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Koroma AS, Stephenson KB, Iversen PO, Manary MJ, Hendrixson DT. The Effect of Breastfeeding Practices of Undernourished Mothers in Rural Sierra Leone on Infant Growth and Mortality. Children (Basel) 2024; 11:233. [PMID: 38397345 PMCID: PMC10888085 DOI: 10.3390/children11020233] [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] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Breastfeeding provides optimal infant nutrition; however, <50% of infants are exclusively breastfed (EBF) for 6 months. We aimed to describe breastfeeding practices and their effects on growth and mortality among a high-risk mother-infant cohort in rural Sierra Leone. This was a secondary analysis of data from a randomized nutrition intervention trial among undernourished pregnant women. The study's primary outcomes were infant weight and length gains at 6 weeks of age. We included 1270 singleton infants in the analysis, with 1092 (85.6%) having 24-week outcome data. At 6 weeks, 88% were EBF, but the rate of EBF decreased to 17% at 24 weeks. The EBF infants at 6 weeks had improved length (difference of 0.9 mm/week; 95% CI 0.4 to 1.3; p < 0.001) and weight (difference of 40 g/week; 95% CI 24 to 53; p < 0.001) gains compared to the non-EBF infants. At 12 weeks, the EBF infants had improved weight (difference of 12 g/week; 95% CI 2 to 22; p = 0.024) gain. The EBF infants had lower mortality than the infants who were not EBF (hazard ratio of 0.39; 95% CI 0.18 to 0.84; p = 0.017). In summary, the infants who were EBF had greater weight and length gain and reduced mortality than those who were not EBF. Efforts to improve breastfeeding should thus be prioritized to improve infant health.
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Affiliation(s)
| | - Kevin B. Stephenson
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Per O. Iversen
- Department of Nutrition, University of Oslo, 0317 Oslo, Norway;
- Department of Haematology, Oslo University Hospital, 0450 Oslo, Norway
- Division of Human Nutrition, Stellenbosch University, Tygerberg 7505, South Africa
| | - Mark J. Manary
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63108, USA
| | - David Taylor Hendrixson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA;
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Stephenson KB, Wegner DR, Hershey TG, Doty T, Davis E, Steiner-Asiedu M, Saalia FK, Shani I, Manary MJ. Effect of Peanut Paste-based Ready-to-use School Meals With and Without Milk on Fluid Cognition in Northern Ghana: A Randomized Controlled Trial. Am J Clin Nutr 2023; 118:782-791. [PMID: 37567391 PMCID: PMC10579044 DOI: 10.1016/j.ajcnut.2023.08.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/24/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Few studies have investigated the role of school feeding in low- and middle-income countries as a means of improving childhood cognition. Peanut/milk ready-to-use food (PM-RUF) or cowpea offers an affordable, scalable option that might improve cognition. OBJECTIVES To determine whether micronutrient-fortified PM-RUF or peanut/cowpea ready-to-use food (PC-RUF) would improve fluid cognition as assessed by 4 tests from the National Institutes of Health Toolbox Cognitive Battery when compared with a micronutrient-fortified millet porridge (FP) after a year of school feeding. METHODS An individually randomly assigned, investigator-blinded, controlled clinical trial was conducted at 6 schools in Mion District in rural northern Ghana. Eight hundred seventy-one school children aged 5-12 y were randomly assigned and allocated to receive PM-RUF (n = 282), PC-RUF (n = 292), or FP (n = 297), each providing ∼400 kcal/d. The primary outcomes were 4 fluid cognition test scores: Dimensional Change Card Sort test, Flanker Inhibitory Control and Attention test, Pattern Comparison Processing Speed test, and a modified List Sorting Working Memory test. Secondary outcomes included a composite median ranking of the 4 primary outcomes and anthropometry changes. RESULTS Among the 871 participants (median age, 8.8 y; 47% female), 795 (91%) completed endline cognitive testing. Median attendance rates exceeded 87% in all groups. PM-RUF group demonstrated better fluid cognition on the Dimensional Change Card Sort test [odds ratio (OR): 1.5; 95% CI: 1.1, 2.0; P = 0.016] and Pattern Comparison Processing Speed test (OR: 1.4; 95% CI: 1.0, 1.9; P = 0.026) than FP, whereas there were no significant differences on Flanker Inhibitory Control and Attention or List Sorting Working Memory tests. PC-RUF group demonstrated no improvement over FP on any cognitive tests. PM-RUF group had superior fluid cognition composite median rankings (OR: 1.5; 95% CI: 1.1, 2.0; P = 0.007). CONCLUSIONS Among rural Ghanaian children aged 5-12 y, PM-RUF compared with FP resulted in superior fluid cognition. This trial was registered at clinicaltrials.gov as NCT04349007.
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Affiliation(s)
- Kevin B Stephenson
- Department of Medicine, Washington University, St. Louis, MO, United States.
| | - Donna R Wegner
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Tamara G Hershey
- Departments of Psychiatry and Radiology, Washington University, St. Louis, MO, United States
| | - Tasha Doty
- Program in Occupational Therapy, Washington University, St. Louis, MO, United States
| | - Ephious Davis
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | | | - Firibu K Saalia
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana
| | - Issah Shani
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO, United States.
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Deblais L, Ojeda A, Brhane M, Mummed B, Hassen KA, Ahmedo BU, Weldesenbet YD, Amin JK, Ahmed IA, Usmane IA, Yusuf EA, Seran AJ, Abrahim FI, Game HT, Mummed BA, Usmail MM, Umer KA, Dawid MM, Gebreyes W, French N, Hassen JY, Roba KT, Mohammed A, Yimer G, Saleem C, Chen D, Singh N, Manary MJ, McKune SL, Havelaar AH, Rajashekara G. Prevalence and Load of the Campylobacter Genus in Infants and Associated Household Contacts in Rural Eastern Ethiopia: a Longitudinal Study from the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) Project. Appl Environ Microbiol 2023; 89:e0042423. [PMID: 37310259 PMCID: PMC10370295 DOI: 10.1128/aem.00424-23] [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: 03/15/2023] [Accepted: 05/22/2023] [Indexed: 06/14/2023] Open
Abstract
In our previous cross-sectional study, multiple species of Campylobacter were detected (88%) in stool samples from children (12 to 14 months of age) in rural eastern Ethiopia. This study assessed the temporal fecal carriage of Campylobacter in infants and identified putative reservoirs associated with these infections in infants from the same region. The prevalence and load of Campylobacter were determined using genus-specific real-time PCR. Stool samples from 106 infants (n = 1,073) were collected monthly from birth until 376 days of age (DOA). Human stool samples (mothers and siblings), livestock feces (cattle, chickens, goats, and sheep), and environmental samples (soil and drinking water) from the 106 households were collected twice per household (n = 1,644). Campylobacter was most prevalent in livestock feces (goats, 99%; sheep, 98%; cattle, 99%; chickens, 93%), followed by human stool samples (siblings, 91%; mothers, 83%; infants, 64%) and environmental samples (soil, 58%; drinking water, 43%). The prevalence of Campylobacter in infant stool samples significantly increased with age, from 30% at 27 DOA to 89% at 360 DOA (1% increase/day in the odds of being colonized) (P < 0.001). The Campylobacter load increased linearly (P < 0.001) with age from 2.95 logs at 25 DOA to 4.13 logs at 360 DOA. Within a household, the Campylobacter load in infant stool samples was positively correlated with the load in mother stool samples (r2 = 0.18) and soil collected inside the house (r2 = 0.36), which were in turn both correlated with Campylobacter loads in chicken and cattle feces (0.60 < r2 < 0.63) (P < 0.01). In conclusion, a high proportion of infants are infected with Campylobacter in eastern Ethiopia, and contact with the mother and contaminated soil may be associated with early infections. IMPORTANCE A high Campylobacter prevalence during early childhood has been associated with environmental enteric dysfunction (EED) and stunting, especially in low-resource settings. Our previous study demonstrated that Campylobacter was frequently found (88%) in children from eastern Ethiopia; however, little is known about potential Campylobacter reservoirs and transmission pathways leading to infection of infants by Campylobacter during early growth. In the longitudinal study presented here, Campylobacter was frequently detected in infants within the 106 surveyed households from eastern Ethiopia, and the prevalence was age dependent. Furthermore, preliminary analyses highlighted the potential role of the mother, soil, and livestock in the transmission of Campylobacter to the infant. Further work will explore the species and genetic composition of Campylobacter in infants and putative reservoirs using PCR and whole-genome and metagenomic sequencing. The findings from these studies can lead to the development of interventions to minimize the risk of transmission of Campylobacter to infants and, potentially, EED and stunting.
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Affiliation(s)
| | - Amanda Ojeda
- University of Florida, Gainesville, Florida, USA
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- Massey University, Palmerston North, New Zealand
| | | | | | | | - Getnet Yimer
- Global One Health Initiative, The Ohio State University, Addis Ababa, Ethiopia
| | - Cyrus Saleem
- University of Florida, Gainesville, Florida, USA
| | - Dehao Chen
- University of Florida, Gainesville, Florida, USA
| | - Nitya Singh
- University of Florida, Gainesville, Florida, USA
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Mechlowitz K, Singh N, Li X, Chen D, Yang Y, Rabil A, Cheraso AJ, Ahmed IA, Amin JK, Gebreyes WA, Hassen JY, Ibrahim AM, Manary MJ, Rajashekara G, Roba KT, Usmane IA, Havelaar AH, McKune SL. Women's empowerment and child nutrition in a context of shifting livelihoods in Eastern Oromia, Ethiopia. Front Nutr 2023; 10:1048532. [PMID: 37457972 PMCID: PMC10338874 DOI: 10.3389/fnut.2023.1048532] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
Agriculture, and particularly livestock and animal source foods, has been closely linked to improvements in human nutrition. Production, income, and women's empowerment improve household food security and child nutritional outcomes in interacting ways. Khat production in Eastern Ethiopia is changing the economic and livelihood landscape for communities that have traditionally relied upon small-scale mixed agriculture and livestock production. How this shifting livelihood landscape and the empowerment of women in these communities are affecting nutritional outcomes has not been investigated. Using cross-sectional data collected during formative research for the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) project, we developed models to examine the roles of livelihood activities, including livestock production, staple crop production, and khat production, and women's empowerment in child nutrition outcomes. Survey participants were randomly selected mothers of children aged 10-15 months from Haramaya district, Eastern Hararghe, Oromia, Ethiopia. Nested logistic regression models were performed for each nutrition outcome: children's animal source food consumption, children's dietary diversity, and child stunting, wasting, and underweight. Explanatory variables included those for livelihood (tropical livestock unit, crop production, and khat production ladder) and women's empowerment (as indicated by domains of the Women's Empowerment in Agriculture Index), and covariates including child sex, mother's age, mother's education, assets, income, and kebele. Results indicated that khat production and tropical livestock units were not significantly associated with any of the child nutrition outcomes. However, results did indicate that the odds of reporting child animal source food consumption in households where the mother was empowered in the leadership domain was 3.33 times that in households where the mother wasn't (p < 0.05). In addition, the odds of having a stunted child in households where the mother was empowered in the time domain was 2.68 times that in households where the mother wasn't (p < 0.05). The results from this study both support and complicate the existing literature on the associations between women's empowerment in agriculture and child nutrition outcomes, underscoring the important role that livelihood, contextual factors, and location may have on the complex relationship between empowerment domains and nutritional outcomes.
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Affiliation(s)
- Karah Mechlowitz
- Department of Social and Behavioral Sciences, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
| | - Nitya Singh
- Department of Animal Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL, United States
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Food Systems Institute, University of Florida, Gainesville, FL, United States
| | - Xiaolong Li
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
| | - Dehao Chen
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
| | - Yang Yang
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Biostatistics, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
| | - Anna Rabil
- Yale School of Public Health, Yale University, New Haven, CT, United States
| | - Adriana Joy Cheraso
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
| | - Ibsa Abdusemed Ahmed
- Department of Public Health and Health Policy, College of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia
- School of Public Health, Haramaya University, Haramaya, Ethiopia
| | - Jafer Kedir Amin
- College of Veterinary Medicine, Haramaya University, Haramaya, Ethiopia
| | - Wondwossen A. Gebreyes
- Global One Health Initiative, College of Veterinary Medicine, The Ohio State University, Columbus, OH, United States
| | - Jemal Y. Hassen
- School of Rural Development and Agricultural Innovation, College of Agriculture and Environmental Science, Haramaya University, Haramaya, Ethiopia
| | | | - Mark J. Manary
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Gireesh Rajashekara
- Center for Food Animal Health, Department of Animal Sciences, College of Food, Agricultural, and Environmental Sciences, The Ohio State University, Wooster, OH, United States
| | - Kedir Teji Roba
- Department of Public Health and Health Policy, College of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia
| | - Ibsa Aliyi Usmane
- School of Rural Development and Agricultural Innovation, College of Agriculture and Environmental Science, Haramaya University, Haramaya, Ethiopia
| | - Arie H. Havelaar
- Department of Animal Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL, United States
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Food Systems Institute, University of Florida, Gainesville, FL, United States
| | - Sarah L. McKune
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
- Center for African Studies, University of Florida, Gainesville, FL, United States
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Hendrixson DT, Naskidashvili N, Stephenson KB, Laury ML, Koroma AS, Manary MJ. An Alternative Oat-Containing, Ready-To-Use, Therapeutic Food Does Not Alter Intestinal Permeability or the 16S Ribosomal RNA Fecal Microbiome Configuration Among Children With Severe Malnutrition in Sierra Leone: A Randomized Controlled Trial. J Nutr 2023; 152:2744-2753. [PMID: 36055798 DOI: 10.1093/jn/nxac207] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/20/2022] [Accepted: 08/29/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Previously, a novel oat ready-to-use therapeutic food (o-RUTF) resulted in improved recovery from severe acute malnutrition (SAM) when compared to a standard RUTF (s-RUTF). The o-RUTF contained 18% oat, while the s-RUTF has no cereal ingredients. OBJECTIVES We determined the effects of o-RUTF on intestinal permeability, as measured by lactulose permeability, and the 16S ribosomal RNA (rRNA) fecal microbiome configuration of children with SAM. METHODS This was a prospective, randomized, double-blinded, controlled clinical trial. Sierra Leonean children aged 6-59 mo with SAM, defined by a midupper arm circumference < 11.5 cm, were randomized to receive o-RUTF or s-RUTF. All children received 7 d of amoxicillin per guidelines. Lactulose permeability testing and fecal 16S rRNA sequencing were performed at baseline and after 4 wk of therapy. The change in lactulose permeability was the primary outcome, while the fecal 16S rRNA configuration at 4 wk was a secondary outcome. RESULTS Of the 129 children enrolled, lactulose permeability testing was completed by 100 at baseline and 82 at week 4. After 4 wk of therapeutic feeding, there were no differences in lactulose permeability between the o-RUTF and s-RUTF groups (P = 0.84), and over half of children had increased lactulose permeability (50% s-RUTF compared with 58% o-RUTF, mean difference = -7.5%; 95% CI: -29.2, 15.2; P = 0.50). After 4 wk of feeding, there were no differences in the 16S rRNA configurations between the o-RUTF and s-RUTF groups (Permanova, 999 permutations; P = 0.648; pseudo-F = 0.581), nor were there differences in α or β diversity. CONCLUSIONS Despite remarkably different compositions of o-RUTF and s-RUTF, no differences were identified in lactulose permeability or the fecal 16S rRNA configuration among children with SAM receiving these foods. These results suggest that the o-RUTF exerts its beneficial effects through mechanisms other than reducing intestinal permeability or altering the fecal 16S configuration. This trial was registered at clinicaltrials.gov as NCT04334538.
