, United States
| | - Omar Dary
- Division of Nutrition and Environmental Health, Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC, United States
| | | | - Parminder S Suchdev
- Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States
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3
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Hess SY, Wessells KR, Haile D, Rogers LM, Tan X, Barros JG, Bourassa MW, Gorstein J, Brown KH. Comparison of Published Estimates of the National Prevalence of Iron, Vitamin A, and Zinc Deficiency and Sources of Inconsistencies. Adv Nutr 2023; 14:1466-1478. [PMID: 37634853 PMCID: PMC10721533 DOI: 10.1016/j.advnut.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/21/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023] Open
Abstract
Micronutrient deficiencies result in a broad range of adverse health and functional consequences, but the true prevalence of specific deficiencies remains uncertain because limited information is available from nationally representative surveys using recommended biomarkers. The present review compares various reported national deficiency prevalence estimates for nutrients and years where the estimates overlap for individual countries that conducted nationally representative surveys and explores possible reasons for any discrepancies discovered. Nationally representative micronutrient status surveys that were conducted since 2000 among preschool-aged children or women of reproductive age and included assessment of iron, vitamin A, or zinc status based on recognized biomarkers were considered eligible for inclusion, along with any modeled deficiency prevalence estimates for these same countries and years. There was considerable variation across different published prevalence estimates, with larger inconsistencies when the prevalence estimate was based on proxies, such as hemoglobin for iron deficiency and dietary zinc availability for zinc deficiency. Numerous additional methodological issues affected the prevalence estimates, such as which biomarker and what cutoff was used to define deficiency, whether the biomarker was adjusted for inflammation, and what adjustment method was used. For some country-years, the various approaches resulted in fairly consistent prevalence estimates. For other country-years, however, the results differed markedly and changed the conclusions regarding the existence and severity of the micronutrient deficiency as a public health concern. In conclusion, to determine micronutrient status, we consider the assessment of one of the recommended biomarkers in a population representative survey as the best available information. If indicated, results should be adjusted for inflammation and generally acceptable cutoffs should be applied to facilitate comparisons, although individual countries may also apply nationally defined cutoffs to determine when and where to intervene. Global consensus is needed on best practices for presenting survey results and defining the prevalence of deficiency.
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Affiliation(s)
- Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California Davis, Davis, CA, United States; Micronutrient Forum, Washington, DC, United States.
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California Davis, Davis, CA, United States
| | - Demewoz Haile
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States
| | | | - Xiuping Tan
- Institute for Global Nutrition and Department of Nutrition, University of California Davis, Davis, CA, United States
| | - Jonathan G Barros
- Institute for Global Nutrition and Department of Nutrition, University of California Davis, Davis, CA, United States
| | | | | | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California Davis, Davis, CA, United States
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4
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Mertens A, Benjamin-Chung J, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Jilek W, Rosete S, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Malenica I, Hejazi N, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Christian P, Brown KH, Arnold BF. Author Correction: Child wasting and concurrent stunting in low- and middle-income countries. Nature 2023; 623:E1. [PMID: 37833391 PMCID: PMC10620077 DOI: 10.1038/s41586-023-06695-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, CA, USA.
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5
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Benjamin-Chung J, Mertens A, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jilek W, Jung E, Chung EO, Rosete S, Hejazi N, Malenica I, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Brown KH, Christian P, Arnold BF. Author Correction: Early-childhood linear growth faltering in low- and middle-income countries. Nature 2023; 623:E2. [PMID: 37833392 PMCID: PMC10620071 DOI: 10.1038/s41586-023-06703-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Affiliation(s)
- Jade Benjamin-Chung
- Department of Epidemiology & Population Health, Stanford University, Stanford, CA, USA.
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
- Chan Zuckerberg Biohub, San Francisco, CA, USA.
| | - Andrew Mertens
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - John M Colford
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Department of Epidemiology & Population Health, Stanford University, Stanford, CA, USA
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, LLC, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
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6
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Benjamin-Chung J, Mertens A, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jilek W, Jung E, Chung EO, Rosete S, Hejazi N, Malenica I, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Brown KH, Christian P, Arnold BF. Early-childhood linear growth faltering in low- and middle-income countries. Nature 2023; 621:550-557. [PMID: 37704719 PMCID: PMC10511325 DOI: 10.1038/s41586-023-06418-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/10/2023] [Indexed: 09/15/2023]
Abstract
Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards)1,2. Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age.
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Affiliation(s)
- Jade Benjamin-Chung
- Department of Epidemiology & Population Health, Stanford University, Stanford, CA, USA.
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
- Chan Zuckerberg Biohub, San Francisco, CA, USA.
| | - Andrew Mertens
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - John M Colford
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Department of Epidemiology & Population Health, Stanford University, Stanford, CA, USA
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, LLC, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
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7
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Mertens A, Benjamin-Chung J, Colford JM, Coyle J, van der Laan MJ, Hubbard AE, Rosete S, Malenica I, Hejazi N, Sofrygin O, Cai W, Li H, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Jilek W, Subramoney V, Hafen R, Häggström J, Norman T, Brown KH, Christian P, Arnold BF. Causes and consequences of child growth faltering in low-resource settings. Nature 2023; 621:568-576. [PMID: 37704722 PMCID: PMC10511328 DOI: 10.1038/s41586-023-06501-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/31/2023] [Indexed: 09/15/2023]
Abstract
Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | | | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
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8
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Mertens A, Benjamin-Chung J, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Jilek W, Rosete S, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Malenica I, Hejazi N, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Christian P, Brown KH, Arnold BF. Child wasting and concurrent stunting in low- and middle-income countries. Nature 2023; 621:558-567. [PMID: 37704720 PMCID: PMC10511327 DOI: 10.1038/s41586-023-06480-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, CA, USA.
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9
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Goh YE, Manger MS, Duggal M, Das R, Saklani S, Agarwal S, Budhija D, Jamwal M, Singh BL, Dahiya N, Luo H, Long JM, Westcott J, Krebs NF, Gibson RS, Brown KH, McDonald CM. Women in Selected Communities of Punjab, India Have a High Prevalence of Iron, Zinc, Vitamin B12, and Folate Deficiencies: Implications for a Multiply-Fortified Salt Intervention. Nutrients 2023; 15:3024. [PMID: 37447352 DOI: 10.3390/nu15133024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
Dietary intake and biomarkers of micronutrient status of 100 non-pregnant women of reproductive age (NPWRA) were assessed to determine optimal levels of iron, zinc, vitamin B12, and folic acid to include in multiply-fortified salt (MFS) that will be evaluated in an upcoming trial. Weighed food records were obtained from participants to measure intake of micronutrients and discretionary salt, and to assess adequacy using Indian Nutrient Reference Values (NRVs). Statistical modeling was used to determine optimal fortification levels to reduce inadequate micronutrient intake while limiting intake above the upper limit. Fasting blood samples were obtained to assess iron, zinc, vitamin B12, and folate status. In usual diets, inadequate intake of iron (46%), zinc (95%), vitamin B12 (83%), and folate (36%) was high. Mean intake of discretionary salt was 4.7 g/day. Prevalence estimates of anemia (37%), iron deficiency (67%), zinc deficiency (34%), vitamin B12 insufficiency (37%), and folate insufficiency (70%) were also high. Simulating the addition of optimized MFS to usual diets resulted in percentage point (pp) reductions in inadequate intake by 29 pp for iron, 76 pp for zinc, 81 pp for vitamin B12, and 36 pp for folate. MFS holds potential to reduce the burden of micronutrient deficiencies in this setting.
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Affiliation(s)
- Yvonne E Goh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, CA 94609, USA
- International Zinc Nutrition Consultative Group, San Francisco, CA 94609, USA
| | - Mari S Manger
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, CA 94609, USA
- International Zinc Nutrition Consultative Group, San Francisco, CA 94609, USA
| | - Mona Duggal
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Reena Das
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Shipra Saklani
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Surbhi Agarwal
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Deepmala Budhija
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Manu Jamwal
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Bidhi L Singh
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Neha Dahiya
- Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Hanqi Luo
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Julie M Long
- Department of Pediatrics-Section of Nutrition, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Jamie Westcott
- Department of Pediatrics-Section of Nutrition, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Nancy F Krebs
- International Zinc Nutrition Consultative Group, San Francisco, CA 94609, USA
- Department of Pediatrics-Section of Nutrition, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Rosalind S Gibson
- Department of Human Nutrition, University of Otago, Dunedin 9054, New Zealand
| | - Kenneth H Brown
- International Zinc Nutrition Consultative Group, San Francisco, CA 94609, USA
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA 95616, USA
| | - Christine M McDonald
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, CA 94609, USA
- International Zinc Nutrition Consultative Group, San Francisco, CA 94609, USA
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA 95616, USA
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10
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Tong H, Piwoz E, Ruel MT, Brown KH, Black RE, Walker N. Maternal and child nutrition in the Lives Saved Tool: Results of a recent update. J Glob Health 2022; 12:08005. [PMID: 36583418 PMCID: PMC9801341 DOI: 10.7189/jogh.12.08005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background The Lives Saved Tool (LiST) is a mathematical modelling tool for estimating the survival, health, and nutritional impacts of scaling intervention coverage in low- and middle-income countries (LMICs). Various nutrition interventions are included in LiST and are regularly (and independently) reviewed and updated as new data emerge. This manuscript describes our latest in-depth review of nutrition evidence, focusing on intervention efficacy, appropriate population-affected fractions, and new interventions for potential inclusion in the LiST model. Methods An external advisory group (EAG) was assembled to review evidence from systematic reviews on intervention-outcome (I-O) pairs for women and children under five years of age. GRADE quality was assigned to each pair based on a LiST-specific checklist to facilitate consistent decisions during the consideration. For existing interventions with new information, the EAG was asked to recommend whether to update the default efficacy values and population-affected fractions. For the new interventions, the EAG decided whether there was sufficient evidence of benefit, and in affirmative cases, information on the efficacy and affected fraction values that could be used. Decisions were based on expert group consensus. Results Overall, the group reviewed 53 nutrition-related I-O pairs, including 25 existing and 28 new ones. Efficacy and population-affected fractions were updated for seven I-O pairs; three pairs were updated for efficacy estimates only, three were updated for population-affected fractions only; and nine new I-O pairs were added to the model, bringing the total of nutrition-related I-O pairs to 34. Included in the new I-O pairs were two new nutrition interventions added to LIST: zinc fortification and neonatal vitamin A supplementation. Conclusions For modelling tools like LiST to be useful, it is crucial to update interventions, efficacy and population-affected fractions as new evidence becomes available. The present updates will enable LiST users to better estimate the potential health, nutrition, and survival benefits of investing in nutrition.
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Affiliation(s)
- Hannah Tong
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ellen Piwoz
- Independent Consultant, Annapolis, Maryland, USA
| | - Marie T Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Kenneth H Brown
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, California, USA
| | - Robert E Black
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Neff Walker
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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11
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McDonald CM, Brown KH, Goh YE, Manger MS, Arnold CD, Krebs NF, Westcott J, Long JM, Gibson RS, Jamwal M, Singh BL, Dahiya N, Budhija D, Das R, Duggal M. Quintuply-fortified salt for the improvement of micronutrient status among women of reproductive age and preschool-aged children in Punjab, India: protocol for a randomized, controlled, community-based trial. BMC Nutr 2022; 8:98. [PMID: 36068647 PMCID: PMC9450288 DOI: 10.1186/s40795-022-00583-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Multiple micronutrient (MN) deficiencies remain highly prevalent among women of reproductive age (WRA) and preschool-aged children (PSC) in many areas within India. Salt is an attractive vehicle for MN fortification in this context, as it is universally consumed in fairly consistent amounts and coverage of iodized salt (IS) is 94%. The overall objective of this trial is to evaluate the nutritional impact of quintuply-fortified salt with iron in the form of encapsulated ferrous fumarate, zinc, vitamin B12, folic acid, and iodine (eFF-Q5S) vs. quintuply-fortified salt with iron in the form of ferric pyrophosphate plus EDTA, zinc, vitamin B12, folic acid, and iodine (FePP-Q5S) vs. IS for the improvement of MN status among non-pregnant WRA and PSC. Methods The study is a community-based, randomized, controlled trial that will be conducted in Punjab, India. 780 non-pregnant WRA 18–49 years old and 468 PSC 12–59 months old will be enrolled and assigned to one of three intervention groups. Salt will be provided to participants monthly for 12 months. Primary outcomes include changes in mean concentration of biomarkers of iron, zinc, vitamin B12, folate and iodine. Secondary outcomes include changes in the composition of the gut microbiome, and discretionary salt intake of PSC. Discussion If proven efficacious, multiply-fortified salt (MFS) has the potential to drastically reduce the burden of MN deficiencies in India, and around the world. Although effectiveness research will be needed to examine the impact of MFS under programmatic conditions, salt fortification will piggy-back on existing platforms to produce IS and doubly-fortified salt (DFS), making it possible to scale-up the intervention quickly. Trial registration Clinicaltrials.gov: NCT05166980; date of registration: December 22, 2021. Clinical Trials Registry-India: CTRI/2022/040332 and CTRI/2022/02/040333; date of registration: February 15, 2022.
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Affiliation(s)
- Christine M McDonald
- Departments of Pediatrics, and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA. .,Department of Nutrition, and Institute for Global Nutrition, University of California, Davis, CA, USA. .,International Zinc Nutrition Consultative Group, Oakland, CA, USA.
| | - Kenneth H Brown
- Department of Nutrition, and Institute for Global Nutrition, University of California, Davis, CA, USA.,International Zinc Nutrition Consultative Group, Oakland, CA, USA
| | - Yvonne E Goh
- Departments of Pediatrics, and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.,International Zinc Nutrition Consultative Group, Oakland, CA, USA
| | - Mari S Manger
- Departments of Pediatrics, and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.,International Zinc Nutrition Consultative Group, Oakland, CA, USA
| | - Charles D Arnold
- Department of Nutrition, and Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Nancy F Krebs
- International Zinc Nutrition Consultative Group, Oakland, CA, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Jamie Westcott
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Julie M Long
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Rosalind S Gibson
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Manu Jamwal
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bidhi L Singh
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neha Dahiya
- Postgraduate Institute of Medical Education and Research, Chandigarh, India.,Indian Council of Medical Research, Delhi, India
| | - Deepmala Budhija
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Reena Das
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mona Duggal
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
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12
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Dewey KG, Arnold CD, Wessells KR, Prado EL, Abbeddou S, Adu-Afarwuah S, Ali H, Arnold BF, Ashorn P, Ashorn U, Ashraf S, Becquey E, Brown KH, Christian P, Colford JM, Dulience SJL, Fernald LCH, Galasso E, Hallamaa L, Hess SY, Humphrey JH, Huybregts L, Iannottie LL, Jannat K, Lartey A, Port AL, Leroy JL, Luby SP, Maleta K, Matias SL, Mbuya MNN, Mridha MK, Nkhoma M, Null C, Paul RR, Okronipa H, Ouédraogo JB, Pickering AJ, Prendergast AJ, Ruel M, Shaikh S, Weber AM, Wolff P, Zongrone A, Stewart CP. Preventive small-quantity lipid-based nutrient supplements reduce severe wasting and severe stunting among young children: an individual participant data meta-analysis of randomized controlled trials. Am J Clin Nutr 2022; 116:1314-1333. [PMID: 36045000 DOI: 10.1093/ajcn/nqac232] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/19/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNS) reduce child wasting and stunting. There is little information regarding effects on severe wasting or stunting. OBJECTIVE We aimed to identify the effect of SQ-LNS on prevalence of severe wasting (weight-for-length z-score < -3) and severe stunting (length-for-age z-score < -3). METHODS We conducted a two-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNS provided to children 6 to 24 mo of age. We generated study-specific and subgroup estimates of SQ-LNS vs. control and pooled the estimates using fixed-effects models. We used random effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS SQ-LNS provision led to a relative reduction of 31% in severe wasting (Prevalence Ratio, PR 0.69 (0.55, 0.86), n=34,373) and 17% in severe stunting (PR 0.83 (95% CI: 0.78, 0.90), n=36,795) at endline. Results were similar in most of the sensitivity analyses but somewhat attenuated when comparisons using passive control arms were excluded: PR 0.74 (0.57, 0.96), n=26,327 for severe wasting and PR 0.88 (0.81, 0.95), n=28,742 for severe stunting. Study-level characteristics generally did not significantly modify the effects of SQ-LNS, but results suggested greater effects of SQ-LNS in sites with greater burdens of wasting or stunting, or with poorer water quality or sanitation. CONCLUSIONS Including SQ-LNS in preventive interventions to promote healthy child growth and development is likely to reduce rates of severe wasting and stunting. Registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.
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Affiliation(s)
- Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, 9000Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Hasmot Ali
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Gaibandha-5700, Bangladesh
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sania Ashraf
- Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, 1201 I Street NW, Washington, DC, 20005, USA
| | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA.,Helen Keller International, New York, NY, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lotta Hallamaa
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Poverty, Health, and Nutrition Division, International Food Policy Research Institute, 1201 I Street NW, Washington, DC, 20005, USA
| | - Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Jean H Humphrey
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, 1201 I Street NW, Washington, DC, 20005, USA
| | | | - Kaniz Jannat
- School of Health Sciences, Western Sydney University, NSW, Australia
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Agnes Le Port
- Montpellier Interdisciplinary center on Sustainable Agri-food systems (MoISA), French National Research Institute for Sustainable Development (IRD), Montpellier, France
| | - Jef L Leroy
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, 1201 I Street NW, Washington, DC, 20005, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California, USA
| | - Kenneth Maleta
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Bangladesh.,Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Bangladesh
| | - Minyanga Nkhoma
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Rina R Paul
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Bangladesh
| | - Harriet Okronipa
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, USA
| | - Jean-Bosco Ouédraogo
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | - Amy J Pickering
- Department of Civil and Environmental Engineering, University of California, Berkeley, Berkeley, CA, USA
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Blizard Institute, Queen Mary University of London, London, UK
| | - Marie Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, 1201 I Street NW, Washington, DC, 20005, USA
| | - Saijuddin Shaikh
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Gaibandha-5700, Bangladesh
| | - Ann M Weber
- School of Public Health, Division of Epidemiology, University of Nevada, Reno, USA
| | | | | | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
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13
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Engle-Stone R, Miller JC, Reario MFD, Arnold CD, Stormer A, Lafuente E, Oxley A, Capanzana MV, Cabanilla CVD, Ford JL, Clark A, Velavan TP, Brown KH, Lietz G, Haskell MJ. Filipino Children with High Usual Vitamin A Intakes and Exposure to Multiple Sources of Vitamin A Have Elevated Total Body Stores of Vitamin A But Do Not Show Clear Evidence of Vitamin A Toxicity. Curr Dev Nutr 2022; 6:nzac115. [PMID: 36060221 PMCID: PMC9429969 DOI: 10.1093/cdn/nzac115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 11/14/2022] Open
Abstract
Background Young children exposed to high-dose vitamin A supplements (VAS) and vitamin A (VA)-fortified foods may be at risk of high VA intake and high VA total body stores (TBS). Objectives TBS and estimated liver VA concentration were compared among children with adequate or high VA intake and different timing of exposure to VAS, and associations between estimated liver VA concentrations and biomarkers of VA toxicity were examined. Methods Children 12-18 mo of age (n = 123) were selected for 3 groups: 1) retinol intake >600 µg/d and VAS within the past mo, 2) retinol intake >600 µg/d and VAS in the past 3-6 mo, and 3) VA intake 200-500 µg retinol activity equivalents (RAE)/d and VAS in the past 3-6 mo. Dietary intake data were collected to measure VA intakes from complementary foods, breast milk, and low-dose, over-the-counter supplements. TBS were assessed by retinol isotope dilution, and VA toxicity biomarkers were measured. Main outcomes were compared by group. Results Mean (95% CI) VA intakes excluding VAS were 1184 (942, 1426), 980 (772, 1187), and 627 (530, 724) µg RAE/d, in groups 1-3, respectively; mean VA intake was higher in groups 1 and 2 compared with group 3 (P < 0.05). Geometric mean (GM) (95% CI) TBS were 589 (525, 661), 493 (435, 559), and 466 (411, 528) µmol, respectively. GM TBS and GM liver VA concentrations were higher in group 1 compared with group 3 (liver VA concentration: 1.62 vs. 1.33 µmol/g; P < 0.05). Plasma retinyl ester and 4-oxo-retinoic acid concentrations and serum markers of bone turnover and liver damage did not indicate VA toxicity. Conclusions In this sample, most children had retinol intakes above the Tolerable Upper Intake Level (UL) and liver VA concentrations above the proposed cutoff for "hypervitaminosis A" (>1 µmol/g liver). There was no evidence of chronic VA toxicity, suggesting that the liver VA cutoff value should be re-evaluated. This trial was registered at www.clinicaltrials.gov as NCT03030339.
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Affiliation(s)
- Reina Engle-Stone
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Jody C Miller
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | | | - Charles D Arnold
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Ame Stormer
- Helen Keller International, Malate, Manila, Philippines
| | | | - Anthony Oxley
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Mario V Capanzana
- Food and Nutrition Research Institute, Department of Science and Technology, Bicutan, Taguig City, Philippines
| | - Carl Vincent D Cabanilla
- Food and Nutrition Research Institute, Department of Science and Technology, Bicutan, Taguig City, Philippines
| | - Jennifer Lynn Ford
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA
| | - Adam Clark
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Thirumalaisamy P Velavan
- Institute of Tropical Medicine, Universitätsklinikum Tübingen, Tubingen, Germany
- Vietnamese German Center for Medical Research (VG-CARE), Hanoi, Vietnam
| | - Kenneth H Brown
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Georg Lietz
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Marjorie J Haskell
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
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14
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Manger MS, Brown KH, Osendarp SJM, Atkin RA, McDonald CM. Barriers to and Enablers of the Inclusion of Micronutrient Biomarkers in National Surveys and Surveillance Systems in Low- and Middle-Income Countries. Nutrients 2022; 14:nu14102009. [PMID: 35631149 PMCID: PMC9145664 DOI: 10.3390/nu14102009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Including biomarkers of micronutrient status in existing or planned national surveys or surveillance systems is a critical step in improving capacity to promote, design, monitor, and evaluate micronutrient policies and programs. We aimed to identify the barriers to and enablers of the inclusion of micronutrient biomarker assessment in national surveys and surveillance systems, to identify the main challenges faced during the survey process, and to review experiences using existing platforms for micronutrient surveys. We conducted a series of key informant interviews with in-country and external representatives from six countries where national-level data on micronutrient status were collected in the past 5 years: Cambodia, Pakistan, Malawi, Uganda, Ghana, and Uzbekistan. Micronutrients associated with specific public health programs were always prioritized for inclusion in the survey. If funding, time, and/or logistics allowed, other considered micronutrients were also included. The most important and frequently reported barrier to inclusion of a more comprehensive panel of micronutrient biomarkers was inadequate funding to cover the laboratory analysis cost for all micronutrients considered at the planning stage. Government support and commitment was stressed as the most important enabling factor by all key informants. Advocacy for funding for micronutrient status assessment is needed.