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Affiliation(s)
| | | | - Kevin B Stephenson
- Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Marie L Laury
- Genome Technology Access Center, Washington University in St Louis, St. Louis, MO, USA
| | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J Manary
- Project Peanut Butter, Freetown, Sierra Leone.,Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,USDA Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
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James G, Stephenson K, Callaghan-Gillespie M, Kamara MT, Park HG, Brenna JT, Manary MJ. Docosahexaenoic Acid Stability in Ready-to-Use Therapeutic Food. Foods 2023; 12:foods12020308. [PMID: 36673399 PMCID: PMC9858440 DOI: 10.3390/foods12020308] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/11/2023] Open
Abstract
Ready-to-use therapeutic food (RUTF) is used to treat young children diagnosed with severe acute malnutrition. RUTF with low and balanced linoleic and alpha-linolenic acid, plus omega-3 docosahexaenoic acid (DHA), supports long-term cognitive recovery. DHA is prone to degradation due to peroxidation, possibly exacerbated by the iron inherently in RUTF. Our goals were to prepare benchtop and manufacturing scale of RUTF formulations that include DHA and measure its retention. Twenty-seven RUTF formulas with base ingredients, including oats, high oleic or commodity peanuts, and encapsulated or oil-based DHA at various levels were prepared at benchtop scale, followed by seven months of climate-controlled storage. These pilot samples had similar relative DHA retention. At the manufacturing scale, DHA was added at one of two stages in the process, either at the initial or the final mixing stage. Samples taken at preliminary or later steps show that less than 20% of DHA added at the early stages disappeared prior to packaging for any recipe tested. Overall, our data indicate that most DHA included in RUTF is retained in the final product and that DHA is best retained when added at the latest manufacturing stage.
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Affiliation(s)
- Genevieve James
- Dell Pediatric Research Institute, The University of Texas at Austin, Austin, TX 78723, USA
| | - Kevin Stephenson
- Department of Medicine, Washington University, St. Louis, MO 63110, USA
| | | | | | - Hui Gyu Park
- Dell Pediatric Research Institute, The University of Texas at Austin, Austin, TX 78723, USA
| | - J. Thomas Brenna
- Dell Pediatric Research Institute, The University of Texas at Austin, Austin, TX 78723, USA
| | - Mark J. Manary
- Department of Pediatrics, Washington University, St. Louis, MO 63110, USA
- Project Peanut Butter, Freetown 47235, Sierra Leone
- Children’s Nutrition Research Center, USDA-Agricultural Research Service, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-(314)-454-2178
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Magalhães M, Ojeda A, Mechlowitz K, Brittain K, Daniel J, Roba KT, Hassen JY, Manary MJ, Gebreyes WA, Havelaar AH, McKune SL. Socioecological predictors of breastfeeding practices in rural eastern Ethiopia. Int Breastfeed J 2022; 17:93. [PMID: 36578078 PMCID: PMC9795740 DOI: 10.1186/s13006-022-00531-3] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 12/11/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Estimates by the World Health Organization indicate that over 800,000 global neonatal deaths each year are attributed to deviations from recommended best practices in infant feeding. Identifying factors promoting ideal breastfeeding practices may facilitate efforts to decrease neonatal and infant death rates and progress towards achieving the Sustainable Development Goals set for 2030. Though numerous studies have identified the benefits of breastfeeding in reducing the risk of childhood undernutrition, infection and illness, and mortality in low- and middle-income countries, no studies have explored predictors of breastfeeding practices in rural eastern Ethiopia, where undernutrition is widespread. The aim of this study is to examine predictors of infant feeding practices in Haramaya, Ethiopia, using a multi-level conceptual framework. METHODS This study uses data collected from household questionnaires during the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) project among 102 households in the Haramaya woreda, Eastern Hararghe Zone, Eastern Ethiopia, and investigates factors influencing breastfeeding practices: early initiation, prelacteal feeding, and untimely complementary feeding. RESULTS Nearly half (47.9%) of infants in this study were non-exclusively breastfed (n = 96). Generalized liner mixed effects models of breastfeeding practices revealed that prelacteal feeding may be a common practice in the region (43.9%, n = 98) and characterized by gender differences (p = .03). No factors evaluated were statistically significantly predictive of early initiation and untimely complementary feeding (82% and 14%, respectively). Severely food insecure mothers had more than 72% lower odds of early breastfeeding initiation, and participants who self-reported as being illiterate had 1.53 times greater odds of untimely complementary feeding (95% CI, [0.30,7.69]) followed by male children having 1.45 greater odds of being untimely complementary fed compared to female (95% CI,[0.40,5.37]). CONCLUSIONS This study found high rates of prelacteal feeding and low prevalence of exclusive breastfeeding, with girls more likely to be exclusively breastfed. While no predictors evaluated in this multi-level framework were associated with prevalence of early initiation or complementary feeding, rates may be clinically meaningful in a region burdened by undernutrition. Findings raise questions about gendered breastfeeding norms, the under-examined role of khat consumption on infant feeding, and the complex factors that affect breastfeeding practices in this region. This information may be used to guide future research questions and inform intervention strategies.
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Affiliation(s)
- Marina Magalhães
- grid.15276.370000 0004 1936 8091Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, USA ,grid.168010.e0000000419368956Present address: Department of Pediatrics, Stanford University School of Medicine, Stanford, CA USA
| | - Amanda Ojeda
- grid.15276.370000 0004 1936 8091Department of Animal Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, USA ,grid.15276.370000 0004 1936 8091Department of Microbiology and Cell Science, University of Florida, Gainesville, USA
| | - Karah Mechlowitz
- grid.15276.370000 0004 1936 8091Department of Environmental and Global Health, College of Public Health, University of Florida, 1225 Center Dr., Gainesville, FL 32603 USA
| | - Kaitlin Brittain
- grid.15276.370000 0004 1936 8091Department of Environmental and Global Health, College of Public Health, University of Florida, 1225 Center Dr., Gainesville, FL 32603 USA
| | - Jenna Daniel
- grid.189967.80000 0001 0941 6502Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Kedir Teji Roba
- grid.192267.90000 0001 0108 7468School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Dire Dawa, Ethiopia
| | - Jemal Yousuf Hassen
- grid.192267.90000 0001 0108 7468Department of Rural Development and Agricultural Extension, College of Agriculture and Environmental Sciences, Haramaya University, Dire Dawa, Ethiopia
| | - Mark J. Manary
- grid.4367.60000 0001 2355 7002Department of Pediatrics, School of Medicine, Washington University, St. Louis, USA
| | - Wondwossen A. Gebreyes
- grid.261331.40000 0001 2285 7943Global One Health Initiative, The Ohio State University, Columbus, USA
| | - Arie H. Havelaar
- grid.15276.370000 0004 1936 8091Department of Animal Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, USA ,grid.15276.370000 0004 1936 8091Emerging Pathogens Institute, University of Florida, Gainesville, USA ,grid.15276.370000 0004 1936 8091Institute for Sustainable Food Systems, University of Florida, Gainesville, USA
| | - Sarah L. McKune
- grid.15276.370000 0004 1936 8091Department of Environmental and Global Health, College of Public Health, University of Florida, 1225 Center Dr., Gainesville, FL 32603 USA ,grid.15276.370000 0004 1936 8091Center for African Studies, University of Florida, Gainesville, USA
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Koroma AS, Ellie M, Bangura K, Iversen PO, Hendrixson DT, Stephenson K, Manary MJ. Supplementary feeding and infection control in pregnant adolescents-A secondary analysis of a randomized trial among malnourished women in Sierra Leone. Matern Child Nutr 2022; 19:e13456. [PMID: 36349973 PMCID: PMC9749587 DOI: 10.1111/mcn.13456] [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] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
Undernutrition during pregnancy in adolescence confers a high risk of maternal morbidity and adverse birth outcomes, particularly in low-resource settings. In a secondary analysis, we hypothesized that younger undernourished pregnant adolescents (<18 years) would benefit more than undernourished pregnant adults (>20 years) from the intervention of supplementary food and anti-infective treatments. The original trial in Sierra Leone enrolled 236 younger adolescents (<18 years), 454 older adolescents (aged 18-19 years), and 741 adults (≥20 years), all with a mid-upper arm circumference ≤23 cm. Younger adolescents had lower final fundal height as well as smaller newborns (-0.3 kg; 95% confidence interval [CI], -0.3, -0.2; p < 0.001) and shorter newborns (-1.1 cm; 95% CI, -1.5, -0.7; p < 0.001) than adults. The intervention's effect varied significantly between maternal age groups: adults benefited more than younger adolescents with respect to newborn birth weight (difference in difference, 166 g; 95% CI, 26, 306; interaction p = 0.02), birth length (difference in difference, 7.4 mm; 95% CI, 0.1, 14.8; interaction p = 0.047), and risk for low birth weight (<2.5 kg) (interaction p = 0.019). The differences in response persisted despite adjustments for maternal anthropometry, the number of prior pregnancies, and human immunodeficiency virus status. Older adolescents similarly benefited more than younger adolescents, though differences did not reach statistical significance. In conclusion, newborns born to younger adolescent mothers had worse outcomes than those born to adult mothers, and adults and their newborns benefited more from the intervention than younger adolescents.
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Affiliation(s)
- Aminata S. Koroma
- Ministry of Health and SanitationRepublic of Sierra LeoneFreetownSierra Leone
| | - Mariama Ellie
- Ministry of Health and SanitationRepublic of Sierra LeoneFreetownSierra Leone
| | - Kadiatu Bangura
- Ministry of Health and SanitationRepublic of Sierra LeoneFreetownSierra Leone
| | - Per O. Iversen
- Department of NutritionUniversity of OsloOsloNorway,Department of HaematologyOslo University HospitalOsloNorway,Division of Human NutritionStellenbosch UniversityTygerbergSouth Africa
| | - David T. Hendrixson
- Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Kevin Stephenson
- Department of MedicineWashington University in St. LouisSt. LouisMissouriUSA
| | - Mark J. Manary
- Department of PediatricsWashington University School of Medicine in St. LouisSt. LouisMissouriUSA
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9
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Havelaar AH, Brhane M, Ahmed IA, Kedir J, Chen D, Deblais L, French N, Gebreyes WA, Hassen JY, Li X, Manary MJ, Mekuria Z, Ibrahim AM, Mummed B, Ojeda A, Rajashekara G, Roba KT, Saleem C, Singh N, Usmane IA, Yang Y, Yimer G, McKune S. Unravelling the reservoirs for colonisation of infants with Campylobacter spp. in rural Ethiopia: protocol for a longitudinal study during a global pandemic and political tensions. BMJ Open 2022; 12:e061311. [PMID: 36198455 PMCID: PMC9535169 DOI: 10.1136/bmjopen-2022-061311] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Undernutrition is an underlying cause of mortality in children under five (CU5) years of age. Animal-source foods have been shown to decrease malnutrition in CU5. Livestock are important reservoirs for Campylobacter bacteria, which are recognised as risk factors for child malnutrition. Increasing livestock production may be beneficial for improving nutrition of children but these benefits may be negated by increased exposure to Campylobacter and research is needed to evaluate the complex pathways of Campylobacter exposure and infection applicable to low-income and middle-income countries. We aim to identify reservoirs of infection with Campylobacter spp. of infants in rural Eastern Ethiopia and evaluate interactions with child health (environmental enteric dysfunction and stunting) in the context of their sociodemographic environment. METHODS AND ANALYSIS This longitudinal study involves 115 infants who are followed from birth to 12 months of age and are selected randomly from 10 kebeles of Haramaya woreda, East Hararghe zone, Oromia region, Ethiopia. Questionnaire-based information is obtained on demographics, livelihoods, wealth, health, nutrition and women empowerment; animal ownership/management and diseases; and water, sanitation and hygiene. Faecal samples are collected from infants, mothers, siblings and livestock, drinking water and soil. These samples are analysed by a range of phenotypic and genotypic microbiological methods to characterise the genetic structure of the Campylobacter population in each of these reservoirs, which will support inference about the main sources of exposure for infants. ETHICS AND DISSEMINATION Ethical approval was obtained from the University of Florida Internal Review Board (IRB201903141), the Haramaya University Institutional Health Research Ethics Committee (COHMS/1010/3796/20) and the Ethiopia National Research Ethics Review Committee (SM/14.1/1059/20). Written informed consent is obtained from all participating households. Research findings will be disseminated to stakeholders through conferences and peer-reviewed journals and through the Feed the Future Innovation Lab for Livestock Systems.
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Affiliation(s)
| | | | | | | | - Dehao Chen
- University of Florida, Gainesville, Florida, USA
| | | | - Nigel French
- Massey University, Palmerston North, New Zealand
| | - Wondwossen A Gebreyes
- The Ohio State University, Columbus, Ohio, USA
- Ohio State Global One Health LLC, Addis Ababa, Ethiopia
| | | | - Xiaolong Li
- University of Florida, Gainesville, Florida, USA
| | - Mark J Manary
- Washington University in St Louis, St Louis, Missouri, USA
| | - Zelealem Mekuria
- The Ohio State University, Columbus, Ohio, USA
- Ohio State Global One Health LLC, Addis Ababa, Ethiopia
| | | | | | - Amanda Ojeda
- University of Florida, Gainesville, Florida, USA
| | | | | | - Cyrus Saleem
- University of Florida, Gainesville, Florida, USA
| | - Nitya Singh
- University of Florida, Gainesville, Florida, USA
| | | | - Yang Yang
- University of Florida, Gainesville, Florida, USA
| | - Getnet Yimer
- Ohio State Global One Health LLC, Addis Ababa, Ethiopia
| | - Sarah McKune
- University of Florida, Gainesville, Florida, USA
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10
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Hendrixson DT, Lasowski PN, Koroma AS, Manary MJ. Newborn Mid-Upper Arm Circumference Identifies Low-Birth Weight and Vulnerable Infants: A Secondary Analysis. Curr Dev Nutr 2022; 6:nzac138. [PMID: 36475019 PMCID: PMC9718650 DOI: 10.1093/cdn/nzac138] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/25/2022] [Accepted: 09/03/2022] [Indexed: 04/22/2024] Open
Abstract
Background Low birth weight (LBW) infants are at increased risk of morbidity and mortality. Identification of LBW may not occur in settings where access to reliable scales is limited. Mid-upper arm circumference (MUAC) may be an accessible, low-cost measure to identify LBW and vulnerable infants. Objectives We explored the validity of newborn MUAC in identifying LBW and vulnerable newborns in rural Sierra Leone. Methods This study was a secondary analysis of infant data from a randomized controlled clinical trial of supplementary food and anti-infective therapies compared with standard care for undernourished pregnant women. Data for singleton liveborn infants with birth measurement and 6-mo survival data were included in this analysis. The primary outcome was validity of MUAC in identifying low-birth weight (LBW) neonates. Secondary outcomes included validity of MUAC and head circumference (HC) in identifying weight-for-length z-score (WLZ) <-2, length-for-age z-score (LAZ) <-2, neonatal mortality, and mortality within the first 6 mo of life. Results The study population included 1167 infants, 229 (19.6%) with LBW. Birth MUAC (r = 0.817) and HC (r = 0.752) were highly correlated with birth weight. MUAC (AUC: 0.905; 95% CI: 0.884, 0.925) performed superiorly to HC (AUC: 0.88; 95% CI: 0.856, 0.904) in identifying LBW. The MUAC for identifying LBW was 9.6 cm (sensitivity: 0.86; specificity: 0.78). Neither MUAC nor HC reliably identified newborns with WLZ <-2 or LAZ <-2. MUAC ≤9.0 cm was the ideal cutoff for neonatal mortality (sensitivity: 53.3%; specificity: 89.7%; HR: 9.57; 95% CI: 1.86, 49.30). Birth anthropometrics did not reliably identify infants at risk of death in the first 6 mo of life. Conclusions MUAC was used successfully to identify LBW infants and infants at risk of neonatal mortality in Sierra Leone. Further evidence is needed to support increased use of newborn MUAC measurement to identify LBW infants and infants at risk of neonatal mortality in community settings where scales are not available. Primary trial was registered at clinicaltrials.gov as NCT03079388. Lay Summary Mid-upper arm circumference (MUAC) can be used to identify infants with low birth weight and infants at risk for neonatal mortality, with an MUAC ≤9.0 cm indicating the highest risk.