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Affiliation(s)
- Mari S. Manger
- International Zinc Nutrition Consultative Group, University of California, San Francisco, CA 94143, USA;
- Correspondence:
| | - Kenneth H. Brown
- Department of Nutrition, Institute for Global Nutrition, University of California Davis, Davis, CA 95616, USA;
| | | | - Reed A. Atkin
- Micronutrient Forum, Washington, DC 20005, USA; (S.J.M.O.); (R.A.A.)
| | - Christine M. McDonald
- International Zinc Nutrition Consultative Group, University of California, San Francisco, CA 94143, USA;
- Departments of Pediatrics, Epidemiology and Biostatistics, University of California, San Francisco, CA 94143, USA
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15
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Haile D, Brown KH, McDonald CM, Luo H, Jarvis M, Teta I, Ndjebayi A, Martial GAJ, Vosti SA, Engle-Stone R. Applying Zinc Nutrient Reference Values as Proposed by Different Authorities Results in Large Differences in the Estimated Prevalence of Inadequate Zinc Intake by Young Children and Women and in Cameroon. Nutrients 2022; 14:nu14040883. [PMID: 35215534 PMCID: PMC8879783 DOI: 10.3390/nu14040883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 02/06/2023] Open
Abstract
Nutrient reference values (NRVs) for zinc set by several expert groups differ widely and may affect the predicted prevalence of inadequate zinc intake. We examined this possibility using NRVs published by four different authorities and nationally representative dietary intake data collected among children aged 12–59 months and women in Cameroon. Usual zinc intake was estimated from 24 h recall data using the National Cancer Institute method. Prevalences of total zinc intake below the dietary requirement and of “absorbable zinc intake” below the physiological requirement were estimated using NRVs published by the World Health Organization (WHO), US Institute of Medicine (IOM), International Zinc Nutrition Consultative Group (IZiNCG), and European Food Safety Authority (EFSA). The prevalence of inadequate zinc intake ranged from 10% (IZiNCG—physiological requirement, 95% CI 7–13%) to 81% (EFSA—physiological requirement, 95% CI 78–84%) among children and 9% (WHO—physiological requirement, 95% CI 8–11.0%) to 94% (IOM—physiological requirement, 95% CI 92–95%) among women These differences in the prevalence of inadequate intake translated into sizeable differences in the predicted benefit and cost-effectiveness of zinc fortification programs. Depending on the NRVs applied, assessments differ regarding the need for and design of zinc fortification programs. Efforts are needed to harmonize NRVs for zinc.
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Affiliation(s)
- Demewoz Haile
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Correspondence: ; Tel.: +1-530-601-3869
| | - Kenneth H. Brown
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
| | - Christine M. McDonald
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Departments of Pediatrics, and Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA 94143, USA
| | - Hanqi Luo
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Michael Jarvis
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
| | - Ismael Teta
- Helen Keller International, Yaoundé 1771, Cameroon; (I.T.); (A.N.)
| | - Alex Ndjebayi
- Helen Keller International, Yaoundé 1771, Cameroon; (I.T.); (A.N.)
| | | | - Stephen A. Vosti
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
- Department of Agricultural and Resource Economics, University of California, Davis, CA 95616, USA
| | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, CA 95616, USA; (K.H.B.); (C.M.M.); (H.L.); (R.E.-S.)
- Institute for Global Nutrition, University of California, Davis, CA 95616, USA; (M.J.); (S.A.V.)
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16
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Brown KH, Atkin R, Gorstein J, Osendarp SJM. Comments on article by Pullakhandam et al: Reference cut-offs to define low serum zinc concentrations in healthy 1-19 year old Indian children and adolescents. Eur J Clin Nutr 2022; 76:1204-1205. [PMID: 35804149 PMCID: PMC9352568 DOI: 10.1038/s41430-022-01174-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/06/2022] [Accepted: 05/26/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Kenneth H. Brown
- grid.27860.3b0000 0004 1936 9684Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA USA ,The Micronutrient Forum, Washington DC, USA
| | - Reed Atkin
- The Micronutrient Forum, Washington DC, USA
| | - Jonathan Gorstein
- grid.418309.70000 0000 8990 8592The Bill & Melinda Gates Foundation, Seattle, WA USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
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17
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Hess SY, McLain AC, Lescinsky H, Brown KH, Afshin A, Atkin R, Osendarp SJM. Basis for changes in the disease burden estimates related to vitamin A and zinc deficiencies in the 2017 and 2019 Global Burden of Disease Studies. Public Health Nutr 2021; 25:1-7. [PMID: 34889182 PMCID: PMC9991746 DOI: 10.1017/s1368980021004821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/01/2021] [Accepted: 12/07/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Global Burden of Disease (GBD) Study provides estimates of death and disability from eighty-seven risk factors, including some micronutrient deficiencies. OBJECTIVES To review methodological changes that led to large differences in the disease burden estimates for vitamin A and Zn deficiencies between the GBD 2017 and 2019 Studies. METHODS GBD publications were reviewed; additional information was provided by GBD researchers. RESULTS Vitamin A deficiency prevalence is based on plasma retinol concentration, whereas the estimate for Zn deficiency prevalence uses dietary adequacy as a proxy. The estimated global prevalence of vitamin A deficiency for children aged 1-4 years in the year 2017 decreased from 0·20 (95 % CI 0·17, 0·24) in GBD 2017 to 0·16 (95 % CI 0·15, 0·19) in GBD 2019, while the global prevalence of Zn deficiency did not change between the two studies (0·09 (95 % CI 0·04, 0·17) and 0·09 (95 % CI 0·03, 0·18)). New to 2019 was that meta-analyses were performed using Meta Regression - Bayesian, Regularized, Trimmed, a method developed for GBD. Due to this and multiple other methodological changes, the estimated number of deaths due to vitamin A deficiency dropped from 233 000 (179 000-294 000) to 24 000 (3000-50 000) from GBD 2017 to 2019, and for Zn deficiency from 29 000 (1000-77 000) to 2800 (700-6500), respectively. CONCLUSION The changes in the estimated disease burdens due to vitamin A and Zn deficiencies in the GBD reports from 2017 to 2019 are due primarily to changes in the analytical methods employed, so may not represent true changes in disease burden. Additional effort is needed to validate these results.
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Affiliation(s)
- Sonja Y Hess
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA95616, USA
| | - Alexander C McLain
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Haley Lescinsky
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kenneth H Brown
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA95616, USA
- The Micronutrient Forum, Washington, DC, USA
| | - Ashkan Afshin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Reed Atkin
- The Micronutrient Forum, Washington, DC, USA
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18
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Hess SY, McLain AC, Frongillo EA, Afshin A, Kassebaum NJ, Osendarp SJM, Atkin R, Rawat R, Brown KH. Challenges for Estimating the Global Prevalence of Micronutrient Deficiencies and Related Disease Burden: A Case Study of the Global Burden of Disease Study. Curr Dev Nutr 2021; 5:nzab141. [PMID: 34993390 PMCID: PMC8728001 DOI: 10.1093/cdn/nzab141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/05/2021] [Accepted: 11/16/2021] [Indexed: 11/12/2022] Open
Abstract
Information on the prevalence of micronutrient deficiencies is needed to determine related disease burden; underpin evidence-based advocacy; and design, deliver, and monitor safe, effective interventions. Assessing the global prevalence of deficiency requires a valid micronutrient status biomarker with an appropriate cutoff to define deficiency and relevant data from representative surveys across multiple locations and years. The Global Burden of Disease Study includes prevalence estimates for iodine, iron, zinc, and vitamin A deficiencies, for which recommended biomarkers and appropriate deficiency cutoffs exist. Because representative survey data are lacking, only retinol concentration is used to model vitamin A deficiency, and proxy indicators are used for the other micronutrients (goiter for iodine, hemoglobin for iron, and dietary food adequacy for zinc). Because of data limitations, complex statistical modeling is required to produce current estimates, relying on assumptions and proxies that likely understate the extent of micronutrient deficiencies and the consequent global health burden.
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Affiliation(s)
- Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Alexander C McLain
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Ashkan Afshin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nicholas J Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Reed Atkin
- The Micronutrient Forum, Washington, DC, USA
| | - Rahul Rawat
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis
, Davis, CA, USA
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19
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Luo H, Brown KH, Stewart CP, Beckett LA, Clermont A, Vosti SA, Guintang Assiene JM, Engle-Stone R. Review of Existing Models to Predict Reductions in Neural Tube Defects Due to Folic Acid Fortification and Model Results Using Data from Cameroon. Adv Nutr 2021; 12:2401-2414. [PMID: 34280291 PMCID: PMC8634386 DOI: 10.1093/advances/nmab083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 12/02/2022] Open
Abstract
Several models have been developed to predict the effects of folic acid fortification programs on prevention of neural tube defects (NTDs), but each relies on different assumptions and data inputs. We identified and reviewed 7 models that predict the effects of folic acid intake or status on NTD risk. We applied 4 of these models [the original and a modified version of the Lives Saved Tool (LiST) and models developed by Arth et al. and Wald et al.] to predict the effect of folic acid fortification of wheat flour on reduction of NTDs using national survey data from Cameroon. The estimated percentage of NTDs averted due to fortified wheat flour (5.0 μg folic acid/g flour) varied by predictive model, with a 21-31% reduction in LiST to 83% in Arth's model, and 15% in Wald's model. As the simulated fortification level was increased from 1.0 to 7.0 μg folic acid/g flour, the pattern of change in estimated numbers of NTDs averted differed due to different model assumptions: the number of NTDs averted increased and then reached a plateau in the modified LiST model (as would be expected in real-world conditions), increased sharply in Arth's model, and increased continuously in Wald's model. This wide variation in predicted effects, and implausible results in some cases, undermines the models' utility for users of model outputs. Concurrent collection of dietary and biomarker data, including plasma and RBC folate concentrations, and NTD outcomes, is necessary to validate these models and monitor change in folic acid intake, folate-related biomarkers, and reduced NTD risk due to fortification. In the meantime, models based on erythrocyte folate concentration are recommended, based on biological plausibility and consistency with empirical evidence. Where erythrocyte folate data are unavailable, sensitivity analyses (using several models) could be conducted to examine the range of possible outcomes.
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Affiliation(s)
- Hanqi Luo
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Christine P Stewart
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Laurel A Beckett
- Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Adrienne Clermont
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, CA, USA
| | | | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
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20
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Tsang BL, Holsted E, McDonald CM, Brown KH, Black R, Mbuya MNN, Grant F, Rowe LA, Manger MS. Effects of Foods Fortified with Zinc, Alone or Cofortified with Multiple Micronutrients, on Health and Functional Outcomes: A Systematic Review and Meta-Analysis. Adv Nutr 2021; 12:1821-1837. [PMID: 34167148 PMCID: PMC8483949 DOI: 10.1093/advances/nmab065] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/02/2021] [Accepted: 05/05/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Becky L Tsang
- IZiNCG Fortification Task Force
- Food Fortification Initiative, Atlanta, GA, USA
| | - Erin Holsted
- IZiNCG Fortification Task Force
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Christine M McDonald
- IZiNCG Fortification Task Force
- International Zinc Nutrition Consultative Group, Oakland, CA, USA
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Kenneth H Brown
- IZiNCG Fortification Task Force
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Robert Black
- IZiNCG Fortification Task Force
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mduduzi N N Mbuya
- IZiNCG Fortification Task Force
- Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Frederick Grant
- IZiNCG Fortification Task Force
- Helen Keller International, Phnom Penh, Cambodia
| | - Laura A Rowe
- IZiNCG Fortification Task Force
- Food Fortification Initiative, Atlanta, GA, USA
| | - Mari S Manger
- IZiNCG Fortification Task Force
- International Zinc Nutrition Consultative Group, Oakland, CA, USA
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21
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Dewey KG, Wessells KR, Arnold CD, Prado EL, Abbeddou S, Adu-Afarwuah S, Ali H, Arnold BF, Ashorn P, Ashorn U, Ashraf S, Becquey E, Bendabenda J, Brown KH, Christian P, Colford JM, Dulience SJL, Fernald LCH, Galasso E, Hallamaa L, Hess SY, Humphrey JH, Huybregts L, Iannotti LL, Jannat K, Lartey A, Le Port A, Leroy JL, Luby SP, Maleta K, Matias SL, Mbuya MNN, Mridha MK, Nkhoma M, Null C, Paul RR, Okronipa H, Ouédraogo JB, Pickering AJ, Prendergast AJ, Ruel M, Shaikh S, Weber AM, Wolff P, Zongrone A, Stewart CP. Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials. Am J Clin Nutr 2021; 114:15S-42S. [PMID: 34590672 PMCID: PMC8560308 DOI: 10.1093/ajcn/nqab278] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design. OBJECTIVES We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes. METHODS We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation. CONCLUSIONS The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.
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Affiliation(s)
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Hasmot Ali
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Bangladesh
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sania Ashraf
- Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, Philadelphia, PA, USA
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Jaden Bendabenda
- Department of Nutrition and Food Safety, WHO, Geneva, Switzerland
| | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA,Helen Keller International, New York, NY, USA
| | - Parul Christian
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lotta Hallamaa
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Jean H Humphrey
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Lora L Iannotti
- Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Kaniz Jannat
- School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | - Jef L Leroy
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe,Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Minyanga Nkhoma
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Rina R Paul
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Harriet Okronipa
- Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA
| | | | | | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe,Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Marie Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Saijuddin Shaikh
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Bangladesh
| | - Ann M Weber
- Division of Epidemiology, School of Community Health Sciences, University of Nevada, Reno, Reno, NV, USA
| | | | | | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
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22
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Wessells KR, Arnold CD, Stewart CP, Prado EL, Abbeddou S, Adu-Afarwuah S, Arnold BF, Ashorn P, Ashorn U, Becquey E, Brown KH, Byrd KA, Campbell RK, Christian P, Fernald L, Fan YM, Galasso E, Hess SY, Huybregts L, Jorgensen JM, Kiprotich M, Kortekangas E, Lartey A, Le Port A, Leroy JL, Lin A, Maleta K, Matias SL, Mbuya M, Mridha MK, Mutasa K, Naser AM, Paul RR, Okronipa H, Ouédraogo JB, Pickering AJ, Rahman M, Schulze K, Smith LE, Weber AM, Zongrone A, Dewey KG. Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child anemia and micronutrient status: an individual participant data meta-analysis of randomized controlled trials. Am J Clin Nutr 2021; 114:68S-94S. [PMID: 34590114 PMCID: PMC8560313 DOI: 10.1093/ajcn/nqab276] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Small-quantity lipid-based nutrient supplements (SQ-LNSs) have been shown to reduce the prevalence of child anemia and iron deficiency, but effects on other micronutrients are less well known. Identifying subgroups who benefit most from SQ-LNSs could support improved program design. OBJECTIVES We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child hemoglobin (Hb), anemia, and inflammation-adjusted micronutrient status outcomes. METHODS We conducted a 2-stage meta-analysis of individual participant data from 13 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 15,946). We generated study-specific and subgroup estimates of SQ-LNSs compared with control, and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine potential study-level effect modifiers. RESULTS SQ-LNS provision decreased the prevalence of anemia (Hb < 110 g/L) by 16% (relative reduction), iron deficiency (plasma ferritin < 12 µg/L) by 56%, and iron deficiency anemia (IDA; Hb < 110 g/L and plasma ferritin <12 µg/L) by 64%. We observed positive effects of SQ-LNSs on hematological and iron status outcomes within all subgroups of the study- and individual-level effect modifiers, but effects were larger in certain subgroups. For example, effects of SQ-LNSs on anemia and iron status were greater in trials that provided SQ-LNSs for >12 mo and provided 9 (as opposed to <9) mg Fe/d, and among later-born (than among first-born) children. There was no effect of SQ-LNSs on plasma zinc or retinol, but there was a 7% increase in plasma retinol-binding protein (RBP) and a 56% reduction in vitamin A deficiency (RBP < 0.70 µmol/L), with little evidence of effect modification by individual-level characteristics. CONCLUSIONS SQ-LNSs can substantially reduce the prevalence of anemia, iron deficiency, and IDA among children across a range of individual, population, and study design characteristics. Policy-makers and program planners should consider SQ-LNSs within intervention packages to prevent anemia and iron deficiency.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020156663.
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Affiliation(s)
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA,Helen Keller International, New York, NY, USA
| | | | - Rebecca K Campbell
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Parul Christian
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Yue-Mei Fan
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Josh M Jorgensen
- Nutrition Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | | | - Emma Kortekangas
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | - Jef L Leroy
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Audrie Lin
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe,Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Abu M Naser
- International Center for Diarrheal Diseases Research (icddr,b), Dhaka, Bangladesh,Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rina R Paul
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Harriet Okronipa
- Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA
| | | | | | - Mahbubur Rahman
- International Center for Diarrheal Diseases Research (icddr,b), Dhaka, Bangladesh
| | - Kerry Schulze
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura E Smith
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Ann M Weber
- Division of Epidemiology, School of Community Health Sciences, University of Nevada, Reno, Reno, NV, USA
| | | | - Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
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23
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Prado EL, Arnold CD, Wessells KR, Stewart CP, Abbeddou S, Adu-Afarwuah S, Arnold BF, Ashorn U, Ashorn P, Becquey E, Brown KH, Chandna J, Christian P, Dentz HN, Dulience SJL, Fernald LC, Galasso E, Hallamaa L, Hess SY, Huybregts L, Iannotti LL, Jimenez EY, Kohl P, Lartey A, Le Port A, Luby SP, Maleta K, Matchado A, Matias SL, Mridha MK, Ntozini R, Null C, Ocansey ME, Parvez SM, Phuka J, Pickering AJ, Prendergast AJ, Shamim AA, Siddiqui Z, Tofail F, Weber AM, Wu L, Dewey KG. Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers. Am J Clin Nutr 2021; 114:43S-67S. [PMID: 34590116 PMCID: PMC8560311 DOI: 10.1093/ajcn/nqab277] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development. OBJECTIVES We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects. METHODS We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024). RESULTS In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11). CONCLUSIONS Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.
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Affiliation(s)
| | - Charles D Arnold
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Christine P Stewart
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Kenneth H Brown
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA,Helen Keller International, New York, NY, USA
| | - Jaya Chandna
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Parul Christian
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Holly N Dentz
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | | | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lotta Hallamaa
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sonja Y Hess
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Lora L Iannotti
- Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Elizabeth Y Jimenez
- Departments of Pediatrics and Internal Medicine and College of Population Health, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Patricia Kohl
- Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrew Matchado
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | | | - Sarker M Parvez
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - John Phuka
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | - Abu A Shamim
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Zakia Siddiqui
- Healthy Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Fahmida Tofail
- Nutrition and Clinical Sciences Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ann M Weber
- Division of Epidemiology, School of Community Health Sciences, University of Nevada, Reno, Reno, NV, USA
| | - Lee S F Wu
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Institute for Global Nutrition & Department of Nutrition, University of California Davis, Davis, CA, USA
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24
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Brown KH, Moore SE, Hess SY, McDonald CM, Jones KS, Meadows SR, Manger MS, Coates J, Alayon S, Osendarp SJM. Increasing the availability and utilization of reliable data on population micronutrient (MN) status globally: the MN Data Generation Initiative. Am J Clin Nutr 2021; 114:862-870. [PMID: 34036318 PMCID: PMC8408880 DOI: 10.1093/ajcn/nqab173] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Micronutrient (MN) deficiencies can produce a broad array of adverse health and functional outcomes. Young, preschool children and women of reproductive age in low- and middle-income countries are most affected by these deficiencies, but the true magnitude of the problems and their related disease burdens remain uncertain because of the dearth of reliable biomarker information on population MN status. The reasons for this lack of information include a limited understanding by policy makers of the importance of MNs for human health and the usefulness of information on MN status for program planning and management; insufficient professional capacity to advocate for this information and design and implement related MN status surveys; high costs and logistical constraints involved in specimen collection, transport, storage, and laboratory analyses; poor access to adequately equipped and staffed laboratories to complete the analyses reliably; and inadequate capacity to interpret and apply this information for public health program design and evaluation. This report describes the current situation with regard to data availability, the reasons for the lack of relevant information, and the steps needed to correct this situation, including implementation of a multi-component MN Data Generation Initiative to advocate for critical data collection and provide related technical assistance, laboratory services, professional training, and financial support.
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Affiliation(s)
- Kenneth H Brown
- Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA, USA
| | - Sophie E Moore
- Department of Women's and Children's Health, Kings College London, London, United Kingdom
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Sonja Y Hess
- Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA, USA
| | - Christine M McDonald
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA
| | - Kerry S Jones
- National Institute for Health Research Biomedical Research Centre Nutritional Biomarker Laboratory, Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Sarah R Meadows
- National Institute for Health Research Biomedical Research Centre Nutritional Biomarker Laboratory, Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Mari S Manger
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA
| | - Jennifer Coates
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Silvia Alayon
- United States Agency for International Development Advancing Nutrition, Arlington, VA, USA
- Save the Children, Washington, DC, USA
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25
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Brown KH, McDonald CM, Wessells KR, Hess SY. Testing metal, proving mettle-findings from the 2016-2018 India Comprehensive National Nutrition Survey regarding the prevalence of low serum zinc concentrations among children and adolescents, and their implications for public health. Am J Clin Nutr 2021; 114:407-409. [PMID: 33963741 DOI: 10.1093/ajcn/nqab159] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kenneth H Brown
- Department of Nutrition, University of California Davis, Davis, CA, USA.,Institute for Global Nutrition, University of California Davis, Davis, CA, USA
| | - Christine M McDonald
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - K Ryan Wessells
- Department of Nutrition, University of California Davis, Davis, CA, USA.,Institute for Global Nutrition, University of California Davis, Davis, CA, USA
| | - Sonja Y Hess
- Department of Nutrition, University of California Davis, Davis, CA, USA.,Institute for Global Nutrition, University of California Davis, Davis, CA, USA
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26
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Gaitonde RS, Martel JA, Porterfield CP, Koide NS, Kobori A, Altemose GT, Brown KH, Dell"orfano J, Gora P, Mathew S. Concomitant utilization of radiofrequency ablation during atrial fibrillation cryoballoon ablation procedures. Europace 2021. [DOI: 10.1093/europace/euab116.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Use of cryoballoon ablation (CBA) for the treatment of atrial fibrillation (AF) has become increasingly common in recent years. While various techniques have been described for use of the cryoballoon to achieve PVI and create selective additional lesion sets, the need for concomitant radiofrequency (RF) ablation in delivering touch-up ablation or non-PVI lesion sets has not been quantified.
Purpose
To quantify the rate of RF ablation catheter use in AF CBA procedures, and to evaluate whether indication for ablation can be used as a predictor of the need for supplementary RF ablation.
Methods
Self-reported data was prospectively collected in AF CBA procedures. Procedural characteristics including concomitant utilization of RF ablation catheters and lesion set delivery were recorded and analyzed. Post-hoc statistical analysis was completed utilizing a two-sample t-test of significance.
Results
Data was collected in a total of 246 AF CBA cases across 44 centers in the USA, Europe, and Japan. Included in the analysis were 170 paroxysmal atrial fibrillation cases (PAF group); 70 PersAF and 6 LsPersAF cases (PersAF group). Utilization rates for RF ablation catheters did not differ between the two groups; 35.9% and 36.8% of cases in PAF and PersAF, respectively (p = 0.885). The number of patients in which non-PV lesion sets were delivered also did not differ between groups; 38.2% and 40.8% in PAF and PersAF, respectively (p = 0.706). The choice of non-PV lesion sets varied as shown in Table 1. Upon completion of ablation, more patients were in sinus rhythm in the PAF group compared to the PersAF group, but the difference did not reach statistical significance; 88.2% and 78.9%, respectively (p = 0.057).