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Affiliation(s)
| | | | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J Manary
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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11
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Stephenson KB, Hendrixson DT, Manary MJ. For good measure: near-birth anthropometry predicts neonatal and infant mortality. Am J Clin Nutr 2022; 115:1259-1260. [PMID: 35348577 DOI: 10.1093/ajcn/nqac042] [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: 11/14/2022] Open
Affiliation(s)
- Kevin B Stephenson
- Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,USDA/Agricultural Research Service Children's Nutrition Research Center, Houston, TX, USA
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12
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Leppänen JM, Butcher JW, Godbout C, Stephenson K, Hendrixson DT, Griswold S, Rogers BL, Webb P, Koroma AS, Manary MJ. Assessing infant cognition in field settings using eye-tracking: a pilot cohort trial in Sierra Leone. BMJ Open 2022; 12:e049783. [PMID: 35177442 PMCID: PMC8860005 DOI: 10.1136/bmjopen-2021-049783] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To investigate the feasibility of eye-tracking-based testing of the speed of visual orienting in malnourished young children at rural clinics in Sierra Leone. DESIGN Prospective dual cohort study nested in a cluster-randomised trial. SETTING 8 sites participating in a cluster-randomised trial of supplementary feeding for moderate acute malnutrition (MAM). PARTICIPANTS For the MAM cohort, all infants aged 7-11 months at the eight sites were enrolled, 138 altogether. For controls, a convenience sample of all non-malnourished infants aged 7-11 months at the same sites were eligible, 60 altogether. A sample of 30 adults at the sites also underwent eye-tracking tests as a further control. INTERVENTIONS Infants with MAM were provided with supplementary feeding. OUTCOME MEASURES The primary outcomes were feasibility and reliability of eye-tracking-based testing of saccadic reaction time (SRT). Feasibility was assessed by the percent of successful tests in the infants. Reliability was measured with intraclass correlation coefficients (ICCs). Secondary outcomes were mean SRT based on nutritional state as well as and changes in mean SRT after supplementary feeding of MAM children. RESULTS Infants exhibited consistent orienting to targets on a computer screen (>95% of valid trials). Mean SRTs had moderate stability within visits (ICCs 0.60-0.69) and across the 4-week test-retest interval (0.53) in infants; the adult control group had greater SRT stability (within visit ICC=0.92). MAM infants had a trend toward higher adjusted SRT at baseline (difference=12.4 ms, 95% CI -2 to 26.9, p=0.09) and improvement in SRT 4 weeks thereafter (difference=-14 ms, 95% CI -26.2 to -1.7, p=0.025) compared with age-matched controls. CONCLUSIONS The results demonstrate the feasibility of eye-tracking-based testing in a resource-poor field setting and suggest eye-tracking measures have utility in the detection of group level effects of supplementary feeding.
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Affiliation(s)
- Jukka M Leppänen
- Department of Psychology and Speech-Language Pathology, University of Turku, Turku, Finland
| | | | - Claire Godbout
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Kevin Stephenson
- Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - D Taylor Hendrixson
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Stacy Griswold
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
| | - Beatrice Lorge Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
| | - Aminata S Koroma
- Food and Nutrition, Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Mark J Manary
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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13
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Rajabi T, Schell SK, Agapova SE, Hassan A, Zalta M, Wegner DR, Callaghan-Gillespie M, Koroma A, Kamara MT, Manary MJ, Stephenson KB. Supplementary Feeding of Moderately Wasted Children in Sierra Leone Reduces Severe Acute Malnutrition and Death When Compared to Nutrition Counseling: a Retrospective Cohort Study. J Nutr 2022; 152:1149-1158. [PMID: 36967172 DOI: 10.1093/jn/nxab451] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/02/2021] [Accepted: 12/28/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is uncertainty about whether children with moderate wasting should receive supplementary feeding. OBJECTIVES We examined whether supplementary feeding compared to counseling alone in children with moderate wasting prevented progression to severe acute malnutrition (SAM) or death. METHODS This was a retrospective, dual cohort study in which 1,791 children with moderate wasting were drawn from two prior randomized controlled trials that took place in the same location in rural Sierra Leone. 1,077 children received supplementary feeding, while 714 children received counseling alone. Children in both cohorts were followed for at least 24 weeks from enrollment. The primary outcome was time to SAM or death using Kaplan-Meier analysis. Secondary outcomes included time to death as well as proportions of children with healthy mid-upper arm circumference (MUAC), moderate wasting, SAM, or death at 6, 12, and 24 weeks from enrollment. RESULTS Children who received supplementary feeding were less likely to develop SAM or die across the entire follow-up period (HR 0.53, 95% CI 0.44, 0.65, P < 0.001). Time to event for death alone also revealed a lower risk for children who received supplementary feeding (HR 0.52, 95% CI 0.28, 0.94, P = 0.03). Children who received supplementary feeding were more likely to have a healthy MUAC at 6 weeks (RR 2.0, 95% CI 1.7, 2.2) and 12 weeks (RR 1.3, 95% CI 1.2, 1.5), were less likely to develop SAM at 6 (RR 0.7, 95% CI 0.6, 0.9), 12 (RR 0.5, 95% CI 0.3, 0.8), and 24 weeks (RR 0.2, 95% CI 0.1, 0.5), and had higher rates of gain in weight and MUAC at 6 and 12 weeks. CONCLUSIONS Supplementary feeding of children with moderate wasting reduces risk of SAM and death across 24 weeks of follow-up.
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Affiliation(s)
| | | | - Sophia E Agapova
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Amir Hassan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Max Zalta
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Donna R Wegner
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Aminata Koroma
- Ministry of Health and Sanitation, Government of Sierra Leone, Freetown, Sierra Leone
| | | | - Mark J Manary
- Project Peanut Butter, Freetown, Sierra Leone.,Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,United States Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center, Houston, TX, USA
| | - Kevin B Stephenson
- Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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14
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Stephenson K, Callaghan-Gillespie M, Maleta K, Nkhoma M, George M, Park HG, Lee R, Humphries-Cuff I, Lacombe RJS, Wegner DR, Canfield RL, Brenna JT, Manary MJ. Low linoleic acid foods with added DHA given to Malawian children with severe acute malnutrition improve cognition: a randomized, triple-blinded, controlled clinical trial. Am J Clin Nutr 2021; 115:1322-1333. [PMID: 34726694 PMCID: PMC9071416 DOI: 10.1093/ajcn/nqab363] [Citation(s) in RCA: 8] [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: 07/16/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is concern that the PUFA composition of ready-to-use therapeutic food (RUTF) for the treatment of severe acute malnutrition (SAM) is suboptimal for neurocognitive recovery. OBJECTIVES We tested the hypothesis that RUTF made with reduced amounts of linoleic acid, achieved using high-oleic (HO) peanuts without added DHA (HO-RUTF) or with added DHA (DHA-HO-RUTF), improves cognition when compared with standard RUTF (S-RUTF). METHODS A triple-blind, randomized, controlled clinical feeding trial was conducted among children with uncomplicated SAM in Malawi with 3 types of RUTF: DHA-HO-RUTF, HO-RUTF, and S-RUTF. The primary outcomes, measured in a subset of subjects, were the Malawi Developmental Assessment Tool (MDAT) global z-score and a modified Willatts problem-solving assessment (PSA) intention score for 3 standardized problems, measured 6 mo and immediately after completing RUTF therapy, respectively. MDAT domain z-scores, plasma fatty acid content, anthropometry, and eye tracking were secondary outcomes. Comparisons were made between the novel PUFA RUTFs and S-RUTF. RESULTS Among the 2565 SAM children enrolled, mean global MDAT z-scores were -0.69 ± 1.19 and -0.88 ± 1.27 for children receiving DHA-HO-RUTF and S-RUTF, respectively (difference 0.19, 95% CI: 0.01, 0.38). Children receiving DHA-HO-RUTF had higher gross motor and social domain z-scores than those receiving S-RUTF. The PSA problem 3 scores did not differ by dietary group (OR: 0.92, 95% CI: 0.67, 1.26 for DHA-HO-RUTF). After 4 wk of treatment, plasma phospholipid EPA and α-linolenic acid were greater in children consuming DHA-HO-RUTF or HO-RUTF when compared with S-RUTF (for all 4 comparisons P values < 0.001), but only plasma DHA was greater in DHA-HO-RUTF than S-RUTF (P < 0.001). CONCLUSIONS Treatment of uncomplicated SAM with DHA-HO-RUTF resulted in an improved MDAT score, conferring a cognitive benefit 6 mo after completing diet therapy. This treatment should be explored in operational settings. This trial was registered at clinicaltrials.gov as NCT03094247.
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Affiliation(s)
- Kevin Stephenson
- Department of Medicine, Washington University, St.
Louis, MO, USA
| | | | - Kenneth Maleta
- Department of Public Health, School of Public Health & Family Medicine,
Kamuzu University of Health Sciences, Blantyre,
Malawi
| | - Minyanga Nkhoma
- Department of Public Health, School of Public Health & Family Medicine,
Kamuzu University of Health Sciences, Blantyre,
Malawi
| | - Matthews George
- Department of Public Health, School of Public Health & Family Medicine,
Kamuzu University of Health Sciences, Blantyre,
Malawi
| | - Hui Gyu Park
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA
| | - Reginald Lee
- Department of Pediatrics, Washington University,
St. Louis, MO, USA
| | | | - R J Scott Lacombe
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA
| | - Donna R Wegner
- Department of Pediatrics, Washington University,
St. Louis, MO, USA
| | - Richard L Canfield
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA
| | - J Thomas Brenna
- Department of Pediatrics, University of Texas at Austin,
Austin, TX, USA,Division of Nutritional Sciences, Cornell University,
Ithaca, NY, USA
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15
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Hendrixson DT, Smith K, Lasowski P, Callaghan-Gillespie M, Weber J, Papathakis P, Iversen PO, Koroma AS, Manary MJ. A novel intervention combining supplementary food and infection control measures to improve birth outcomes in undernourished pregnant women in Sierra Leone: A randomized, controlled clinical effectiveness trial. PLoS Med 2021; 18:e1003618. [PMID: 34582451 PMCID: PMC8478228 DOI: 10.1371/journal.pmed.1003618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/09/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Innovations for undernourished pregnant women that improve newborn survival and anthropometry are needed to achieve the Sustainable Development Goals 1 and 3. This study tested the hypothesis that a combination of a nutritious supplementary food and several proven chemotherapeutic interventions to control common infections would increase newborn weight and length in undernourished pregnant women. METHODS AND FINDINGS This was a prospective, randomized, controlled clinical effectiveness trial of a ready-to-use supplementary food (RUSF) plus anti-infective therapies compared to standard therapy in undernourished pregnant women in rural Sierra Leone. Women with a mid-upper arm circumference (MUAC) ≤23.0 cm presenting for antenatal care at one of 43 government health clinics in Western Rural Area and Pujehun districts were eligible for participation. Standard of care included a blended corn/soy flour and intermittent preventive treatment for malaria in pregnancy (IPTp). The intervention replaced the blended flour with RUSF and added azithromycin and testing and treatment for vaginal dysbiosis. Since the study involved different foods and testing procedures for the intervention and control groups, no one except the authors conducting the data analyses were blinded. The primary outcome was birth length. Secondary outcomes included maternal weight gain, birth weight, and neonatal survival. Follow-up continued until 6 months postpartum. Modified intention to treat analyses was undertaken. Participants were enrolled and followed up from February 2017 until February 2020. Of the 1,489 women enrolled, 752 were allocated to the intervention and 737 to the standard of care. The median age of these women was 19.5 years, of which 42% were primigravid. Twenty-nine women receiving the intervention and 42 women receiving the standard of care were lost to follow-up before pregnancy outcomes were obtained. There were 687 singleton live births in the intervention group and 657 in the standard of care group. Newborns receiving the intervention were 0.3 cm longer (95% confidence interval (CI) 0.09 to 0.6; p = 0.007) and weighed 70 g more (95% CI 20 to 120; p = 0.005) than those receiving the standard of care. Those women receiving the intervention had greater weekly weight gain (mean difference 40 g; 95% CI 9.70 to 71.0, p = 0.010) than those receiving the standard of care. There were fewer neonatal deaths in the intervention (n = 13; 1.9%) than in the standard of care (n = 28; 4.3%) group (difference 2.4%; 95% CI 0.3 to 4.4), (HR 0.62 95% CI 0.41 to 0.94, p = 0.026). No differences in adverse events or symptoms between the groups was found, and no serious adverse events occurred. Key limitations of the study are lack of gestational age estimates and unblinded administration of the intervention. CONCLUSIONS In this study, we observed that the addition of RUSF, azithromycin, more frequent IPTp, and testing/treatment for vaginal dysbiosis in undernourished pregnant women resulted in modest improvements in anthropometric status of mother and child at birth, and a reduction in neonatal death. Implementation of this combined intervention in rural, equatorial Africa may well be an important, practical measure to reduce infant mortality in this context. TRIAL REGISTRATION ClinicalTrials.gov NCT03079388.
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Affiliation(s)
- David Taylor Hendrixson
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, United States of America
| | - Kristie Smith
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, United States of America
| | - Patrick Lasowski
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, United States of America
| | - Meghan Callaghan-Gillespie
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, United States of America
| | - Jacklyn Weber
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, United States of America
| | - Peggy Papathakis
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, California, United States of America
| | | | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J. Manary
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, United States of America
- Children’s Nutrition Research Center, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail:
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16
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Singh A, Potani I, Griswold SP, Suri D, Langlois B, Shen Y, Walton SM, Kwan Ho Chui K, Manary MJ, Webb P, Rogers BL, Rosenberg IH. Host Fecal mRNAs Predicted Environmental Enteric Dysfunction among Children with Moderate Acute Malnutrition in Sierra Leone. Am J Trop Med Hyg 2021; 105:1376-1382. [PMID: 34460425 PMCID: PMC8592211 DOI: 10.4269/ajtmh.21-0348] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/28/2021] [Indexed: 11/22/2022] Open
Abstract
Examining the role of environmental enteric dysfunction (EED) in child growth requires noninvasive, field-appropriate biomarkers. Alternatives to the traditionally used lactulose:mannitol (L:M) test have been explored, but few studies have compared the L:M test to host fecal mRNA transcripts. The objectives of this study were to examine whether 1) host fecal mRNA transcripts could predict presence and severity of EED, measured using the L:M test, and 2) EED modifies the effect of specialized nutritious foods (SNFs) on recovery from moderate acute malnutrition (MAM). This substudy was nested within a cluster randomized trial comparing four SNFs in the treatment of MAM among children 6 to 59 months in Sierra Leone. EED was assessed at enrollment using the L:M test and 15 host fecal mRNA transcripts on 522 children. Recovery from MAM was defined as achieving mid-upper arm circumference ≥ 12.5 cm within 12 weeks of supplementation. Random forest classification models were used to examine prediction of presence and severity of EED by host fecal mRNA transcripts. Logistic regression was used to test for effect modification by L:M test variables including % lactulose excreted (%L). Eight host fecal mRNA transcripts (AQP9, REG3A, IFI30, DECR1, BIRC3, SELL, PIK3AP1, DEFA6) identified EED (%L ≥ 0.2) and severe EED (%L ≥ 0.45) with high sensitivity and specificity. The L:M test variables did not modify the effect of SNFs on recovery from MAM. In this study, we found host fecal mRNA transcripts that could be biomarkers of EED but did not find EED to modify the effect of SNFs on MAM treatment.