Conclusions
RF ablation catheter utilization rates were similar between groups, suggesting that indication (PAF vs. PersAF) alone is not a good predictor of whether concomitant RF ablation catheter utilization will be required during an AF CBA procedure. Table 1 Incidence Lesion Set PAF (n = 170) PersAF (n = 76) CTI Line 26.5% (45/170) 15.8% (12/76) Isolation/Homogenization of Fibrotic Areas 2.9% (5/170) 3.9% (3/76) CFE 2.9% (5/170) 0.0% (0/76) Posterior Wall Isolation 1.8% (3/170) 21.1% (16/76) Roof Line 1.8% (3/170) 7.9% (6/76) Other 9.4% (16/170) 27.6% (21/76) Utilization rate of non-PVI lesion sets
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Affiliation(s)
- RS Gaitonde
- University of Louisville Health Jewish Hospital Campus, Louisville, KY, United States of America
| | - JA Martel
- South Miami Hospital, Miami, FL, United States of America
| | - CP Porterfield
- French Hospital, San Luis Obispo, CA, United States of America
| | - NS Koide
- Mountainview Hospital, Las Vegas, NV, United States of America
| | - A Kobori
- Kobe City Medical Center General Hospital, Kobe, Japan
| | - GT Altemose
- Methodist Texsan Hospital, San Antonio, TX, United States of America
| | - KH Brown
- Parkview Medical Center, Pueblo, CO, United States of America
| | - J Dell"orfano
- Trinity Health of New England, Hartford, CT, United States of America
| | - P Gora
- Abbott, Minneapolis, United States of America
| | - S Mathew
- Uniklinik Giessen, Giessen, Germany
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27
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Bourassa MW, Bergeron G, Brown KH. A fresh look at thiamine deficiency-new analyses by the global thiamine alliance. Ann N Y Acad Sci 2021; 1498:5-8. [PMID: 33939178 PMCID: PMC8453888 DOI: 10.1111/nyas.14594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022]
Abstract
Severe thiamine (vitamin B1 ) deficiency is generally regarded as a problem affecting mostly infants in low-income communities of Southeast Asia and adult alcoholics regardless of their location. However, recent scholarship shows that the disorders associated with thiamine deficiency may also affect heretofore unsuspected populations, and that the scope of disorders, including some long-lasting neurocognitive consequences, is broader than previously thought.
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Affiliation(s)
- Megan W Bourassa
- Nutrition Science, The New York Academy of Sciences, New York, New York
| | - Gilles Bergeron
- Nutrition Science, The New York Academy of Sciences, New York, New York
| | - Kenneth H Brown
- Department of Nutrition, University of California Davis, Davis, California
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28
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Barffour MA, Hinnouho GM, Wessells KR, Kounnavong S, Ratsavong K, Sitthideth D, Bounheuang B, Sengnam K, Chanhthavong B, Arnold CD, Brown KH, Larson CP, Hess SY. Effects of therapeutic zinc supplementation for diarrhea and two preventive zinc supplementation regimens on the incidence and duration of diarrhea and acute respiratory tract infections in rural Laotian children: A randomized controlled trial. J Glob Health 2021; 10:010424. [PMID: 32612816 PMCID: PMC7321011 DOI: 10.7189/jogh.10.010424] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Diarrhea and respiratory tract infections are leading causes of childhood morbidity and mortality. This individually randomized, double-blind placebo-controlled trial was designed to evaluate the effects of different zinc supplementation regimens on the incidence and duration of diarrhea and acute lower (ALRI) and upper (AURI) respiratory tract infections among rural Laotian children. The study included 3407 children, 6-23 months at enrollment. Methods Children were randomized to one of four study groups: therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days with each episode; TZ), daily preventive zinc tablets (7 mg/d; PZ), daily multiple micronutrient powder (10 mg/d zinc, 6 mg/d iron and 13 other micronutrients; MNP), or daily placebo powder for 9 months. Incidence and duration of diarrhea (≥3 liquid stools/24 hours), ALRI (persistent cough with wheezing, stridor or chest in-drawing) and AURI (purulent nasal discharge with cough) were assessed by parental report during weekly home visits and analyzed using negative binomial models. Results Baseline mean age was 14.2 ± 5.1 months, and 71% had low plasma zinc (<65 μg/dL). Overall diarrhea incidence (0.61 ± 0.01 episodes/100 days at risk) and duration (2.12 ± 0.03 days/episode) did not differ by study group. Age modified the impact of the interventions on diarrhea incidence (P = 0.06) and duration (P = 0.01). In children >18 months, TZ reduced diarrhea incidence by 24% vs MNP (P = 0.035), and 36% vs Control (P = 0.004), but there was no difference with PZ. This patterned remained when analyses were restricted to diarrhea episode occurring after the first treatment with TZ. Also, in children >18 months, TZ reduced diarrhea duration by 15% vs PZ (P = 0.03), and 16% vs Control (P = 0.03), but there was no difference with MNP. There were no overall effects of study group on incidence of ALRI (overall mean 0.005 ± 0.001 episodes/100 days, P = 0.14) or AURI (overall mean 0.09 ± 0.01 episodes/100 days, P = 0.72). Conclusions There was no overall impact of TZ, PZ or MNP on diarrhea, ALRI and AURI. However, in children >18 months, TZ significantly reduced both the duration of diarrhea episodes and the incidence of future diarrhea episodes compared with placebo. Trial registration ClinicalTrials.gov: NCT02428647.
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Affiliation(s)
- Maxwell A Barffour
- Institute for Global Nutrition, University of California, Davis, California, USA.,College of Health and Human Services, Public Health Program, Missouri State University, Springfield, Missouri, USA
| | - Guy-Marino Hinnouho
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - K Ryan Wessells
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Kethmany Ratsavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Dalaphone Sitthideth
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Bangone Bounheuang
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Khanpaseuth Sengnam
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Bigphone Chanhthavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Kenneth H Brown
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Charles P Larson
- School of Population and Global Health, McGill University, Montreal, Canada
| | - Sonja Y Hess
- Institute for Global Nutrition, University of California, Davis, California, USA
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Wessells KR, Brown KH, Arnold CD, Barffour MA, Hinnouho GM, Killilea DW, Kounnavong S, Hess SY. Plasma and Nail Zinc Concentrations, But Not Hair Zinc, Respond Positively to Two Different Forms of Preventive Zinc Supplementation in Young Laotian Children: a Randomized Controlled Trial. Biol Trace Elem Res 2021; 199:442-452. [PMID: 32356207 PMCID: PMC7746564 DOI: 10.1007/s12011-020-02163-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/15/2020] [Indexed: 11/29/2022]
Abstract
Plasma zinc concentrations (PZC) have been shown to significantly increase during zinc supplementation. This study investigated the effects of daily preventive zinc supplementation on hair and nail zinc concentrations compared with a control group. In a randomized controlled trial, 6- to 23-month-old children (n = 3407) in Lao PDR were randomly assigned to one of four groups and followed for ~ 36 weeks: daily preventive zinc dispersible tablet (7 mg/d; PZ), daily micronutrient powder (10 mg zinc/d; MNP), therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days; TZ), or daily placebo powder (Control). Plasma, hair, and nail zinc concentrations were assessed in a sub-sample of participants (n = 457) at baseline and endline. At baseline, 75% of children had low PZC (< 65 μg/dL). At endline, geometric mean (95% CI) PZC were greater in the PZ and MNP groups compared with the TZ and control groups (P < 0.01), but hair zinc concentrations did not differ among groups (P = 0.99). Nail zinc concentrations were marginally higher in the PZ (115.8 (111.6, 119.9) μg/g) and the MNP (117.8 (113.3, 122.3) μg/g) groups than in the TZ group (110.4 (106.0, 114.8) μg/g; P = 0.055) at endline. This study does not support the use of hair zinc as a biomarker of zinc exposure in young children. However, it provides some evidence that zinc concentrations in nails may respond to supplemental zinc interventions and supports the need for collecting additional data on this emerging biomarker.
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Affiliation(s)
- K. Ryan Wessells
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, One Shields Ave, Davis, CA 95616 USA
| | - Kenneth H. Brown
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, One Shields Ave, Davis, CA 95616 USA
| | - Charles D. Arnold
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, One Shields Ave, Davis, CA 95616 USA
| | - Maxwell A. Barffour
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, One Shields Ave, Davis, CA 95616 USA
- McQueary College of Health and Human Services, Public Health Program, Missouri State University, 606E Cherry St, Springfield, MO 65897 USA
| | - Guy-Marino Hinnouho
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, One Shields Ave, Davis, CA 95616 USA
| | - David W. Killilea
- Children’s Hospital of Oakland Research Institute, 5700 Martin Luther King Jr Way, Oakland, CA 94609 USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Ban Kaognot, Sisattanak District, Vientiane, Lao People’s Democratic Republic
| | - Sonja Y. Hess
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, One Shields Ave, Davis, CA 95616 USA
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Affiliation(s)
| | - Kenneth H Brown
- Micronutrient Forum, Washington, DC 20005-3915, USA; Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Lynnette M Neufeld
- Global Alliance for Improved Nutrition, Geneva, Switzerland; Micronutrient Forum, Washington, DC 20005-3915, USA
| | - Emorn Udomkesmalee
- Institute of Nutrition, Mahidol University, Salaya, Nakhon Pathom, Thailand; Micronutrient Forum, Washington, DC 20005-3915, USA
| | - Sophie E Moore
- Micronutrient Forum, Washington, DC 20005-3915, USA; Department of Women and Children's Health, King's College London, London, UK; Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
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31
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Kewcharoenwong C, Schuster GU, Wessells KR, Hinnouho GM, Barffour MA, Kounnavong S, Brown KH, Hess SY, Samer W, Tussakhon I, Peerson JM, Lertmemongkolchai G, Stephensen CB. Daily Preventive Zinc Supplementation Decreases Lymphocyte and Eosinophil Concentrations in Rural Laotian Children from Communities with a High Prevalence of Zinc Deficiency: Results of a Randomized Controlled Trial. J Nutr 2020; 150:2204-2213. [PMID: 32119742 DOI: 10.1093/jn/nxaa037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/09/2019] [Accepted: 02/04/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Zinc deficiency impairs immune function and is common among children in South-East Asia. OBJECTIVES The effect of zinc supplementation on immune function in young Laotian children was investigated. METHODS Children (n = 512) aged 6-23 mo received daily preventive zinc tablets (PZ; 7 mg Zn/d), daily multiple micronutrient powder (MNP; 10 mg Zn/d, 6 mg Fe/d, plus 13 other micronutrients), therapeutic dispersible zinc tablets only in association with diarrhea episodes (TZ; 20 mg Zn/d for 10 d after an episode), or daily placebo powder (control). These interventions continued for 9 mo. Cytokine production from whole blood cultures, the concentrations of T-cell populations, and a complete blood count with differential leukocyte count were measured at baseline and endline. Endline means were compared via ANCOVA, controlling for the baseline value of the outcome, child age and sex, district, month of enrollment, and baseline zinc status (below, or above or equal to, the median plasma zinc concentration). RESULTS T-cell cytokines (IL-2, IFN-γ, IL-13, IL-17), LPS-stimulated cytokines (IL-1β, IL-6, TNF-α, and IL-10), and T-cell concentrations at endline did not differ between intervention groups, nor was there an interaction with baseline zinc status. However, mean ± SE endline lymphocyte concentrations were significantly lower in the PZ than in the control group (5018 ± 158 compared with 5640 ± 160 cells/μL, P = 0.032). Interactions with baseline zinc status were seen for eosinophils (Pixn = 0.0036), basophils (Pixn = 0.023), and monocytes (P = 0.086) but a significant subgroup difference was seen only for eosinophils, where concentrations were significantly lower in the PZ than in the control group among children with baseline plasma zinc concentrations below the overall median (524 ± 44 compared with 600 ± 41 cells/μL, P = 0.012). CONCLUSIONS Zinc supplementation of rural Laotian children had no effect on cytokines or T-cell concentrations, although zinc supplementation affected lymphocyte and eosinophil concentrations. These cell subsets may be useful as indicators of response to zinc supplementation.This trial was registered at clinicaltrials.gov as NCT02428647.