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Affiliation(s)
- Akriti Singh
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Isabel Potani
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Stacy P Griswold
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Devika Suri
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Breanne Langlois
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Ye Shen
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Shelley M Walton
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | | | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
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17
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Griswold SP, Langlois BK, Shen Y, Cliffer IR, Suri DJ, Walton S, Chui K, Rosenberg IH, Koroma AS, Wegner D, Hassan A, Manary MJ, Vosti SA, Webb P, Rogers BL. Effectiveness and cost-effectiveness of 4 supplementary foods for treating moderate acute malnutrition: results from a cluster-randomized intervention trial in Sierra Leone. Am J Clin Nutr 2021; 114:973-985. [PMID: 34020452 PMCID: PMC8408853 DOI: 10.1093/ajcn/nqab140] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/05/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Moderate acute malnutrition (MAM) affects 33 million children annually. Investments in formulations of corn-soy blended flours and lipid-based nutrient supplements have effectively improved MAM recovery rates. Information costs and cost-effectiveness differences are still needed. OBJECTIVES We assessed recovery and sustained recovery rates of MAM children receiving a supplementary food: ready-to-use supplementary food (RUSF), corn soy whey blend with fortified vegetable oil (CSWB w/oil), or Super Cereal Plus with amylase (SC + A) compared to Corn Soy Blend Plus with fortified vegetable oil (CSB+ w/oil). We also estimated differences in costs and cost effectiveness of each supplement. METHODS In Sierra Leone, we randomly assigned 29 health centers to provide a supplement containing 550 kcal/d for ∼12 wk to 2691 children with MAM aged 6-59 mo. We calculated cost per enrollee, cost per child who recovered, and cost per child who sustained recovery each from 2 perspectives: program perspective and caregiver perspective, combined. RESULTS Of 2653 MAM children (98.6%) with complete data, 1676 children (63%) recovered. There were no significant differences in the odds of recovery compared to CSB+ w/oil [0.83 (95% CI: 0.64-1.08) for CSWB w/oil, 1.01 (95% CI: 0.78-1.3) for SC + A, 1.05 (95% CI: 0.82-1.34) for RUSF]. The odds of sustaining recovery were significantly lower for RUSF (0.7; 95% CI 0.49-0.99) but not CSWB w/oil or SC + A [1.08 (95% CI: 0.73-1.6) and 0.96 (95% CI: 0.67-1.4), respectively] when compared to CSB+ w/oil. Costs per enrollee [US dollars (USD)/child] ranged from $105/child in RUSF to $112/child in SC + A and costs per recovered child (USD/child) ranged from $163/child in RUSF to $179/child in CSWB w/oil, with overlapping uncertainty ranges. Costs were highest per sustained recovery (USD/child), ranging from $214/child with the CSB+ w/oil to $226/child with the SC + A, with overlapping uncertainty ranges. CONCLUSIONS The 4 supplements performed similarly across recovery (but not sustained recovery) and costed measures. Analyses of posttreatment outcomes are necessary to estimate the full cost of MAM treatment. This trial was registered at clinicaltrials.gov as NCT03146897.
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Affiliation(s)
| | - Breanne K Langlois
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ye Shen
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ilana R Cliffer
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Devika J Suri
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Shelley Walton
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ken Chui
- Department of Public Health and Community Medicine, School of Medicine, Tufts University, Boston, MA, USA
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Aminata S Koroma
- Ministry of Health and Sanitation, Directorate of Food and Nutrition, Freetown, Sierra Leone
| | - Donna Wegner
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Amir Hassan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California‐Davis, Davis, CA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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18
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Singh A, Ghosh S, Ward H, Manary MJ, Rogers BL, Rosenberg IH. Biomarkers of environmental enteric dysfunction are differently associated with recovery and growth among children with moderate acute malnutrition in Sierra Leone. Am J Clin Nutr 2021; 113:1556-1564. [PMID: 33668048 PMCID: PMC8243924 DOI: 10.1093/ajcn/nqaa434] [Citation(s) in RCA: 3] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 12/16/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Environmental enteric dysfunction (EED) may influence growth during and recovery from moderate acute malnutrition (MAM), however, biomarkers to assess these relations have yet to be identified. OBJECTIVES The objectives of this study were to: 1) develop a score for EED based on host fecal mRNA transcripts, 2) compare biomarkers of EED with each other, and 3) examine associations between the EED biomarkers and recovery from MAM and growth outcomes. METHODS In a cohort of 520 Sierra Leonean MAM children, biomarkers of EED included the lactulose: mannitol (L: M) test, 15 host fecal mRNA transcripts, and host fecal proteins [α-1-antitrypsin (AAT), myeloperoxidase (MPO), neopterin (NEO)]. Anthropometry data were also collected and z scores were computed for length-for-age (LAZ) and weight-for-length (WLZ). Recovery from MAM was defined as midupper arm circumference ≥12.5 cm. Factor analysis was used to identify EED scores using the mRNA transcripts, and mixed effects regression was conducted to test for associations. RESULTS The 15 host fecal mRNA transcripts were clustered into 3 scores: gut inflammation (GI) score, gut structure (GS) score, and gut defense (GD) score. We found agreement between certain inflammation markers (GI score and MPO), and permeability markers (GS score and AAT; AAT and the L: M excretion ratio). Antimicrobial gut defense (GD score) was inversely associated with percent lactulose excreted, a measure of intestinal permeability. LAZ (β: -0.08; 95% CI: -0.14, -0.02) and WLZ (β: -0.03; 95% CI: -0.06, -0.01) were negatively associated with GI score. A high GD score (β: 0.36; 95% CI: 0.08, 0.64) and low AAT (β: -1.35; 95% CI: -2.35, -0.36) were associated with recovery from MAM. CONCLUSIONS Scores derived from host fecal mRNA transcript variably correlated with the L: M test and host fecal proteins. Markers of intestinal inflammation, permeability, and defense were associated with growth outcomes and recovery from MAM.
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Affiliation(s)
| | - Shibani Ghosh
- Friedman School of Nutrition Science and Policy, Tufts
University, Boston, MA, USA
| | - Honorine Ward
- Tufts Medical Center and Tufts University School of
Medicine, Boston, MA, USA
| | - Mark J Manary
- Department of Pediatrics, Washington University,
St Louis, MO, USA
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts
University, Boston, MA, USA
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts
University, Boston, MA, USA
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19
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Bierut T, Duckworth L, Grabowsky M, Ordiz MI, Laury ML, Callaghan-Gillespie M, Maleta K, Manary MJ. The effect of bovine colostrum/egg supplementation compared with corn/soy flour in young Malawian children: a randomized, controlled clinical trial. Am J Clin Nutr 2021; 113:420-427. [PMID: 33330913 DOI: 10.1093/ajcn/nqaa325] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Bovine colostrum with egg powder (BC/egg) is rich in essential amino acids and immunoactive compounds. OBJECTIVES This trial tested the hypothesis that a daily supplement of BC/egg would reduce linear growth faltering and environmental enteric dysfunction (EED) in Malawian infants when compared with an isoenergetic ration of corn/soy flour used as a control. EED was defined by a lactulose permeability test. METHODS This was a prospective, randomized, blinded, placebo-controlled clinical trial in which 9-mo-old infants received BC/egg or a control for 3 mo. The primary outcomes were change in length-for-age z-score (ΔLAZ) and urinary lactulose excretion (%L) at 12-mo-old. Secondary outcomes included episodes of diarrhea, stunting, EED, and the 16S configuration of the fecal microbiota. RESULTS Of the 277 children enrolled, 267 completed the intervention phase of the study. LAZ decreased in all children from 9 to 17 mo, although ΔLAZ was less in children receiving BC/egg from 9 to 12 mo (difference = 0.12 z-scores; P = 0.0011). This difference persisted after feeding was completed, with less ΔLAZ (difference = 0.09 z-scores). A lower prevalence of stunting was seen in the intervention group (n = 47/137) than the control group (n = 62/127) at 17 mo (RR = 0.70; 95% CI: 0.52, 0.94).The median %L at 12 mo of age in the children receiving BC/egg was 0.14%, compared with 0.17% in the control group (P = 0.74). In children with %L >0.45% at enrollment (severe EED), the BC/egg group had more children with normal %L at 12 mo of age (10/20, 50%) than was seen in controls (2/15, 13%; P = 0.024). Episodes of diarrhea and β-diversity of the 16S configuration of fecal microbiota did not differ between the 2 groups. CONCLUSIONS Addition of BC/egg to complementary feeding in Malawian infants resulted in less linear growth faltering. This trial was registered at clinicaltrials.gov as NCT03801317.
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Affiliation(s)
- Tatiana Bierut
- Department of Pediatrics, Washington University in St Louis, St Louis, MO, USA
| | - Laura Duckworth
- Department of Pediatrics, Washington University in St Louis, St Louis, MO, USA
| | | | - M Isabel Ordiz
- Department of Pediatrics, Washington University in St Louis, St Louis, MO, USA
| | - Marie L Laury
- Genome Technology Access Center, Washington University in St Louis, MO, USA
| | | | - Ken Maleta
- Department of Community Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University in St Louis, St Louis, MO, USA
- Department of Community Health, College of Medicine, University of Malawi, Blantyre, Malawi
- United States Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center, Houston, TX, USA
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20
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Stephenson KB, Agapova SE, Hendrixson DT, Koroma AS, Manary MJ. An Optimized Dose of Therapeutic Feeding Results in Noninferior Growth in Midupper Arm Circumference Compared with a Standard Dose in Children in Sierra Leone Recovering from Acute Malnutrition. Curr Dev Nutr 2021; 5:nzab007. [PMID: 33659773 PMCID: PMC7904386 DOI: 10.1093/cdn/nzab007] [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: 12/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ready-to-use therapeutic food (RUTF) given at 175 kcal/kg per day throughout severe acute malnutrition (SAM) treatment is recommended. Some treatment programs have diverged from this paradigm in 2 ways: reducing the supplemental food dose to 75 kcal/kg per day when midupper arm circumference (MUAC) is >11.4 cm or simplifying to a fixed-dose regimen. OBJECTIVE The objective was to determine if transitioning to an optimized, fixed-dose supplementary feeding regimen during SAM treatment when MUAC is >11.4 cm would result in noninferior gain in MUAC compared with standard treatment. METHODS Using data from 2 clinical trials conducted in Sierra Leone, a retrospective dual-cohort study was performed. The 2 cohorts included children with SAM who had improved to meet criteria for moderate acute malnutrition (MAM). The standard dose cohort continued to receive weight-based RUTF at 175 kcal/kg per day, while the optimized dose cohort received fixed-dose, 500 kcal/d of supplementary feeding. The primary outcome was a noninferiority margin of 1 mm of MUAC after 4 wk of treatment, while secondary outcomes included rate of anthropometric changes as well as time-to-relapse to SAM or death. RESULTS MUAC after 4 wk was noninferior (Δ: -0.1 mm; 95% CI: -0.05, 0.03; inferiority rejected P = 0.008). Rates of weight gain and MUAC gain were the same in the optimized-dose and standard-dose groups, whereas the rate of length gain was slower in the optimized-dose cohort. Time-to-relapse to SAM or death was not different (HR: 1.05; P = 0.71). CONCLUSIONS This study supports the practice of treating children with SAM who have recovered to meet criteria for MAM with a reduced and fixed-dose regimen of RUTF. The results also raise the question of whether this strategy might adversely impact linear growth during SAM treatment.
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Affiliation(s)
| | - Sophia E Agapova
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | | | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO, USA
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21
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Chen D, McKune SL, Singh N, Yousuf Hassen J, Gebreyes W, Manary MJ, Bardosh K, Yang Y, Diaz N, Mohammed A, Terefe Y, Roba KT, Ketema M, Ameha N, Assefa N, Rajashekara G, Deblais L, Ghanem M, Yimer G, Havelaar AH. Campylobacter Colonization, Environmental Enteric Dysfunction, Stunting, and Associated Risk Factors Among Young Children in Rural Ethiopia: A Cross-Sectional Study From the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) Project. Front Public Health 2021; 8:615793. [PMID: 33553097 PMCID: PMC7862945 DOI: 10.3389/fpubh.2020.615793] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 10/09/2020] [Accepted: 12/17/2020] [Indexed: 11/19/2022] Open
Abstract
Livestock farming provides a possible mechanism by which smallholder farmers can meet their household need for animal source foods (ASF), which may reduce the risk of stunting. However, direct/indirect contacts with domestic animals may increase colonization by Campylobacter spp., which has been associated with Environmental Enteric Dysfunction (EED) and stunting. A cross-sectional study involving 102 randomly selected children between 12 and 16 months of age was conducted in rural eastern Ethiopia to establish prevalence rates of Campylobacter colonization, EED, and stunting, and evaluate potential risk factors. Data were collected between September and December 2018. The prevalence of EED and stunting was 50% (95% CI: 40-60%) and 41% (95% CI: 32-51%), respectively. Among enrolled children, 56% had consumed some ASF in the previous 24 h; 47% had diarrhea and 50% had fever in the past 15 days. 54, 63, 71 or 43% of households owned at least one chicken, cow/bull, goat, or sheep; 54 (53%) households kept chickens indoors overnight and only half of these confined the animals. Sanitation was poor, with high levels of unimproved latrines and open defecation. Most households had access to an improved source of drinking water. The prevalence of Campylobacter colonization was 50% (95% CI: 41-60%) by PCR. In addition to the thermotolerant species Campylobacter jejuni, Campylobacter coli and Campylobacter upsaliensis, non-thermotolerant species related to Campylobacter hyointestinalis and Campylobacter fetus were frequently detected by Meta-total RNA sequencing (MeTRS). Current breastfeeding and ASF consumption increased the odds of Campylobacter detection by PCR, while improved drinking water supply decreased the odds of EED. No risk factors were significantly associated with stunting. Further studies are necessary to better understand reservoirs and transmission pathways of Campylobacter spp. and their potential impact on child health.
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Affiliation(s)
- Dehao Chen
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
| | - Sarah L. McKune
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
- Center for African Studies, University of Florida, Gainesville, FL, United States
| | - Nitya Singh
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Animal Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL, United States
| | - Jemal Yousuf Hassen
- Department of Rural Development and Agricultural Extension, Haramaya University, Dire Dawa, Ethiopia
| | - Wondwossen Gebreyes
- Department of Veterinary Preventive Medicine, The Ohio State University, Columbus, OH, United States
| | - Mark J. Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
| | - Kevin Bardosh
- Department of Anthropology, University of Florida, Gainesville, FL, United States
| | - Yang Yang
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Biostatistics, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL, United States
| | - Nicholas Diaz
- Center for African Studies, University of Florida, Gainesville, FL, United States
| | | | - Yitagele Terefe
- College of Veterinary Medicine, Haramaya University, Dire Dawa, Ethiopia
| | - Kedir Teji Roba
- College of Health and Medical Sciences, Haramaya University, Dire Dawa, Ethiopia
| | - Mengistu Ketema
- School of Agricultural Economics and Agribusiness, Haramaya University, Dire Dawa, Ethiopia
| | - Negassi Ameha
- School of Animal and Range Science, Haramaya University, Dire Dawa, Ethiopia
| | - Nega Assefa
- College of Health and Medical Sciences, Haramaya University, Dire Dawa, Ethiopia
| | - Gireesh Rajashekara
- Department of Veterinary Preventive Medicine, The Ohio State University, Columbus, OH, United States
| | - Loïc Deblais
- Department of Veterinary Preventive Medicine, The Ohio State University, Columbus, OH, United States
| | - Mostafa Ghanem
- Department of Veterinary Preventive Medicine, The Ohio State University, Columbus, OH, United States
| | - Getnet Yimer
- Global One Health initiative, Office of International Affairs, The Ohio State University, Eastern Africa Regional Office, Addis Ababa, Ethiopia
| | - Arie H. Havelaar
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Animal Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL, United States
- Institute for Sustainable Food Systems, University of Florida, Gainesville, FL, United States
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22
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Hendrixson DT, Godbout C, Los A, Callaghan-Gillespie M, Mui M, Wegner D, Bryant T, Koroma A, Manary MJ. Treatment of severe acute malnutrition with oat or standard ready-to-use therapeutic food: a triple-blind, randomised controlled clinical trial. Gut 2020; 69:2143-2149. [PMID: 32179568 DOI: 10.1136/gutjnl-2020-320769] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We hypothesised that an alternative RUTF (ready-to-use therapeutic food) made with oats (oat-RUTF) would be non-inferior to standard RUTF (s-RUTF). DESIGN This was a randomised, triple-blind, controlled, clinical non-inferiority trial comparing oat-RUTF to s-RUTF in rural Sierra Leone. Children aged 6-59 months with severe acute malnutrition (SAM) were randomised to oat-RUTF or s-RUTF. s-RUTF was composed of milk powder, sugar, peanut paste and vegetable oil, with a hydrogenated vegetable oil additive. Oat-RUTF contained oats and no hydrogenated vegetable oil additives. The primary outcome was graduation, an increase in anthropometric measurements such that the child was not acutely malnourished. Secondary outcomes were rates of growth, time to graduation and presence of adverse events. Intention to treat analyses was used. RESULTS Of the 1406 children were enrolled, graduation was attained in 404/721 (56%) children receiving oat-RUTF and 311/685 (45%) receiving s-RUTF (difference 10.6%, 95% CI 5.4% to 15.8%). Death, hospitalisation or remaining with SAM was seen in 87/721 (12%) receiving oat-RUTF and in 125/685 (18%) receiving s-RUTF (difference 6.2%, 95% CI 2.3 to 10.0, p=0.001). Time to graduation was less for children receiving oat RUTF; 3.9±1.8 versus 4.5±1.8 visits, respectively (p<0.001). Rates of weight in the oat-RUTF group were greater than in the s-RUTF group; 3.4±2.7 versus 2.5±2.3 g/kg/d, p<0.001. CONCLUSION Oat-RUTF is superior to s-RUTF in the treatment of SAM in Sierra Leone. We speculate that might be because of beneficial bioactive components or the absence of hydrogenated vegetable oil in oat-RUTF. TRIAL REGISTRATION NUMBER NCT03407326.
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Affiliation(s)
| | - Claire Godbout
- Pediatrics, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Alyssa Los
- Pediatrics, Washington University in Saint Louis, St Louis, Missouri, USA
| | | | - Melody Mui
- Pediatrics, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Donna Wegner
- Pediatrics, Washington University in Saint Louis, St Louis, Missouri, USA
| | | | - Aminata Koroma
- Directorate of Nutrition, Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Mark J Manary
- Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
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23
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Affiliation(s)
- Rebecca Roediger
- Department of Internal Medicine, Washington University at St. Louis, St. Louis, MO, USA
| | - D Taylor Hendrixson
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO, USA
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24
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Desai C, Handley SA, Rodgers R, Rodriguez C, Ordiz MI, Manary MJ, Holtz LR. Growth velocity in children with Environmental Enteric Dysfunction is associated with specific bacterial and viral taxa of the gastrointestinal tract in Malawian children. PLoS Negl Trop Dis 2020; 14:e0008387. [PMID: 32574158 PMCID: PMC7310680 DOI: 10.1371/journal.pntd.0008387] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 08/07/2019] [Accepted: 05/13/2020] [Indexed: 12/22/2022] Open
Abstract
Environmental enteric dysfunction (EED) is characterized by diffuse villous atrophy of the small bowel. EED is strongly associated with stunting, a major public health problem linked to increased childhood morbidity and mortality. EED and subsequent stunting of linear growth are surmised to have microbial origins. To interrogate this relationship, we defined the comprehensive virome (eukaryotic virus and bacteriophage) and bacterial microbiome of a longitudinal cohort of rural Malawian children with extensive metadata and intestinal permeability testing at each time point. We found thirty bacterial taxa differentially associated with linear growth. We detected many eukaryotic viruses. Neither the total number of eukaryotic families nor a specific viral family was statistically associated with improved linear growth. We identified 3 differentially abundant bacteriophage among growth velocities. Interestingly, there was a positive correlation between bacteria and bacteriophage richness in children with subsequent adequate/moderate growth which children with subsequent poor growth lacked. This suggests that a disruption in the equilibrium between bacteria and bacteriophage communities might be associated with subsequent poor growth. Future studies of EED and stunting should include the evaluation of viral communities in addition to bacterial microbiota to understand the complete microbial ecology of these poorly understood entities.
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Affiliation(s)
- Chandni Desai
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Scott A. Handley
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Rachel Rodgers
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Cynthia Rodriguez
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Maria I. Ordiz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Mark J. Manary
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Pediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lori R. Holtz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
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25
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Zuzarte A, Mui M, Ordiz MI, Weber J, Ryan K, Manary MJ. Reducing Oil Separation in Ready-to-Use Therapeutic Food. Foods 2020; 9:foods9060706. [PMID: 32492836 PMCID: PMC7353625 DOI: 10.3390/foods9060706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 05/07/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Ready-to-use therapeutic food (RUTF) is a shelf-stable, low moisture, energy dense medicinal food composed of peanut butter, vegetable oils, milk powder, a multiple micronutrient premix and sugar. RUTF is used by millions of children annually to treat malnutrition. After mixing, RUTF is a semisolid covered with oil. To produce a homogenous RUTF, hydrogenated vegetable oils are incorporated in small quantities. This study utilized a benchtop methodology to test the effect of RUTF ingredients on oil separation. An acceptable oil separation was <4%. This method compared 15 different vegetable oil stabilizers with respect to oil separation. The dynamic progression of oil separation followed a Michaelis–Menten pattern, reaching a maximum after 60 days when stored at 30 °C. Hydrogenated vegetable oils with triglyceride or 50% monoglycerides reduced the oil separation to acceptable levels. The additive showing the largest reduction in oil separation was used in an industrial trial, where it also performed acceptably. In conclusion, fully hydrogenated soybean and rapeseed oil added as 1.5% controlled oil separation in RUTF.
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26
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Grenov B, Larnkjær A, Lee R, Serena A, Mølgaard C, Michaelsen KF, Manary MJ. Circulating Insulin-Like Growth Factor-1 Is Positively Associated with Growth and Cognition in 6- to 9-Year-Old Schoolchildren from Ghana. J Nutr 2020; 150:1405-1412. [PMID: 32211798 DOI: 10.1093/jn/nxaa075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 09/06/2019] [Revised: 11/08/2019] [Accepted: 03/02/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Milk intake stimulates linear growth and improves cognition in children from low-income countries. These effects may be mediated through insulin-like growth factor-1 (IGF-1). OBJECTIVE The objective was to assess the effect of milk supplement on circulating IGF-1 and to assess IGF-1 as a correlate of growth and cognition in children. METHODS Secondary data on blood spot IGF-1 from a randomized, double-blind, controlled trial in 6-9-y-old children from rural Ghana were analyzed. Intervention groups received porridge with non-energy-balanced supplements: 8.8 g milk protein/d, 100 kcal/d (Milk8); 4.4 g milk and 4.4 g rice protein/d, 100 kcal/d (Milk/rice); 4.4 g milk protein/d, 48 kcal/d (Milk4); or a control (no protein, 10 kcal/d). IGF-1, length, body composition, and Cambridge Neuropsychological Test Automated Battery (CANTAB) were measured at 3.5 or 8.5 mo. Linear regressions were used to assess the effect of milk interventions on IGF-1 and IGF-1 as a correlate of growth and cognition. RESULTS The increase in IGF-1 was 15.3 (95% CI: 3.3, 27.3) ng/mL higher in children receiving Milk8 compared with the control. The IGF-1 increases in the isonitrogenous, isoenergetic Milk/rice or the Milk4 groups were not different from the control (P ≥ 0.49). The increase in IGF-1 was associated with improvements in 4 out of 5 CANTAB domains. The strongest associations included reductions in "mean correct latency" from Pattern Recognition Memory and "pre-extradimensional (pre-ED) shift errors" from Intra/Extradimensional Set Shift (P ≤ 0.005). In addition, change in IGF-1 was positively associated with changes in height, weight, and fat-free mass (P ≤ 0.001). CONCLUSIONS Intake of skimmed milk powder corresponding to one, but not half a glass of milk on school days stimulates IGF-1 in 6-9-y-old Ghanian children. IGF-1 seems to mediate the effect of milk intake on growth and cognition. The association between IGF-1 and cognition in relation to milk intake is novel and opens possibilities for dietary interventions to improve cognition.
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Affiliation(s)
- Benedikte Grenov
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Anni Larnkjær
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Reginald Lee
- Department of Pediatrics, Washington University, St Louis, MO, USA
| | - Anja Serena
- Global Nutrition, Arla Foods amba, Skejby, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Mark J Manary
- Department of Pediatrics, Washington University, St Louis, MO, USA
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
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Terefe Y, Deblais L, Ghanem M, Helmy YA, Mummed B, Chen D, Singh N, Ahyong V, Kalantar K, Yimer G, Yousuf Hassen J, Mohammed A, McKune SL, Manary MJ, Ordiz MI, Gebreyes W, Havelaar AH, Rajashekara G. Co-occurrence of Campylobacter Species in Children From Eastern Ethiopia, and Their Association With Environmental Enteric Dysfunction, Diarrhea, and Host Microbiome. Front Public Health 2020; 8:99. [PMID: 32351922 PMCID: PMC7174729 DOI: 10.3389/fpubh.2020.00099] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 12/05/2019] [Accepted: 03/12/2020] [Indexed: 12/20/2022] Open
Abstract
High Campylobacter prevalence during early childhood has been associated with stunting and environmental enteric dysfunction (EED), especially in low resource settings. This study assessed the prevalence, diversity, abundance, and co-occurrence of Campylobacter spp. in stools from children in a rural area of eastern Ethiopia and their association with microbiome, diarrhea, and EED in children. Stool samples (n = 100) were collected from randomly selected children (age range: 360-498 days) in five kebeles in Haramaya District, Ethiopia. Diarrhea, compromised gut permeability, and gut inflammation were observed in 48, 45, and 57% of children, respectively. Campylobacter prevalence and species diversity were assessed using PCR and meta-total RNA sequencing (MeTRS). The prevalence of Campylobacter spp. in the children's stools was 50% (41-60%) by PCR and 88% (80-93.6%) by MeTRS (P < 0.01). Further, seven Campylobacter species (Campylobacter jejuni, Campylobacter upsaliensis, Campylobacter hyointestinalis, Campylobacter coli, Campylobacter sp. RM6137, uncultured Campylobacter sp., and Campylobacter sp. RM12175) were detected by MeTRS in at least 40% of children stools in high abundance (>1.76-log read per million per positive stool sample). Four clusters of Campylobacter species (5-12 species per cluster) co-occurred in the stool samples, suggesting that Campylobacter colonization of children may have occurred through multiple reservoirs or from a reservoir in which several Campylobacter species may co-inhabit. No associations between Campylobacter spp., EED, and diarrhea were detected in this cross-sectional study; however, characteristic microbiome profiles were identified based on the prevalence of Campylobacter spp., EED severity, and diarrhea. Forty-seven bacterial species were correlated with Campylobacter, and 13 of them also correlated with gut permeability, gut inflammation and/or EED severity. Forty-nine species not correlated with Campylobacter were correlated with gut permeability, gut inflammation, EED severity and/or diarrhea. This study demonstrated that (1) in addition to C. jejuni and C. coli, multiple non-thermophilic Campylobacter spp. (i.e., Campylobacter hyointestinalis, Campylobacter fetus, and Campylobacter concisus) were frequently detected in the children's stools and (2) the Campylobacter, gut permeability, gut inflammation, EED severity, and diarrhea were associated with characteristic microbiome composition. Additional spatial and longitudinal studies are needed to identify environmental reservoirs and sources of infection of children with disparate Campylobacter species and to better define their associations with EED in low-income countries.
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Affiliation(s)
- Yitagele Terefe
- The Ohio State University, Columbus, OH, United States
- Veterinary Medicine, Haramaya University, Dire Dawa, Ethiopia
- Global One Health Initiative, The Ohio State University, Addis Ababa, Ethiopia
| | - Loïc Deblais
- The Ohio State University, Columbus, OH, United States
- Global One Health Initiative, The Ohio State University, Addis Ababa, Ethiopia
| | - Mostafa Ghanem
- The Ohio State University, Columbus, OH, United States
- Global One Health Initiative, The Ohio State University, Addis Ababa, Ethiopia
| | | | - Bahar Mummed
- Veterinary Medicine, Haramaya University, Dire Dawa, Ethiopia
| | - Dehao Chen
- Department of Environmental and Global Health, University of Florida, Gainesville, FL, United States
| | - Nitya Singh
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
| | - Vida Ahyong
- Chan Zuckerberg Biohub, San Francisco, CA, United States
| | | | - Getnet Yimer
- The Ohio State University, Columbus, OH, United States
- Global One Health Initiative, The Ohio State University, Addis Ababa, Ethiopia
| | - Jemal Yousuf Hassen
- Department of Rural Development and Agricultural Extension, Haramaya University, Dire Dawa, Ethiopia
| | | | - Sarah L. McKune
- Department of Environmental and Global Health, University of Florida, Gainesville, FL, United States
| | - Mark J. Manary
- Department of Pediatrics, Washington University, St. Louis, MI, United States
| | - Maria Isabel Ordiz
- Department of Pediatrics, Washington University, St. Louis, MI, United States
| | - Wondwossen Gebreyes
- The Ohio State University, Columbus, OH, United States
- Global One Health Initiative, The Ohio State University, Addis Ababa, Ethiopia
| | - Arie H. Havelaar
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
| | - Gireesh Rajashekara
- The Ohio State University, Columbus, OH, United States
- Global One Health Initiative, The Ohio State University, Addis Ababa, Ethiopia
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28
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Ordiz MI, Janssen S, Humphrey G, Ackermann G, Stephenson K, Agapova S, Divala O, Kaimila Y, Maleta K, Zhong C, Knight R, Trehan I, Tarr PI, Rusconi B, Manary MJ. The effect of legume supplementation on the gut microbiota in rural Malawian infants aged 6 to 12 months. Am J Clin Nutr 2020; 111:884-892. [PMID: 32047925 PMCID: PMC8287943 DOI: 10.1093/ajcn/nqaa011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 09/14/2019] [Accepted: 01/21/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Common bean and cowpea contain about 25% protein and 25% fiber, and are recommended as complementary foods in sub-Saharan Africa. OBJECTIVE The objective of this study was to determine if a daily legume supplement given to Malawian infants aged 6 to 12 mo alters the 16S configuration of the fecal microbiota as read out by amplicon sequence variants (ASVs). METHODS This study was conducted within the context of a randomized, double-blind, controlled clinical trial to assess whether cowpea or common bean supplementation reduced intestinal permeability or increased linear growth. There were 2 village clusters in which the study was conducted. Fresh stool collections were flash frozen from 236 infants at ≤6 time points. The stools were sequenced using Earth Microbiome project protocols and data were processed using Qiime and Qiita, open-source, validated software packages. α-diversity was measured using the Faith's test. The 16S configuration was characterized by determining the weighted UniFrac distances of the ASVs and comparing them using permutational multivariate ANOVA. RESULTS Among the 1249 samples analyzed, the α-diversity of the fecal microbiome was unchanged among subjects after initiation of legume supplementation. Neither cowpea nor common bean altered the overall 16S configuration at any age. The 16S configuration differed between children with adequate and poor linear growth aged from 6 to 9 mo, but no specific ASVs differed in relative abundance. The 16S configuration differed between children with normal and abnormal intestinal permeability at 9 mo, but no specific ASVs differed in relative abundance. Among categorical characteristics of the population associated with different 16S configurations, village cluster was most pronounced. CONCLUSION Legume supplementation in breastfed, rural African infants did not affect the structure of the gut microbial communities until the children were aged 9 mo. This trial was registered at clinicaltrials.gov as NCT02472262.