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Affiliation(s)
- Chidchamai Kewcharoenwong
- The Centre for Research & Development of Medical Diagnostic Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Gertrud U Schuster
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA.,Agricultural Research Service, Western Human Nutrition Research Center, USDA, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Guy-Marino Hinnouho
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Maxwell A Barffour
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA.,College of Health and Human Services, Public Health Program, Missouri State University, Springfield, MO, USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Kenneth H Brown
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Sonja Y Hess
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Waraporn Samer
- The Centre for Research & Development of Medical Diagnostic Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Inthira Tussakhon
- The Centre for Research & Development of Medical Diagnostic Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand.,Department of Medical Technology and Pathology, Nakhonphanom Hospital, Nakhon Phanom, Thailand
| | - Janet M Peerson
- Agricultural Research Service, Western Human Nutrition Research Center, USDA, Davis, CA, USA
| | - Ganjana Lertmemongkolchai
- The Centre for Research & Development of Medical Diagnostic Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Charles B Stephensen
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA.,Agricultural Research Service, Western Human Nutrition Research Center, USDA, Davis, CA, USA
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Barney DE, Olson CI, Brown KH, Hennigar SR. An Organic Matrix to Improve the Bioavailability and Sensory Properties of Micronutrient Fortificants. J Nutr 2020; 150:981-982. [PMID: 32232403 DOI: 10.1093/jn/nxaa084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- David E Barney
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - Cassandra I Olson
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - Kenneth H Brown
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Stephen R Hennigar
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
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McDonald CM, Suchdev PS, Krebs NF, Hess SY, Wessells KR, Ismaily S, Rahman S, Wieringa FT, Williams AM, Brown KH, King JC. Adjusting plasma or serum zinc concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr 2020; 111:927-937. [PMID: 32266402 PMCID: PMC7138668 DOI: 10.1093/ajcn/nqz304] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The accurate estimation of zinc deficiency at the population level is important, as it guides the design, targeting, and evaluation of nutrition interventions. Plasma or serum zinc concentration (PZC) is recommended to estimate zinc nutritional status; however, concentrations may decrease in the presence of inflammation. OBJECTIVES We aimed to assess the relation between PZC and inflammation in preschool children (PSC; 6-59 mo) and nonpregnant women of reproductive age (WRA; 15-49 y), and to compare different inflammation adjustment approaches, if adjustment is warranted. METHODS Cross-sectional data from 13 nationally representative surveys (18,859 PSC, 22,695 WRA) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed. Correlation and decile analyses were conducted, and the following 3 adjustment methods were compared if a consistent negative association between PZC and C-reactive protein (CRP) or α-1-acid glycoprotein (AGP) was observed: 1) exclude individuals with CRP > 5 mg/L or AGP > 1 g/L; 2) apply arithmetic correction factors; and 3) use the BRINDA regression correction (RC) approach. RESULTS In 6 of 12 PSC surveys, the estimated prevalence of zinc deficiency increased with increasing CRP deciles, and to a lesser extent, with increasing AGP deciles. In WRA, the association of PZC with CRP and AGP was weak and inconsistent. In the 6 PSC surveys in which adjustment methods were compared, application of RC reduced the estimated prevalence of zinc deficiency by a median of 11 (range: 4-18) percentage points, compared with the unadjusted prevalence. CONCLUSIONS Relations between PZC and inflammatory markers were inconsistent, suggesting that correlation and decile analyses should be conducted before applying any inflammation adjustments. In populations of PSC that exhibit a significant negative association between PZC and CRP or AGP, application of the RC approach is supported. At this time, there is insufficient evidence to warrant inflammation adjustment in WRA.
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Affiliation(s)
- Christine M McDonald
- Children's Hospital Oakland Research Institute, Oakland, CA, USA
- Department of Pediatrics, School of Medicine, University of California, San Francisco, CA, USA
- Address correspondence to CMM (e-mail: )
| | - Parminder S Suchdev
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Nutrition Branch, CDC, Atlanta, GA, USA
| | - Nancy F Krebs
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sonja Y Hess
- Department of Nutrition, University of California, Davis, CA, USA
| | - K Ryan Wessells
- Department of Nutrition, University of California, Davis, CA, USA
| | - Sanober Ismaily
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sabuktagin Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | | | - Anne M Williams
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Nutrition Branch, CDC, Atlanta, GA, USA
- McKing Consulting Corporation, Atlanta, GA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, CA, USA
| | - Janet C King
- Children's Hospital Oakland Research Institute, Oakland, CA, USA
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Vosti SA, Kagin J, Engle-Stone R, Luo H, Tarini A, Clermont A, Assiene JG, Nankap M, Brown KH. Strategies to achieve adequate vitamin A intake for young children: options for Cameroon. Ann N Y Acad Sci 2019; 1465:161-180. [PMID: 31797386 PMCID: PMC7187426 DOI: 10.1111/nyas.14275] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 10/21/2019] [Accepted: 10/25/2019] [Indexed: 01/05/2023]
Abstract
Meeting children's vitamin A (VA) needs remains a policy priority. Doing so efficiently is a fiscal imperative and protecting at-risk children during policy transitions is a moral imperative. Using the Micronutrient Intervention Modeling tool and data for Cameroon, we predict the impacts and costs of alternative VA intervention programs, identify the least-cost strategy for meeting targets nationally, and compare it to a business-as-usual (BAU) strategy over 10 years. BAU programs effectively cover ∼12.8 million (m) child-years (CY) and cost ∼$30.1 m; ∼US$2.34 per CY effectively covered. Improving the VA-fortified oil program, implementing a VA-fortified bouillon cube program, and periodic VA supplements (VAS) in the North macroregion for 3 years effectively cover ∼13.1 m CY at a cost of ∼US$9.5 m, or ∼US$0.71 per CY effectively covered. The tool then identifies a sequence of subnational policy choices leading from the BAU toward the more efficient strategy, while addressing VA-attributable mortality concerns. By year 4, fortification programs are predicted to eliminate inadequate VA intake in the South and Cities macroregions, but not the North, where VAS should continue until additional delivery platforms are implemented. This modeling approach offers a concrete example of the strategic use of data to follow the Global Alliance for VA framework and do so efficiently.
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Affiliation(s)
- Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, Davis, California
| | | | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, Davis, California
| | - Hanqi Luo
- Department of Nutrition, University of California, Davis, Davis, California
| | - Ann Tarini
- Ann Tarini International Public Health Consulting, Montreal, Quebec, Canada
| | - Adrienne Clermont
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, California
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McDonald CM, Ackatia-Armah RS, Doumbia S, Brown KH. Reply to C Fabiansen et al. J Nutr 2019; 149:2265-2266. [PMID: 31792544 DOI: 10.1093/jn/nxz1962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Seydou Doumbia
- Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, CA, USA
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36
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McDonald CM, Ackatia-Armah RS, Doumbia S, Brown KH. Reply to C Fabiansen et al. J Nutr 2019. [DOI: 10.1093/jn/nxz196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Seydou Doumbia
- Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, CA, USA
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Zyba SJ, Wegmüller R, Woodhouse LR, Ceesay K, Prentice AM, Brown KH, Wessells KR. Effect of exogenous phytase added to small-quantity lipid-based nutrient supplements (SQ-LNS) on the fractional and total absorption of zinc from a millet-based porridge consumed with SQ-LNS in young Gambian children: a randomized controlled trial. Am J Clin Nutr 2019; 110:1465-1475. [PMID: 31504101 DOI: 10.1093/ajcn/nqz205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/26/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Dietary phytate inhibits zinc absorption from composite meals in adults. OBJECTIVE The objective of this study was to investigate the effect of adding exogenous phytase to a small-quantity lipid-based nutrient supplement (SQ-LNS) on zinc absorption among young children. METHODS In a double-blind randomized controlled trial, intraindividual differences in fractional and total absorption of zinc (FAZ and TAZ, respectively) from a millet-based porridge containing SQ-LNS with and without phytase were measured in 30 asymptomatic children 18-23 mo of age in the Kiang West district of The Gambia. Using a crossover design, children received for 1 d each porridge test meals with 20 g SQ-LNS containing 8 mg zinc and either 1) exogenous phytase or 2) no exogenous phytase. The test meals were provided on consecutive days in randomized order. FAZ was measured using a triple stable isotope tracer ratio technique with Zn-67 and Zn-70 as oral tracers and Zn-68 as the intravenous tracer. RESULTS Twenty-six participants completed the study. The prevalence of stunting and wasting were 20% and 13%, respectively; no children had low plasma zinc concentrations (<65 μg/dL). Total mean ± SD dietary zinc intake from the test meals was 7.3 ± 2.2 mg (phytate:zinc molar ratio = 3.1 ± 0.3, not accounting for phytase activity). Mean FAZ increased from 8.6% ± 1.3% to 16.0% ± 1.3% when exogenous phytase was added to the SQ-LNS product (P < 0.001). Mean TAZ from test meals containing SQ-LNS with phytase was more than double that from test meals containing SQ-LNS without phytase (1.1 ± 0.1 mg and 0.5 ± 0.1 mg, respectively; P < 0.001). CONCLUSIONS The addition of exogenous phytase to SQ-LNS increased both FAZ and TAZ. These results suggest that phytate reduction may be an important strategy to increase zinc absorption among young children. This trial was registered at clinicaltrials.gov as NCT02668133.
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Affiliation(s)
- Sarah J Zyba
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Rita Wegmüller
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia.,Department of Health Sciences and Technology, Human Nutrition Laboratory, Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Leslie R Woodhouse
- Agricultural Research Service, Western Human Nutrition Research Center, US Department of Agriculture, Davis, CA, USA
| | - Kabiru Ceesay
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Andrew M Prentice
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Kenneth H Brown
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - K Ryan Wessells
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
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Mark HE, Assiene JG, Luo H, Nankap M, Ndjebayi A, Ngnie-Teta I, Tarini A, Pattar A, Killilea DW, Brown KH, Engle-Stone R. Monitoring of the National Oil and Wheat Flour Fortification Program in Cameroon Using a Program Impact Pathway Approach. Curr Dev Nutr 2019; 3:nzz076. [PMID: 31367692 PMCID: PMC6660062 DOI: 10.1093/cdn/nzz076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/04/2019] [Accepted: 06/18/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Since 2011 Cameroon has mandated the fortification of refined vegetable oil with vitamin A and wheat flour with iron, zinc, folic acid, and vitamin B-12. In 2012, measured fortification levels for flour, and particularly oil, were below target. OBJECTIVES We assessed Cameroon's food fortification program using a program impact pathway (PIP) to identify barriers to optimal performance. METHODS We developed a PIP through literature review and key informant interviews. We conducted interviews at domestic factories for refined vegetable oil (n = 9) and wheat flour (n = 10). In 12 sentinel sites distributed nationally, we assessed availability and storage conditions of fortified foods in markets and frequency of consumption of fortified foods among women and children (n = 613 households). Food samples were collected from factories, markets, and households for measurement of micronutrient content. RESULTS Two-thirds of factories presented quality certificates for recent premix purchases. All factories had in-house capacity for micronutrient analysis, but most used qualitative methods. Industries cited premix import taxes and access to external laboratories as constraints. Mean vitamin A levels were 141% (95% CI: 116%, 167%), 75% (95% CI: 62%, 89%), and 75% (95% CI: 60%, 90%) of target in individual samples from factories, markets, and households, respectively. Most industry flour samples appeared to be fortified, but micronutrient levels were low. Among composite flour samples from markets and households, the mean iron and zinc content was 25 mg/kg and 43 mg/kg, respectively, ∼45% of target levels; folic acid (36%) and vitamin B-12 (29%) levels were also low. In the previous week, the majority of respondents had consumed "fortifiable" oil (63% women and 52% children) and wheat flour (82% women and 86% children). CONCLUSIONS In Cameroon, oil fortification program performance appears to have improved since 2012, but fortification levels remain below target, particularly for wheat flour. Consistent regulatory monitoring and program support, possibly through premix procurement and micronutrient analysis, are needed.