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Affiliation(s)
- M Isabel Ordiz
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
| | - Stefan Janssen
- Department of Pediatrics, University of California San Diego, La
Jolla, CA, USA
| | - Greg Humphrey
- Department of Pediatrics, University of California San Diego, La
Jolla, CA, USA
| | - Gail Ackermann
- Department of Pediatrics, University of California San Diego, La
Jolla, CA, USA
| | - Kevin Stephenson
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
| | - Sophia Agapova
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
| | - Oscar Divala
- Department of Community Health, College of Medicine, University of
Malawi, Malawi
| | - Yankho Kaimila
- Department of Community Health, College of Medicine, University of
Malawi, Malawi
| | - Ken Maleta
- Department of Community Health, College of Medicine, University of
Malawi, Malawi
| | - Caroline Zhong
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
| | - Rob Knight
- Department of Pediatrics, University of California San Diego, La
Jolla, CA, USA
- Department of Computer Science and Engineering, University of
California San Diego, La Jolla, CA, USA
- Department of Bioengineering, University of California San Diego,
La Jolla, CA, USA
- Center for Microbiome Innovation, University of California San
Diego, La Jolla, CA, USA
| | - Indi Trehan
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
- Department of Paediatrics and Child Health, University of Malawi,
Blantyre, Malawi
| | - Phillip I Tarr
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
| | - Brigida Rusconi
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
| | - Mark J Manary
- Department of Pediatrics, Washington University at St. Louis, St.
Louis, MO, USA
- Department of Community Health, College of Medicine, University of
Malawi, Malawi
- USDA/Agricultural Research Service Children's Nutrition Research
Center, Houston, TX, USA
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29
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Schulze KV, Swaminathan S, Howell S, Jajoo A, Lie NC, Brown O, Sadat R, Hall N, Zhao L, Marshall K, May T, Reid ME, Taylor-Bryan C, Wang X, Belmont JW, Guan Y, Manary MJ, Trehan I, McKenzie CA, Hanchard NA. Edematous severe acute malnutrition is characterized by hypomethylation of DNA. Nat Commun 2019; 10:5791. [PMID: 31857576 PMCID: PMC6923441 DOI: 10.1038/s41467-019-13433-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 12/08/2018] [Accepted: 11/06/2019] [Indexed: 02/06/2023] Open
Abstract
Edematous severe acute childhood malnutrition (edematous SAM or ESAM), which includes kwashiorkor, presents with more overt multi-organ dysfunction than non-edematous SAM (NESAM). Reduced concentrations and methyl-flux of methionine in 1-carbon metabolism have been reported in acute, but not recovered, ESAM, suggesting downstream DNA methylation changes could be relevant to differences in SAM pathogenesis. Here, we assess genome-wide DNA methylation in buccal cells of 309 SAM children using the 450 K microarray. Relative to NESAM, ESAM is characterized by multiple significantly hypomethylated loci, which is not observed among SAM-recovered adults. Gene expression and methylation show both positive and negative correlation, suggesting a complex transcriptional response to SAM. Hypomethylated loci link to disorders of nutrition and metabolism, including fatty liver and diabetes, and appear to be influenced by genetic variation. Our epigenetic findings provide a potential molecular link to reported aberrant 1-carbon metabolism in ESAM and support consideration of methyl-group supplementation in ESAM.
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Affiliation(s)
- Katharina V Schulze
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Shanker Swaminathan
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Sharon Howell
- Tropical Metabolism Research Unit, Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - Aarti Jajoo
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Natasha C Lie
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
- Graduate Program in Integrative Molecular and Biomedical Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Orgen Brown
- Tropical Metabolism Research Unit, Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - Roa Sadat
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Nancy Hall
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Liang Zhao
- Precision Medicine Research Center, Taihe Hospital, Shiyan City, China
| | - Kwesi Marshall
- Tropical Metabolism Research Unit, Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - Thaddaeus May
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Marvin E Reid
- Tropical Metabolism Research Unit, Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - Carolyn Taylor-Bryan
- Tropical Metabolism Research Unit, Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - Xueqing Wang
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - John W Belmont
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Yongtao Guan
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Mark J Manary
- Departments of Paediatrics and Child Health and Community Health, University of Malawi, Blantyre, Malawi
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Indi Trehan
- Departments of Paediatrics and Child Health and Community Health, University of Malawi, Blantyre, Malawi
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, USA
| | - Colin A McKenzie
- Tropical Metabolism Research Unit, Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - Neil A Hanchard
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
- USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA.
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30
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Ordiz MI, Semba RD, Moaddel R, Rolle-Kampczyk U, von Bergen M, Herberth G, Khadeer M, Röder S, Manary MJ. Serum Amino Acid Concentrations in Infants from Malawi are Associated with Linear Growth. Curr Dev Nutr 2019; 3:nzz100. [PMID: 31620672 PMCID: PMC6785685 DOI: 10.1093/cdn/nzz100] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2019] [Indexed: 01/14/2023] Open
Abstract
Serum amino acid (AA) concentrations are correlated with childhood stunting, but their relation to linear growth velocity has not been explored. This was a secondary analysis of a clinical trial where Malawian infants aged 6-12 mo were given a legume supplement providing 8.2 g/d of protein; anthropometry was conducted at multiple intervals, and fasted serum AA concentrations were measured at 12 mo of age. Lysine, proline, tryptophan, tyrosine, and valine concentrations were higher in infants with a linear growth velocity z-score >0 than those <0. Corrected Spearman correlation coefficients between individual AA concentrations and weight-for-height and length velocity from 6 to 12 mo of age were positively correlated for glycine, isoleucine, proline, serine, threonine, tyrosine, and valine. Additionally, weight-for-height was correlated with arginine, asparagine, glutamine, leucine, lysine, methionine, and phenylalanine. The observed associations suggest that testing the hypothesis that essential AA provision will reduce linear growth faltering is warranted. This trial was registered at clinicaltrials.gov as NCT02472262.
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Affiliation(s)
- M Isabel Ordiz
- Department of Pediatrics, Washington University in Saint Louis, St Louis, MO, USA
| | - Richard D Semba
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Gunda Herberth
- Department of Environmental Immunology, Helmholtz Centre for Environmental Research, Leipzig, Germany
| | | | - Stefan Röder
- Department of Environmental Immunology, Helmholtz Centre for Environmental Research, Leipzig, Germany
| | - Mark J Manary
- Department of Pediatrics, Washington University in Saint Louis, St Louis, MO, USA
- School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
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31
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Kohlmann K, Callaghan-Gillespie M, Gauglitz JM, Steiner-Asiedu M, Saalia K, Edwards C, Manary MJ. Alternative Ready-To-Use Therapeutic Food Yields Less Recovery Than the Standard for Treating Acute Malnutrition in Children From Ghana. Glob Health Sci Pract 2019; 7:203-214. [PMID: 31189698 PMCID: PMC6641811 DOI: 10.9745/ghsp-d-19-00004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/02/2019] [Indexed: 11/23/2022]
Abstract
In Ghana, an alternative ready-to-use food (RUTF) formulation that met all specifications was not as good as standard RUTF in affecting recovery from acute malnutrition among children aged 6 to 59 months. Background: Only 20% of children with severe acute malnutrition (SAM) have access to ready-to-use therapeutic food (RUTF), and RUTF cost limits its accessibility. Methods: This randomized, double-blind controlled study involved a clinical equivalence trial comparing the effectiveness of an alternative RUTF with standard RUTF in the home-based treatment of uncomplicated SAM and moderate malnutrition in Ghanaian children aged 6 to 59 months. The primary outcome was recovery, equivalence was defined as being within 5 percentage points of the control group, and an intention-to-treat analysis was used. Alternative RUTF was composed of whey protein, soybeans, peanuts, sorghum, milk, sugar, and vegetable oil. Standard RUTF included peanuts, milk, sugar, and vegetable oil. The cost of alternative RUTF ingredients was 14% less than standard RUTF. Untargeted metabolomics was used to characterize the bioactive metabolites in the RUTFs. Results: Of the 1,270 children treated for SAM or moderate malnutrition, 554 of 628 (88%) receiving alternative RUTF recovered (95% confidence interval [CI]=85% to 90%) and 516 of 642 (80%) receiving standard RUTF recovered (95% CI=77% to 83%). The difference in recovery was 7.7% (95% CI=3.7% to 11.7%). Among the 401 children with SAM, the recovery rate was 130 of 199 (65%) with alternative RUTF and 156 of 202 (77%) with standard RUTF (P=.01). The default rate in SAM was 60 of 199 (30%) for alternative RUTF and 41 of 202 (20%) for standard RUTF (P=.04). Children enrolled with SAM who received alternative RUTF had less daily weight gain than those fed standard RUTF (2.4 ± 2.4 g/kg vs. 2.9 ± 2.6 g/kg, respectively; P<.05). Among children with moderate wasting, recovery rates were lower for alternative RUTF, 386 of 443 (87%), than standard RUTF, 397 of 426 (93%) (P=.003). More isoflavone metabolites were found in alternative RUTF than in the standard. Conclusion: The lower-cost alternative RUTF was less effective than standard RUTF in the treatment of severe and moderate malnutrition in Ghana.
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Affiliation(s)
- Kristin Kohlmann
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | | | - Julia M Gauglitz
- Collaborative Mass Spectrometry Innovation Center, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, USA
| | | | - Kwesi Saalia
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | | | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO, USA. .,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
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32
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Pitman RT, Mui M, Michelson PH, Manary MJ. Ready-to-Use Supplemental Food for Nutritional Supplementation in Cystic Fibrosis. Curr Dev Nutr 2019; 3:nzz016. [PMID: 31011716 PMCID: PMC6468303 DOI: 10.1093/cdn/nzz016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 10/22/2018] [Revised: 01/15/2019] [Accepted: 03/11/2019] [Indexed: 01/23/2023] Open
Abstract
Undernutrition is common in cystic fibrosis (CF) and is correlated with long-term outcomes, yet current nutritional interventions have not demonstrated consistent improvements in energy intake, and subsequently, growth. Development of novel nutritional interventions to increase energy intake is essential to improve clinical outcomes of individuals with CF. Ready-to-use supplemental food (RUSF) is a modifiable, inexpensive, palatable, safe, and nutrient-dense food for treatment or prevention of acute malnutrition in developing countries. Utilizing a linear-programming tool we identified 6 RUSF formulations with sufficient nutrient density (495 kcal/100 g), protein, and fat for children with CF. Palatability was established by a taste-trial and affirmed by a 2-wk tolerability assessment that demonstrated consistent consumption and tolerance of the RUSF. Although preliminary, this study demonstrates the potential for developing RUSF as a nutritional supplement for increasing energy intake in children with CF.
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Affiliation(s)
- Ryan T Pitman
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Melody Mui
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Peter H Michelson
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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33
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Maleta KM, Manary MJ. WASH alone cannot prevent childhood linear growth faltering. Lancet Glob Health 2019; 7:e16-e17. [PMID: 30554752 DOI: 10.1016/s2214-109x(18)30420-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Kenneth M Maleta
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Private Bag 360 Blantyre 3, Malawi.
| | - Mark J Manary
- Department of Pediatrics, St Louis Children's Hospital, St Louis, MO, USA
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34
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Stobaugh HC, Mayberry A, McGrath M, Bahwere P, Zagre NM, Manary MJ, Black R, Lelijveld N. Relapse after severe acute malnutrition: A systematic literature review and secondary data analysis. Matern Child Nutr 2018; 15:e12702. [PMID: 30246929 PMCID: PMC6587999 DOI: 10.1111/mcn.12702] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 09/13/2018] [Accepted: 09/15/2018] [Indexed: 12/02/2022]
Abstract
The objectives of most treatment programs for severe acute malnutrition (SAM) in children focus on initial recovery only, leaving post‐discharge outcomes, such as relapse, poorly understood and undefined. This study aimed to systematically review current literature and conduct secondary data analyses of studies that captured relapse rates, up to 18‐month post‐discharge, in children following recovery from SAM treatment. The literature search (including PubMed and Google Scholar) built upon two recent reviews to identify a variety of up‐to‐date published studies and grey literature. This search yielded 26 articles and programme reports that provided information on relapse. The proportion of children who relapsed after SAM treatment varied greatly from 0% to 37% across varying lengths of time following discharge. The lack of a standard definition of relapse limited comparability even among the few studies that have quantified post‐discharge relapse. Inconsistent treatment protocols and poor adherence to protocols likely add to the wide range of relapse reported. Secondary analysis of a database from Malawi found no significant association between potential individual risk factors at admission and discharge, except being an orphan, which resulted in five times greater odds of relapse at 6 months post‐discharge (95% CI [1.7, 12.4], P = 0.003). The development of a standard definition of relapse is needed for programme implementers and researchers. This will allow for assessment of programme quality regarding sustained recovery and better understanding of the contribution of relapse to local and global burden of SAM.
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Affiliation(s)
- Heather C Stobaugh
- Food, Nutrition, and Obesity Policy and Research Team, RTI International, Research Triangle Park, North Carolina
| | - Amy Mayberry
- No Wasted Lives Team, Action Against Hunger, London, UK
| | | | - Paluku Bahwere
- Valid International, Oxford, UK.,Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de santé publique, Université Libre de Bruxelles, City of Brussels, Belgium
| | - Noël Marie Zagre
- West and Central Africa Regional Office, UNICEF West and Central Africa Regional Office, Dakar, Senegal
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Robert Black
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Natasha Lelijveld
- No Wasted Lives Team, Action Against Hunger, London, UK.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
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Ordiz MI, Wold K, Kaimila Y, Divala O, Gilstrap M, Lu HZ, Manary MJ. Detection and interpretation of fecal host mRNA in rural Malawian infants aged 6-12 months at risk for environmental enteric dysfunction. Exp Biol Med (Maywood) 2018; 243:985-989. [PMID: 30099958 DOI: 10.1177/1535370218794418] [Citation(s) in RCA: 4] [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] [Indexed: 12/16/2022] Open
Abstract
Recent studies have suggested that environmental enteric dysfunction can be assessed in rural African children by measuring levels of fecal mRNA transcripts. The field collection of fecal samples is less invasive and cumbersome than administration of the lactulose:mannitol test, which is typically used to assess environmental enteric dysfunction. This study sought to determine if, as in children aged 12-60 months, an array of seven fecal host transcripts (CD53, CDX1, HLA-DRA, TNF, S100A8, MUC12, and REG1A) could predict environmental enteric dysfunction in rural African infants. Host fecal transcript abundance was correlated to the percentage of lactulose (%L) excreted in the urine for 340 samples from Malawian children aged 6-12 months. Permeability was categorized as not severe (%L < 0.45) and severe (%L ≥ 0.45). This study found the prevalence of severe environmental enteric dysfunction to be 114/834 (14%), lower than what was previously reported for 12-60 months old children, 595/1521 (39%, P = 0.001). In linear regression analysis with the seven host transcripts, two were associated with %L: β coefficients of -1.843 ( P = 0.035) and 0.215 ( P = 0.006) for CDX1 and REG1A, respectively. The seven fecal host transcripts in a random forest model did not predict severe environmental enteric dysfunction. Future models utilizing different transcripts identified from an untargeted, agnostic assessment of all potential host transcripts could provide accurate predictions of environmental enteric dysfunction in infants. Impact statement Environmental enteric dysfunction (EED) is associated with reduced linear growth. The dual sugar absorption test has been used as a non-invasive method to determine the gut health of individuals. Alternative methods using fecal host mRNAs as predictors of the gut health are promising. In older children, we have determined that seven transcripts can predict the gut health in a random forest model. Our current study determined that the host fecal mRNA is abundant in infants and toddlers alike. Severe EED in rural Malawian children is less prevalent in infants than in young children. REG1A and CDX1 are associated with gut health. Fecal host mRNA may well be a means to assess gut health in African infants, but the panel of transcripts used to do this will differ from that in older children.
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Affiliation(s)
- M Isabel Ordiz
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Karl Wold
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Yankho Kaimila
- 2 School of Public Health and Family Medicine, University of Malawi, Blantyre 3, Malawi
| | - Oscar Divala
- 2 School of Public Health and Family Medicine, University of Malawi, Blantyre 3, Malawi
| | - Madeline Gilstrap
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Henry Z Lu
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Mark J Manary
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA.,2 School of Public Health and Family Medicine, University of Malawi, Blantyre 3, Malawi.,3 Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX 77030, USA
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Ngoma TN, Chimimba UK, Mwangwela AM, Thakwalakwa C, Maleta KM, Manary MJ, Trehan I. Effect of cowpea flour processing on the chemical properties and acceptability of a novel cowpea blended maize porridge. PLoS One 2018; 13:e0200418. [PMID: 29990380 PMCID: PMC6039016 DOI: 10.1371/journal.pone.0200418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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] [Received: 06/30/2017] [Accepted: 06/26/2018] [Indexed: 11/17/2022] Open
Abstract
Childhood growth stunting is a pervasive problem in Malawi and is in large part due to low quality complementary foods and chronic gut inflammation. Introducing legumes such as cowpea (Vigna unguiculata) into the complementary diet has the potential to improve childhood growth by improving diet quality through improvements in macro- and micronutrients and also by reducing gut inflammation. However, cowpea is relatively underutilized in complementary feeding in Malawi due to its strong taste, long processing time, and high energy requirements for processing. Effective utilization of cowpea in complementary feeding requires processing which may affect chemical composition as well as sensory quality. The present study evaluated the effect of processing on the retention of zinc, crude fibre, and flavonoid in roasted, boiled, and dehulled cowpea flours, and assessed the acceptability of maize porridge (70%) enriched with one of the three cowpea flours (30%). Roasting, dehulling, and boiling did not have any effect on zinc content. Crude fibre content increased after processing by all methods. Processing had no effect on measurable flavonoids. Roasted, boiled, and dehulled cowpea blended maize porridges were acceptable to children with mean quantities of leftover food of less than 3g from the given 100g. Caregivers also rated the blended flours to be highly acceptable to them as well, with maize porridge blended with dehulled cowpea flour the most acceptable to both children and caregivers. These results demonstrate that cowpea flour, processed by any of these three different methods, could serve as a useful addition to maize porridge for complementary feeding of children in sub-Saharan Africa.
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Affiliation(s)
- Theresa N Ngoma
- Department of Food Science and Technology, Lilongwe University of Agriculture and Natural Resources, Lilongwe, Malawi
| | - Ulemu K Chimimba
- Department of Food Science and Technology, Lilongwe University of Agriculture and Natural Resources, Lilongwe, Malawi
| | - Agnes M Mwangwela
- Department of Food Science and Technology, Lilongwe University of Agriculture and Natural Resources, Lilongwe, Malawi
| | - Chrissie Thakwalakwa
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Mark J Manary
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Pediatrics, Washington University in St. Louis, St Louis, Missouri, United States of America
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St Louis, Missouri, United States of America.,Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
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Glosz CM, Schaffner AA, Reaves SK, Manary MJ, Papathakis PC. Effect of Nutritional Interventions on Micronutrient Status in Pregnant Malawian Women with Moderate Malnutrition: A Randomized, Controlled Trial. Nutrients 2018; 10:nu10070879. [PMID: 29986492 PMCID: PMC6073606 DOI: 10.3390/nu10070879] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 06/10/2018] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 01/12/2023] Open
Abstract
Micronutrient deficiencies during pregnancy are common in Africa and can cause adverse outcomes. The objective was to measure micronutrient status and change in moderately malnourished pregnant Malawian women randomized to one of three nutritional interventions. Serum vitamin B12, 25-hydroxyvitamin D, folate, retinol, ferritin, zinc, albumin and C-reactive protein were measured in pregnant women with MUAC ≥20.6 cm and ≤23.0 cm at enrollment (n = 343) and after 10 weeks (n = 229) of receiving: (1) ready-to-use supplementary food (RUSF); (2) fortified corn-soy blend (CSB+) with multiple-micronutrient supplement (CSB+UNIMMAP); or (3) CSB+ with iron and folic acid (CSB+IFA). Each provided 100⁻300% Recommended Dietary Allowance of most micronutrients and 900 kcal/day. Birth length was measured in 272 infants. Enrollment measurements indicated deficiencies in vitamin B12 (20.9%) and zinc (22.3%), low values of ferritin (25.1%) and albumin (33.7%), and elevated CRP (46.0%). Vitamin B12 is known to decrease in the third trimester; the RUSF group had the smallest decrease from enrollment to week 10 (3%), compared to 20% decrease in the CSB+IFA group and 8% decrease in the CSB+UNIMMAP group (p = 0.001). Mean serum 25-hydroxyvitamin D increased most in the RUSF group (+6.4 ng/mL), compared to CSB+IFA (+1.7 ng/mL) and CSB+UNIMMAP (+2.7 ng/mL) (p < 0.001). Micronutrient deficiencies and inflammation are common among moderately malnourished pregnant women and had little improvement despite supplementation above the RDA, with the exception of vitamins B12 and D.
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Affiliation(s)
- Cambria M Glosz
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
| | - Andrew A Schaffner
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
| | - Scott K Reaves
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
| | - Mark J Manary
- Washington University School of Medicine, Washington University, St. Louis, MO 63110, USA.
| | - Peggy C Papathakis
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
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Lee R, Singh L, van Liefde D, Callaghan-Gillespie M, Steiner-Asiedu M, Saalia K, Edwards C, Serena A, Hershey T, Manary MJ. Milk Powder Added to a School Meal Increases Cognitive Test Scores in Ghanaian Children. J Nutr 2018; 148:1177-1184. [PMID: 29905824 DOI: 10.1093/jn/nxy083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 04/02/2018] [Indexed: 12/16/2022] Open
Abstract
Background The inclusion of milk in school feeding is accepted as good nutritional practice, but specific benefits remain uncertain. Objective The objective was to determine whether consumption of 8.8 g milk protein/d given as milk powder with a multiple micronutrient-enriched porridge resulted in greater increases in linear growth and Cambridge Neuropsychological Test Automated Battery (CANTAB) scores in Ghanaian schoolchildren when compared with 1 of 3 control groups. Methods A randomized, double-blind, placebo-controlled clinical trial in healthy children aged 6-9 y was conducted comparing 8.8 g milk protein/d with 4.4 g milk protein/d or 4.4 g milk protein + 4.4 g rice protein/d (isonitrogenous, half of the protein from milk and half from rice) or a non-nitrogenous placebo. Primary outcomes were changes in length after 9 mo and CANTAB scores after 4.5 mo; secondary outcomes were body-composition measures. Supplements were added to porridge each school day and consumed for 9 mo. Anthropometric and body-composition measures and CANTAB tests were completed upon enrollment and after 4.5 and 9 mo. Group results were compared by using ANCOVA for anthropometric measures and the Kruskal-Wallis test for CANTAB scores. Results Children receiving 8.8 g milk protein/d showed greater increases on percentage correct in Pattern Recognition Memory (mean ± SD: 5.5% ± 16.8%; P < 0.05) and Intra/Extradimensional Set Shift completed stages compared with all other food groups (0.6 ± 2.3; P < 0.05). No differences were seen in linear growth between the groups. The children receiving either 4.4 or 8.8 g milk protein/d had a higher fat-free body mass index than those who received no milk, with an effect size of 0.34 kg/m2. Conclusion Among schoolchildren, the consumption of 8.8 g milk protein/d improved executive cognitive function compared with other supplements and led to the accretion of more lean body mass, but not more linear growth. This trial was registered at www.clinicaltrials.gov">www.clinicaltrials.gov as NCT02757508.
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Affiliation(s)
- Reginald Lee
- Departments of Pediatrics, Washington University, St. Louis, MO
| | - Lauren Singh
- Departments of Pediatrics, Washington University, St. Louis, MO
| | | | | | | | - Kwesi Saalia
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | | | - Anja Serena
- Global Nutrition and Clinicals, Arla Foods Amba, Brabrand, Denmark
| | - Tamara Hershey
- Departments of Psychiatry, Washington University, St. Louis, MO.,Departments of Neurology, Washington University, St. Louis, MO.,Departments of Radiology, Washington University, St. Louis, MO
| | - Mark J Manary
- Departments of Pediatrics, Washington University, St. Louis, MO.,School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
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Stobaugh HC, Rogers BL, Rosenberg IH, Webb P, Maleta KM, Manary MJ, Trehan I. Children with Poor Linear Growth Are at Risk for Repeated Relapse to Wasting after Recovery from Moderate Acute Malnutrition. J Nutr 2018; 148:974-979. [PMID: 29726948 DOI: 10.1093/jn/nxy033] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/30/2018] [Indexed: 02/06/2023] Open
Abstract
Background Nutrition programs frequently approach wasting and stunting as 2 separate conditions with distinct causes and effects. Although several cross-sectional studies have identified an association between the 2 conditions, longitudinal studies are useful to quantify the risk of acute malnutrition based on the trajectory of linear growth. Objective We analyzed data from a longitudinal study to explore associations between linear growth and relapse to acute malnutrition in high-risk children during the year after recovery from moderate acute malnutrition (MAM). Methods This was a secondary data analysis from a cluster randomized trial involving 1487 Malawian children 6-62 mo old treated for MAM and enrolled upon recovery. Children were followed for 1 y, during which data were collected on anthropometric progress, symptoms of illness, and household food security. Multivariate fixed-effects logistic regression was used to identify associations between linear growth and relapse to acute malnutrition. Results Children who have recovered from MAM proved to be a high-risk population, with nearly half experiencing a decrease in height-for-age z score (HAZ) for 12 mo. Children whose HAZ was declining were more likely to relapse to MAM or SAM than were those whose linear growth rate maintained or increased their HAZ (P < 0.001). Mean changes of +0.15, -0.03, -0.17, and -0.53 in HAZ were observed for those who sustained recovery, relapsed to MAM once, relapsed to MAM multiple times, and developed SAM, respectively. Conclusion Our results add to the body of evidence suggesting that acute wasting is a harbinger of subsequent stunting. Children who experience poor linear growth after MAM are more likely to experience relapse. Given this bidirectional relation between wasting and stunting, supplementary feeding programs should consider both when designing protocols, aiming to optimize linear growth and achieve acute weight gain, as a means of reducing relapse. This trial was registered at clinicaltrials.gov as NCT02351687.
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Affiliation(s)
- Heather C Stobaugh
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA.,RTI International, Research Triangle Park, NC
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, and Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,School of Public Health and Family Medicine, and Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi.,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi.,Lao Friends Hospital for Children, Luang Prabang, Lao PDR
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Hendrixson DT, Koroma AS, Callaghan-Gillespie M, Weber J, Papathakis P, Manary MJ. Use of a novel supplementary food and measures to control inflammation in malnourished pregnant women in Sierra Leone to improve birth outcomes: study protocol for a prospective, randomized, controlled clinical effectiveness trial. BMC Nutr 2018; 4:15. [PMID: 32153879 PMCID: PMC7050866 DOI: 10.1186/s40795-018-0218-y] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 03/07/2018] [Indexed: 12/11/2022] Open
Abstract
Background The negative synergy between poor nutritional status and infectious diseases is doubly detrimental in pregnancy. In Sierra Leone, maternal malnutrition is amongst the highest in the world, while maternal mortality is high at 1320/100,000 live births and stunting in under-five is 37.9%, ranked 110/132 worldwide. Maternal malnutrition has been associated with preterm birth, small-for-gestational age infants, and poor maternal outcomes. Infants born prematurely or small-for-gestational age experience higher mortality and are at risk for stunting and decreased cognitive performance. Nutritional interventions alone during pregnancy may not be as effective in the setting of increased inflammation from repeated infections. Interventions are needed to improve maternal outcomes and reduce stunting in this population. Methods/design This will be a prospective, randomized, controlled clinical effectiveness trial of an improved supplementary food plus anti-infective therapies compared to standard therapy in malnourished pregnant women. Pregnant women will be randomized to receive a low water activity, ready-to-use supplementary food plus five anti-infective interventions or the standard of care which is 3.5 kg corn/ soy blended flour with 350 mL vegetable oil every two weeks. The five anti-infective interventions are 1) insecticide-treated mosquito net at the time of enrollment into the study, 2) sulfadoxine-pyrimethamine given every 4 weeks, beginning at enrollment or at 13 weeks’ gestation, whichever is later, 3)azithromycin at a dose of 1 g given once at enrollment (after first trimester)and again during 28–34 weeks of gestation, 4)single dose 400 mg albendazole given in second trimester, and 5) testing and treatment for bacterial vaginosis at enrollment and again at 28–34 weeks of gestation. Treatment will be provided for the duration of the pregnancy. The primary outcome measure will be birth length. Secondary outcomes in the mothers will include rates of maternal weight gain and increase in mid-upper arm circumference, and time to maternal anthropometric recovery. Secondary outcomes in the infants will include birth weight, birth head circumference, and linear and ponderal growth. Discussion Malnutrition remains a major problem in the developing world with lasting maternal and infant consequences. Maternal malnutrition has been associated with intrauterine growth retardation, low birth weight (LBW), pre-term delivery and poor cognitive development. Nutritional interventions alone have not been successful in reducing stunting. By bundling nutritional and anti-infective interventions, we aim to reduce intrauterine growth restriction and low birth weight in moderately malnourished pregnant women in Sierra Leone. If successful, this bundle can easily be implemented by governments or non-governmental organizations. Trial registration Clinicaltrials.govNCT03079388; Date: March 5, 2017.