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Affiliation(s)
- Henry E Mark
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | | | - Hanqi Luo
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | | | | | | | | | - Amrita Pattar
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - David W Killilea
- Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, Davis, CA, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Engle-Stone R, Vosti SA, Luo H, Kagin J, Tarini A, Adams KP, French C, Brown KH. Weighing the risks of high intakes of selected micronutrients compared with the risks of deficiencies. Ann N Y Acad Sci 2019; 1446:81-101. [PMID: 31168822 PMCID: PMC6618252 DOI: 10.1111/nyas.14128] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/22/2019] [Accepted: 05/03/2019] [Indexed: 12/31/2022]
Abstract
Several intervention strategies are available to reduce micronutrient deficiencies, but uncoordinated implementation of multiple interventions may result in excessive intakes. We reviewed relevant data collection instruments and available information on excessive intakes for selected micronutrients and considered possible approaches for weighing competing risks of intake above tolerable upper intake levels (ULs) versus insufficient intakes at the population level. In general, population‐based surveys in low‐ and middle‐income countries suggest that dietary intakes greater than the UL are uncommon, but simulations indicate that fortification and supplementation programs could lead to high intakes under certain scenarios. The risk of excessive intakes can be reduced by considering baseline information on dietary intakes and voluntary supplement use and continuously monitoring program coverage. We describe a framework for comparing risks of micronutrient deficiency and excess, recognizing that critical information for judging these risks is often unavailable. We recommend (1) assessing total dietary intakes and nutritional status; (2) incorporating rapid screening tools for routine monitoring and surveillance; (3) addressing critical research needs, including evaluations of the current ULs, improving biomarkers of excess, and developing methods for predicting and comparing risks and benefits; and (4) ensuring that relevant information is used in decision‐making processes.
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Affiliation(s)
- Reina Engle-Stone
- Department of Nutrition, University of California, Davis, California
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, California
| | - Hanqi Luo
- Department of Nutrition, University of California, Davis, California
| | | | - Ann Tarini
- Independent consultant, Laval, Quebec, Canada
| | - Katherine P Adams
- Department of Nutrition, University of California, Davis, California
| | - Caitlin French
- Department of Nutrition, University of California, Davis, California
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, California
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41
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McDonald CM, Ackatia-Armah RS, Doumbia S, Kupka R, Duggan CP, Brown KH. Percent Fat Mass Increases with Recovery, But Does Not Vary According to Dietary Therapy in Young Malian Children Treated for Moderate Acute Malnutrition. J Nutr 2019; 149:1089-1096. [PMID: 30968123 PMCID: PMC6543204 DOI: 10.1093/jn/nxz037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/29/2018] [Accepted: 02/20/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Moderate acute malnutrition (MAM) affects 34.1 million children globally. Treatment effectiveness is generally determined by the amount and rate of weight gain. Body composition (BC) assessment provides more detailed information on nutritional stores and the type of tissue accrual than traditional weight measurements alone. OBJECTIVE The aim of this study was to compare the change in percentage fat mass (%FM) and other BC parameters among young Malian children with MAM according to receipt of 1 of 4 dietary supplements, and recovery status at the end of the 12-wk intervention period. METHODS BC was assessed using the deuterium oxide dilution method in a subgroup of 286 children aged 6-35 mo who participated in a 12-wk community-based, cluster-randomized effectiveness trial of 4 dietary supplements for the treatment of MAM: 1) lipid-based, ready-to-use supplementary food (RUSF); 2) special corn-soy blend "plus plus" (CSB++); 3) locally processed, fortified flour (MI); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). Multivariate linear regression modeling was used to evaluate change in BC parameters by treatment group and recovery status. RESULTS Mean ± SD %FM at baseline was 28.6% ± 5.32%. Change in %FM did not vary between groups. Children who received RUSF vs. MI gained more (mean; 95% CI) weight (1.43; 1.13, 1.74 kg compared with 0.84; 0.66, 1.03 kg; P = 0.02), FM (0.70; 0.45, 0.96 kg compared with 0.20; 0.05, 0.36 kg; P = 0.01), and weight-for-length z score (1.23; 0.79, 1.54 compared with 0.49; 0.34, 0.71; P = 0.03). Children who recovered from MAM exhibited greater increases in all BC parameters, including %FM, than children who did not recover. CONCLUSIONS In this study population, children had higher than expected %FM at baseline. There were no differences in %FM change between groups. International BC reference data are needed to assess the utility of BC assessment in community-based management of acute malnutrition programs. This trial was registered at clinicaltrials.gov as NCT01015950.
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Affiliation(s)
- Christine M McDonald
- Children's Hospital Oakland Research Institute, Oakland, CA,Address correspondence to CMM (e-mail: )
| | | | - Seydou Doumbia
- Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali
| | | | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA,Departments of Nutrition, and Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA
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Wessells KR, Peerson JM, Brown KH. Within-individual differences in plasma ferritin, retinol-binding protein, and zinc concentrations in relation to inflammation observed during a short-term longitudinal study are similar to between-individual differences observed cross-sectionally. Am J Clin Nutr 2019; 109:1484-1492. [PMID: 30976780 DOI: 10.1093/ajcn/nqz014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/21/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cross-sectional (CS) surveys indicate that individuals with acute inflammation have higher plasma ferritin (pF), and lower retinol-binding protein (RBP) and zinc (pZn) concentrations than those without. In populations with a high burden of infection, correction factors (CFs) or regression corrections (RCs) are applied to biomarkers to estimate the prevalence of micronutrient (MN) deficiencies adjusted for inflammation. This assumes that individuals with and without inflammation have the same nutritional status, which may not be the case. OBJECTIVES The aim of this study was to investigate relations between short-term, longitudinal within-individual changes in acute phase proteins (C-reactive protein [CRP], α-1-acid glycoprotein [AGP]) and biomarkers of MN status (pF, soluble transferrin receptor [sTfR], RBP, and pZn), and compare them to CS differences. METHODS Two blood samples were obtained 21 d apart from 451 asymptomatic Burkinabé children aged 6-23 mo. To calculate CFs, inflammation was defined as CRP >5 mg/L or AGP >1 g/L, or both. The RC approach adjusted MN biomarkers to a presumably healthy reference point within the study population (10th percentile CRP or AGP concentration). CS CFs and RCs were estimated from a naive regression model, treating observations from the same children as independent. Longitudinal CFs and RCs, to estimate effects of within-individual changes in CRP and/or AGP, were estimated from general linear models, accounting for repeated measures. RESULTS In CS models, geometric mean pF and sTfR concentrations were 8-340% greater, and RBP and pZn 2-18% lower, in children with inflammation than those without. Except for sTfR, biomarker concentrations differed in the same direction and by similar magnitude within individuals whose inflammation status changed during the observation period. Although geometric mean MN concentrations differed significantly when adjusted with CS compared with longitudinal models, the estimated prevalence of MN deficiencies in CS and longitudinally adjusted models was similar. CONCLUSIONS The CF and RC approaches to adjust MN biomarkers for inflammation between individuals in CS surveys are valid approaches for data collection and programmatic decisions in comparable populations. This study was registered at clinicaltrials.gov as NCT00944853.
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Affiliation(s)
- K Ryan Wessells
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA
| | - Janet M Peerson
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA
| | - Kenneth H Brown
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA.,Nutrition and Global Development, Bill & Melinda Gates Foundation, Seattle, WA
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43
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Isanaka S, Barnhart DA, McDonald CM, Ackatia-Armah RS, Kupka R, Doumbia S, Brown KH, Menzies NA. Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali. BMJ Glob Health 2019; 4:e001227. [PMID: 31139441 PMCID: PMC6509694 DOI: 10.1136/bmjgh-2018-001227] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/21/2018] [Accepted: 01/12/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Moderate acute malnutrition (MAM) causes substantial child morbidity and mortality, accounting for 4.4% of deaths and 6.0% of disability-adjusted life years (DALY) lost among children under 5 each year. There is growing consensus on the need to provide appropriate treatment of MAM, both to reduce associated morbidity and mortality and to halt its progression to severe acute malnutrition. We estimated health outcomes, costs and cost-effectiveness of four dietary supplements for MAM treatment in children 6–35 months of age in Mali. Methods We conducted a cluster-randomised MAM treatment trial to describe nutritional outcomes of four dietary supplements for the management of MAM: ready-to-use supplementary foods (RUSF; PlumpySup); a specially formulated corn–soy blend (CSB) containing dehulled soybean flour, maize flour, dried skimmed milk, soy oil and a micronutrient pre-mix (CSB++; Super Cereal Plus); Misola, a locally produced, micronutrient-fortified, cereal–legume blend (MI); and locally milled flour (LMF), a mixture of millet, beans, oil and sugar, with a separate micronutrient powder. We used a decision tree model to estimate long-term outcomes and calculated incremental cost-effectiveness ratios (ICERs) comparing the health and economic outcomes of each strategy. Results Compared to no MAM treatment, MAM treatment with RUSF, CSB++, MI and LMF reduced the risk of death by 15.4%, 12.7%, 11.9% and 10.3%, respectively. The ICER was US$9821 per death averted (2015 USD) and US$347 per DALY averted for RUSF compared with no MAM treatment. Conclusion MAM treatment with RUSF is cost-effective across a wide range of willingness-to-pay thresholds. Trial registration NCT01015950.
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Affiliation(s)
- Sheila Isanaka
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Dale A Barnhart
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Robert S Ackatia-Armah
- Department of Nutrition and Program in International and Community Nutrition, University of California, Davis, CA, USA
| | - Roland Kupka
- United Nations Children's Fund, Nutrition Section, New York, NY, USA
| | - Seydou Doumbia
- Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technology of Bamako, Bamako, Mali
| | - Kenneth H Brown
- Department of Nutrition and Program in International and Community Nutrition, University of California, Davis, CA, USA
| | - Nicolas A Menzies
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Anaya-Loyola MA, Brito A, Brown KH, Allen LH. Breast milk provides inadequate amounts of vitamin B12 for predominantly breastfed Guatemalan infants. INT J VITAM NUTR RES 2019; 90:395-402. [PMID: 30987548 DOI: 10.1024/0300-9831/a000583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Vitamin B12 (B12) plays in an important role in the development and function of the brain and nervous system, and adequate B12 status is especially important for the normal development of infants. In previous research conducted in Guatemala City we reported a high prevalence of B12 deficiency in lactating women and their infants 3 and 12 months of age, and low B12 concentrations in breast milk. The objective of this study was to assess predictors of serum B12 concentration in predominantly breastfed Guatemalan infants including intake of B12 from breast milk and other foods. Serum B12, breast milk and other food intakes, anthropometry, morbidity and socioeconomic status were assessed in infants 6.7 ± 0.6 months of age (n = 127, 52% female) in peri-urban Guatemala City. Twenty-four percent of infants had deficient B12 status (serum B12 concentration < 148 pmol/L) and 37% had marginal B12 status (148-220 pmol/L). Serum B12 concentrations were negatively correlated with infants' consumption of energy from breast milk (r = -0.37, p = 0.001), and positively correlated with their total consumption of animal source foods, especially cow's milk (r = 0.40, p = 0.001). Based on previously analyzed breast milk B12 concentrations in a nearby community, breast milk provided < 10% of the recommended daily B12 intake for this age. We conclude that there was a high prevalence of B12 deficiency in these Guatemalan infants by 6 months of age. Serum B12 was higher in infants consuming more cow's milk and lower in those consuming more breast milk.
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Affiliation(s)
| | - Alex Brito
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Lindsay H Allen
- USDA, ARS, Western Human Nutrition Research Center, Davis, CA, USA
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45
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Wessells KR, Brown KH, Kounnavong S, Barffour MA, Hinnouho GM, Sayasone S, Stephensen CB, Ratsavong K, Larson CP, Arnold CD, Harding KB, Reinhart GA, Lertmemongkolchai G, Fucharoen S, Bernstein RM, Hess SY. Comparison of two forms of daily preventive zinc supplementation versus therapeutic zinc supplementation for diarrhea on young children's physical growth and risk of infection: study design and rationale for a randomized controlled trial. BMC Nutr 2018; 4:39. [PMID: 32153900 PMCID: PMC7050875 DOI: 10.1186/s40795-018-0247-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/13/2018] [Indexed: 12/04/2022] Open
Abstract
Background Zinc is an essential nutrient that is required for children’s normal growth and resistance to infections, including diarrhea and pneumonia, two major causes of child mortality. Daily or weekly preventive zinc supplementation has been shown to improve growth and reduce the risk of infection, while therapeutic zinc supplementation for 10–14 days is recommended for the treatment of diarrhea. The overall objective of the present study is to compare several regimens for delivering zinc to young children, both for the prevention of zinc deficiency and the treatment of diarrhea. Methods The present study is a community-based, randomized controlled trial in the Lao People’s Democratic Republic (PDR). Three thousand, four hundred children 6–23 months of age will be randomized to one of four intervention groups (daily preventive zinc dispersible tablet, daily preventive multiple micronutrient powder, therapeutic zinc dispersible tablet for diarrhea, or placebo control); interventions will be delivered for 9 months and outcomes measured at pre-determined intervals. Primary outcomes include physical growth (length and weight), diarrhea incidence, hemoglobin and micronutrient status, and innate and adaptive immune function. Secondary outcomes include mid-upper-arm circumference, neuro-behavioral development, hair cortisol concentrations, markers of intestinal inflammation and parasite burden. Incidence of adverse events and the modifying effects of inherited hemoglobin disorders and iron status on the response to the intervention will also be examined. We will estimate unadjusted effects and effects adjusted for selected baseline covariates using ANCOVA. Discussion Many countries are now rolling out large-scale programs to include therapeutic zinc supplementation in the treatment of childhood diarrhea, but few have established programs demonstrated to be effective in the prevention of zinc deficiency. This study will address how best to deliver supplemental zinc to prevent zinc deficiency and reduce the severity of diarrhea-related health complications. Trial registration Trial registration identifier (NCT02428647) ; Date of registration: April 29, 2015.
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Affiliation(s)
- K Ryan Wessells
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Kenneth H Brown
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA.,2Nutrition and Global Development, Bill & Melinda Gates Foundation, Seattle, WA USA
| | - Sengchanh Kounnavong
- 3National Institute of Public Health, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Maxwell A Barffour
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Guy-Marino Hinnouho
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Somphou Sayasone
- 3National Institute of Public Health, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Charles B Stephensen
- 4United States Department of Agriculture, Western Human Nutrition Research Center, Davis, CA USA
| | - Kethmany Ratsavong
- 3National Institute of Public Health, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | | | - Charles D Arnold
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Kimberly B Harding
- 6Nutrition International, formerly The Micronutrient Initiative, Ottawa, Canada
| | - Gregory A Reinhart
- 7The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH USA
| | - Ganjana Lertmemongkolchai
- 8Centre for Research and Development of Medical Diagnostics Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Supan Fucharoen
- 8Centre for Research and Development of Medical Diagnostics Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Robin M Bernstein
- 9Department of Anthropology, University of Colorado, Boulder, CO USA
| | - Sonja Y Hess
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
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Abstract
Weanlings in less developed countries commonly grow more slowly than reference populations from industrialized societies. Although the functional implications of these different patterns of growth are not certain, it is generally believed that children's diets should permit full expression of their growth potential. To achieve this goal, the focus of public health nutrition programmes in less developed countries has evolved from an earlier emphasis on enhanced protein consumption to a current emphasis on increased energy intake. However, these programmes often neglect consideration of the quality of weanlings’ diets and its potential importance for a variety of functional outcomes, including its relation to appetite and energy consumption. These issues are discussed in greater detail, and a conceptual framework is presented for the classification of different aspects of dietary quality.
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Brown KH, Creed-Kanashiro H, Dewey KG. Optimal Complementary Feeding Practices to Prevent Childhood Malnutrition in Developing Countries. Food Nutr Bull 2018. [DOI: 10.1177/156482659501600407] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Optimal nutritional care of young children requires application of feeding guidelines based on scientific knowledge of children's nutrient requirements and the ability of breastmilk and other foods to satisfy these nutritional needs. This paper reviews recent information on the appropriate duration of exclusive breastfeeding and timing of introduction of complementary foods; the relationship between frequency of feeding, dietary energy density, and total daily energy consumption; and the importance of nutrient composition and selected organoleptic characteristics of complementary foods as determinants of dietary intake. The role of child appetite is also discussed Finally, programmatic options for the promotion of enhanced complementary feeding and relevant practical experiences in Peru are reviewed.
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49
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Whitfield KC, Bourassa MW, Adamolekun B, Bergeron G, Bettendorff L, Brown KH, Cox L, Fattal‐Valevski A, Fischer PR, Frank EL, Hiffler L, Hlaing LM, Jefferds ME, Kapner H, Kounnavong S, Mousavi MP, Roth DE, Tsaloglou M, Wieringa F, Combs GF. Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs. Ann N Y Acad Sci 2018; 1430:3-43. [PMID: 30151974 PMCID: PMC6392124 DOI: 10.1111/nyas.13919] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/05/2018] [Indexed: 12/20/2022]
Abstract
Thiamine is an essential micronutrient that plays a key role in energy metabolism. Many populations worldwide may be at risk of clinical or subclinical thiamine deficiencies, due to famine, reliance on staple crops with low thiamine content, or food preparation practices, such as milling grains and washing milled rice. Clinical manifestations of thiamine deficiency are variable; this, along with the lack of a readily accessible and widely agreed upon biomarker of thiamine status, complicates efforts to diagnose thiamine deficiency and assess its global prevalence. Strategies to identify regions at risk of thiamine deficiency through proxy measures, such as analysis of food balance sheet data and month-specific infant mortality rates, may be valuable for understanding the scope of thiamine deficiency. Urgent public health responses are warranted in high-risk regions, considering the contribution of thiamine deficiency to infant mortality and research suggesting that even subclinical thiamine deficiency in childhood may have lifelong neurodevelopmental consequences. Food fortification and maternal and/or infant thiamine supplementation have proven effective in raising thiamine status and reducing the incidence of infantile beriberi in regions where thiamine deficiency is prevalent, but trial data are limited. Efforts to determine culturally and environmentally appropriate food vehicles for thiamine fortification are ongoing.
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Affiliation(s)
- Kyly C. Whitfield
- Department of Applied Human NutritionMount Saint Vincent UniversityHalifaxNova ScotiaCanada
| | - Megan W. Bourassa
- The Sackler Institute for Nutrition ScienceThe New York Academy of SciencesNew YorkNew York
| | - Bola Adamolekun
- University of Tennessee Health Science CenterMemphisTennessee
| | - Gilles Bergeron
- The Sackler Institute for Nutrition ScienceThe New York Academy of SciencesNew YorkNew York
| | - Lucien Bettendorff
- Laboratory of Neurophysiology, GIGA‐NeurosciencesUniversity of LiègeLiègeBelgium
| | | | - Lorna Cox
- Medical Research Council Elsie Widdowson LaboratoryCambridgeUnited Kingdom
| | - Aviva Fattal‐Valevski
- Tel Aviv Medical Center, Dana‐Dwek Children's Hospital, Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | | | | | | | - Lwin Mar Hlaing
- National Nutrition Center, Ministry of Health and SportsMyanmar
| | | | | | - Sengchanh Kounnavong
- The Lao Tropical and Public Health Institute, Ministry of HealthVientianeLao PDR
| | - Maral P.S. Mousavi
- Department of Chemistry and Chemical BiologyHarvard UniversityCambridgeMassachusetts
| | - Daniel E. Roth
- Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | | | - Frank Wieringa
- Institut de Recherche pour le DeveloppmentMontpellierFrance
| | - Gerald F. Combs
- Jean Mayer USDA Human Nutrition Research CenterTufts UniversityBostonMassachusetts
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50
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Roth DE, Abrams SA, Aloia J, Bergeron G, Bourassa MW, Brown KH, Calvo MS, Cashman KD, Combs G, De-Regil LM, Jefferds ME, Jones KS, Kapner H, Martineau AR, Neufeld LM, Schleicher RL, Thacher TD, Whiting SJ. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann N Y Acad Sci 2018; 1430:44-79. [PMID: 30225965 DOI: 10.1111/nyas.13968] [Citation(s) in RCA: 273] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 12/15/2022]
Abstract
Vitamin D is an essential nutrient for bone health and may influence the risks of respiratory illness, adverse pregnancy outcomes, and chronic diseases of adulthood. Because many countries have a relatively low supply of foods rich in vitamin D and inadequate exposure to natural ultraviolet B (UVB) radiation from sunlight, an important proportion of the global population is at risk of vitamin D deficiency. There is general agreement that the minimum serum/plasma 25-hydroxyvitamin D concentration (25(OH)D) that protects against vitamin D deficiency-related bone disease is approximately 30 nmol/L; therefore, this threshold is suitable to define vitamin D deficiency in population surveys. However, efforts to assess the vitamin D status of populations in low- and middle-income countries have been hampered by limited availability of population-representative 25(OH)D data, particularly among population subgroups most vulnerable to the skeletal and potential extraskeletal consequences of low vitamin D status, namely exclusively breastfed infants, children, adolescents, pregnant and lactating women, and the elderly. In the absence of 25(OH)D data, identification of communities that would benefit from public health interventions to improve vitamin D status may require proxy indicators of the population risk of vitamin D deficiency, such as the prevalence of rickets or metrics of usual UVB exposure. If a high prevalence of vitamin D deficiency is identified (>20% prevalence of 25(OH)D < 30 nmol/L) or the risk for vitamin D deficiency is determined to be high based on proxy indicators (e.g., prevalence of rickets >1%), food fortification and/or targeted vitamin D supplementation policies can be implemented to reduce the burden of vitamin D deficiency-related conditions in vulnerable populations.
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Affiliation(s)
- Daniel E Roth
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Steven A Abrams
- Department of Pediatrics, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - John Aloia
- NYU Winthrop Hospital, Mineola, New York
| | - Gilles Bergeron
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | - Megan W Bourassa
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | | | - Mona S Calvo
- Retired, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kevin D Cashman
- Cork Centre for Vitamin D and Nutrition Research, University College Cork, Cork, Ireland
| | | | | | | | - Kerry S Jones
- MRC Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | | | - Adrian R Martineau
- Blizard Institute, Queen Mary University of London, London, United Kingdom
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