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Affiliation(s)
- D Taylor Hendrixson
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
| | - Aminata Shamit Koroma
- 2Ministry of Health and Sanitation, The Republic of Sierra Leone, 4th Floor Youyi Building, Freetown, Sierra Leone
| | - Meghan Callaghan-Gillespie
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
| | - Jacklyn Weber
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
| | - Peggy Papathakis
- 3Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407 USA
| | - Mark J Manary
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
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Ordiz MI, Davitt C, Stephenson K, Agapova S, Divala O, Shaikh N, Manary MJ. EB 2017 Article: Interpretation of the lactulose:mannitol test in rural Malawian children at risk for perturbations in intestinal permeability. Exp Biol Med (Maywood) 2018; 243:677-683. [PMID: 29597877 DOI: 10.1177/1535370218768508] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The dual sugar absorption test, specifically the lactulose:mannitol test, is used to assess gut health. Lactulose absorption is said to represent gut damage and mannitol absorption is used as a measure of normal small bowel function and serves as normalizing factor for lactulose. A underappreciated limitation of this common understanding of the lactulose:mannitol test is that mannitol is not absorbed to any substantial extent by a transcellular process. Additionally, this interpretation of lactulose:mannitol is not consistent with current understanding of paracellular pathways, where three pathway types exist: pore, leak, and unrestricted. Pore and leak pathways are regulated biological constructions of the small bowel barrier, and unrestricted pathways represent micropathological damage. We analyzed 2334 lactulose:mannitol measurements rigorously collected from 622 young rural Malawian children at high risk for poor gut health in light of the pathway model. An alternative method of normalizing for gut length utilizing autopsy data is described. In our population, absorbed lactulose and mannitol are strongly correlated, r = 0.68 P <0.0001, suggesting lactulose and mannitol are traversing the gut barrier via the same pathways. Considering measurements where pore pathways predominate, mannitol flux is about 14 times that of lactulose. As more leak pathways are present, this differential flux mannitol:lactulose falls to 8:1 and when increased numbers of unrestricted pathways are present, the differential flux of mannitol:lactulose is 6:1. There was no substantial correlation between the lactulose:mannitol and linear growth. Given that mannitol will always pass through a given pathway at a rate at least equal to that of lactulose, and lactulose absorption is a composite measure of flux through both physiologic and pathologic pathways, we question the utility of the lactulose:mannitol test. We suggest using lactulose alone is as informative as lactulose:mannitol in a sugar absorption testing in subclinical gut inflammation. Impact statement Our work integrates the standard interpretation of the lactulose:mannitol test (L:M), with mechanistic insight of intestinal permeability. There are three paracellular pathways in the gut epithelium; pore, leak, and unrestricted. Using thousands of L:M measurements from rural Malawian children at risk for increased intestinal permeability, we predict the differential flux of L and M through the pathways. Our findings challenge the traditional notions that little L is absorbed through a normal epithelial barrier and that M is a normalizing factor for L. Our observations are consistent with pore pathways allowing only M to pass. And that substantial amounts of L and M pass through leak pathways which are normal, regulated, cell-junctional adaptations. So M is a composite measure of all pathways, and L is not a measure solely of pathologic gut damage. Using L alone as a probe will yield more information about gut health than L:M.
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Affiliation(s)
- M Isabel Ordiz
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Caroline Davitt
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Kevin Stephenson
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Sophia Agapova
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Oscar Divala
- 2 School of Public Health and Family Medicine, University of Malawi, Blantyre 3, Malawi
| | - Nurmohammad Shaikh
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA
| | - Mark J Manary
- 1 Department of Pediatrics, Washington University at Saint Louis, St. Louis, MO 63110, USA.,2 School of Public Health and Family Medicine, University of Malawi, Blantyre 3, Malawi.,3 Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX 77030, USA
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Agapova SE, Stephenson KB, Divala O, Kaimila Y, Maleta KM, Thakwalakwa C, Ordiz MI, Trehan I, Manary MJ. Additional Common Bean in the Diet of Malawian Children Does Not Affect Linear Growth, but Reduces Intestinal Permeability. J Nutr 2018; 148:267-274. [PMID: 29490090 DOI: 10.1093/jn/nxx013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 10/18/2017] [Indexed: 01/26/2023] Open
Abstract
Background Chronic malnutrition, as manifested by linear growth faltering, is pervasive among rural African children. Improvements in complementary feeding may decrease the burden of environmental enteric dysfunction (EED) and thus improve growth in children during the critical first 1000 d of development. Objective We tested the hypothesis that systematically including common bean or cowpea into complementary feeding would reduce EED and growth faltering among children in rural Malawi. Methods This was a double-blind clinical trial in which children 12-23 mo of age were randomly assigned to receive complementary feeding with 1 of 3 foods: roasted cowpea or common bean flour, or an isoenergetic amount of corn-soy blend as a control food for 48 wk. Children aged 12-23 mo received 155 kcal/d and thereafter until 35 mo received 200 kcal/d. The primary outcomes were change in length-for-age z score (LAZ) and improvements in a biomarker of EED, the percentage of lactulose (%L) excreted as part of the lactulose:mannitol dual-sugar absorption test. Anthropometric measurements and urinary %L excretion were compared between the 2 intervention groups and the control group separately with the use of linear mixed model analyses for repeated measures. Results A total of 331 children completed the clinical trial. Compliance with the study interventions was excellent, with >90% of the intervention flour consumed as intended. No significant effects on LAZ, change in LAZ, or weight-for-length z score were observed due to either intervention legume, compared to the control. %L was reduced with common bean consumption (effect estimate was -0.07 percentage points of lactulose, P = 0.0007). The lactulose:mannitol test was not affected by the legume intervention. Conclusion The addition of common bean to complementary feeding of rural Malawian children during the second year of life led to an improvement in a biomarker of gut health, although this did not directly translate into improved linear growth. This trial was registered at clinicaltrials.gov as NCT02472301.
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Affiliation(s)
| | | | - Oscar Divala
- School of Public Health and Family Medicine and Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Yankho Kaimila
- School of Public Health and Family Medicine and Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kenneth M Maleta
- School of Public Health and Family Medicine and Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Chrissie Thakwalakwa
- School of Public Health and Family Medicine and Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - M Isabel Ordiz
- Department of Pediatrics, Washington University, St Louis, MO
| | - Indi Trehan
- Department of Pediatrics, Washington University, St Louis, MO.,Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University, St Louis, MO.,School of Public Health and Family Medicine and Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
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Semba RD, Trehan I, Li X, Salem N, Moaddel R, Ordiz MI, Maleta KM, Kraemer K, Manary MJ. Low serum ω-3 and ω-6 polyunsaturated fatty acids and other metabolites are associated with poor linear growth in young children from rural Malawi. Am J Clin Nutr 2017; 106:1490-1499. [PMID: 29070563 PMCID: PMC5698844 DOI: 10.3945/ajcn.117.164384] [Citation(s) in RCA: 21] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/03/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Stunting affects ∼25% of children <5 y of age and is associated with impaired cognitive and motor development and increased morbidity and mortality. The pathogenesis of stunting is poorly understood.Objective: The purpose of this study was to identify altered metabolic pathways associated with child stunting.Design: We measured 677 serum metabolites using liquid chromatography-tandem mass spectrometry in a cross-sectional study of 400 Malawian children aged 12-59 mo, of whom 62% were stunted.Results: A low height-for-age z score (HAZ) was associated with lower serum concentrations of 1) ω-3 (n-3) and ω-6 (n-6) polyunsaturated fatty acids (PUFAs), 2) sulfated neurosteroids, which play a role in brain development, 3) carnitine, a conditionally essential nutrient with an important role in the carnitine shuttle for the metabolism of fatty acids and energy production, and 4) γ-glutamyl amino acids, which represent an altered γ-glutamyl cycle of glutathione metabolism. A low HAZ was associated with significantly higher serum concentrations of 5 biomarkers related to cigarette smoke exposure.Conclusions: This metabolomics study shows a cross-sectional association between stunting and low serum ω-3 and ω-6 long-chain PUFAs, which are essential for growth and development; low sulfated neurosteroids, which play a role in brain development; low carnitine, which is essential for β-oxidation of fatty acids; alterations in glutathione metabolism; and increased serum metabolites that are associated with secondhand tobacco smoke exposure. This trial was registered at www.controlled-trials.com as ISRCTN14597012.
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Affiliation(s)
- Richard D Semba
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD;
| | - Indi Trehan
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO
| | - Ximin Li
- Departments of Biostatistics and
| | | | | | - M Isabel Ordiz
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO
| | - Kenneth M Maleta
- College of Medicine, University of Malawi, Blantyre, Malawi; and
| | - Klaus Kraemer
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;,Sight and Life, Basel, Switzerland
| | - Mark J Manary
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO
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Stephenson KB, Agapova SE, Divala O, Kaimila Y, Maleta KM, Thakwalakwa C, Ordiz MI, Trehan I, Manary MJ. Complementary feeding with cowpea reduces growth faltering in rural Malawian infants: a blind, randomized controlled clinical trial. Am J Clin Nutr 2017; 106:1500-1507. [PMID: 29092882 PMCID: PMC6482976 DOI: 10.3945/ajcn.117.160986] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 05/22/2017] [Accepted: 10/04/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Growth faltering is common in rural African children and is attributed to inadequate dietary intake and environmental enteric dysfunction (EED).Objective: We tested the hypothesis that complementary feeding with cowpea or common bean flour would reduce growth faltering and EED in 6-mo-old rural Malawians compared with the control group receiving a corn-soy blend.Design: A prospective, double-blind, randomized controlled clinical trial was conducted in which children received daily feeding for 6 mo (200 kcal/d when 6-9 mo old and 300 kcal/d when 10-12 mo old). The primary outcomes were change in length-for-age z score (LAZ) and improvements in EED, as measured by percentage of lactulose excretion (%L). %L <0.2% was considered normal. Anthropometric measurements and %L through urine were compared between each legume group and the control group with Student's t test.Results: Of the 355 infants enrolled, 291 infants completed the trial, and 288 were breastfed throughout the duration of the study. Cowpea and common bean added 4.6-5.2 g protein/d and 4-5 g indigestible carbohydrate/d to the diet. LAZ and weight-for-height z score were reduced in all 3 groups from 6 to 12 mo of age. The changes in LAZ [mean (95% CI)] for the cowpea, common bean, and control groups from 6 to 9 mo were -0.14 (-0.24, -0.04), -0.27 (-0.38, -0.16), and -0.27 (-0.35, -0.19), respectively. LAZ was reduced less in infants receiving cowpea than in those receiving control food from 6 to 9 mo (P = 0.048). The absolute value of %L did not differ between the dietary groups at 9 mo of age (mean ± SD: 0.30 ± 0.43, 0.23 ± 0.21, and 0.26 ± 0.31 for cowpea, common bean, and control, respectively), nor did the change in %L from 6 to 9 mo.Conclusion: Addition of cowpea to complementary feeding in Malawian infants resulted in less linear growth faltering. This trial was registered at clinicaltrials.gov as NCT02472262.
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Affiliation(s)
| | | | - Oscar Divala
- School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
| | - Yankho Kaimila
- School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
| | - Chrissie Thakwalakwa
- School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
| | - M Isabel Ordiz
- Department of Pediatrics, Washington University, St. Louis, MO
| | - Indi Trehan
- Department of Pediatrics, Washington University, St. Louis, MO,Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO; .,School of Public Health and Family Medicine and.,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
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45
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Cheng WD, Wold KJ, Benzoni NS, Thakwalakwa C, Maleta KM, Manary MJ, Trehan I. Lactoferrin and lysozyme to reduce environmental enteric dysfunction and stunting in Malawian children: study protocol for a randomized controlled trial. Trials 2017; 18:523. [PMID: 29110675 PMCID: PMC5674751 DOI: 10.1186/s13063-017-2278-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 04/20/2017] [Accepted: 10/25/2017] [Indexed: 12/11/2022] Open
Abstract
Background Chronic childhood malnutrition, as manifested by stunted linear growth, remains a persistent barrier to optimal child growth and societal development. Environmental enteric dysfunction (EED) is a significant underlying factor in the causal pathway to stunting, delayed cognitive development, and ultimately morbidity and mortality. Effective therapies against EED and stunting are lacking and further clinical trials are warranted to effectively identify and operationalize interventions. Methods/design A prospective randomized placebo-controlled parallel-group randomized controlled trial will be conducted to determine if a daily supplement of lactoferrin and lysozyme, two important proteins found in breast milk, can decrease the burden of EED and stunting in rural Malawian children aged 12–23 months old. The intervention and control groups will have a sample size of 86 subjects each. All field and laboratory researchers will be blinded to the assigned intervention group, as will the subjects and their caregivers. The percentage of ingested lactulose excreted in the urine (Δ%L) after 4 h will be used as the biomarker for EED and linear growth as the measure of chronic malnutrition (stunting). The primary outcomes of interest will be change in Δ%L from baseline to 8 weeks and to 16 weeks. Intention-to-treat analyses will be used. Discussion A rigorous clinical trial design will be used to assess the biologically plausible use of lactoferrin and lysozyme as dietary supplements for children at high risk for EED. If proven effective, these safe proteins may serve to markedly reduce the burden of childhood malnutrition and improve survival. Trial Registration Clinicaltrials.gov, NCT02925026. Registered on 4 October 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2278-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- William D Cheng
- Department of Pediatrics, Washington University in St. Louis, One Children's Place, Campus Box 8116, Saint Louis, MO, 63110, USA
| | - Karl J Wold
- Department of Pediatrics, Washington University in St. Louis, One Children's Place, Campus Box 8116, Saint Louis, MO, 63110, USA
| | - Nicole S Benzoni
- Department of Pediatrics, Washington University in St. Louis, One Children's Place, Campus Box 8116, Saint Louis, MO, 63110, USA
| | - Chrissie Thakwalakwa
- School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, One Children's Place, Campus Box 8116, Saint Louis, MO, 63110, USA.,School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi.,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, One Children's Place, Campus Box 8116, Saint Louis, MO, 63110, USA. .,Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi. .,Lao Friends Hospital for Children, Luang Prabang, Lao PDR.
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46
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Friebert A, Callaghan-Gillespie M, Papathakis PC, Manary MJ. Adolescent pregnancy and nutrition: a subgroup analysis from the Mamachiponde study in Malawi. Ann N Y Acad Sci 2017; 1416:140-146. [PMID: 29044558 DOI: 10.1111/nyas.13465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 06/06/2017] [Revised: 08/01/2017] [Accepted: 08/10/2017] [Indexed: 11/26/2022]
Abstract
Young age at childbearing (≤19 years) is common and associated with poor birth outcomes. A trial among Malawian pregnant women with moderate malnutrition was used to determine outcomes of young adolescents (≤18 years), older adolescents (18-20 years), and adults (>20 years). Women received one of three supplementary foods that provided ∼900 kcal/day and 33-36 g protein/day and returned every 2 weeks. Newborn/maternal measurements were taken at delivery and after 6 and 12 weeks. Upon enrollment, adolescents had greater body mass index than adults (19.9 ± 1.3 versus 19.5 ± 1.4 kg/m2 , P < 0.001). Young adolescents received more rations of food and enrolled and delivered with a lower fundal height than adults (21.7 ± 5.2 versus 23.0 ± 5.6, P = 0.00 enrollment; 30.2 ± 3.1 versus 31.0 ± 2.8, P < 0.001 delivery). Among newborns, length for age was lowest in young adolescents, greater in older adolescents, and greatest in adults (Z-scores -1.7 ± 1.2, -1.4 ± 1.2, and -1.1 ± 1.1, respectively; P < 0.001). These differences persisted in length for age at 6 and 12 weeks of age for infants. Adolescents enrolled earlier in pregnancy and appeared more nutritionally adequate than adults; adolescent outcomes were inferior to those of adults, suggesting that they were subject to more physiologic stressors and/or different nutritional needs.
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Affiliation(s)
- Alyssa Friebert
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, California
| | | | - Peggy C Papathakis
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, California
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, Missouri
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
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47
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Borresen EC, Zhang L, Trehan I, Nealon NJ, Maleta KM, Manary MJ, Ryan EP. The Nutrient and Metabolite Profile of 3 Complementary Legume Foods with Potential to Improve Gut Health in Rural Malawian Children. Curr Dev Nutr 2017; 1:e001610. [PMID: 29955682 PMCID: PMC5998778 DOI: 10.3945/cdn.117.001610] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 06/30/2017] [Revised: 08/15/2017] [Accepted: 09/19/2017] [Indexed: 01/09/2023] Open
Abstract
Background: Environmental enteric dysfunction (EED), frequently seen in rural Malawian children, causes chronic inflammation and increases the risk of stunting. Legumes may be beneficial for improving nutrition and reducing the risk of developing EED in weaning children. Objective: The objectives of this study were to determine the nutritional value, verify the food safety, and identify metabolite profiles of 3 legume-based complementary foods: common bean (CB), cowpea (CP), and traditional corn-soy blend (CSB). Methods: Foods were prepared by using local ingredients and analyzed for nutrient composition with the use of Association of Official Analytical Chemists (AOAC) standards (950.46, 991.43, 992.15, 996.06, and 991.36) for macro- and micronutrient proximate analysis. Food safety analysis was conducted in accordance with the Environmental Protection Agency (7471B) and AOAC (2008.02) standards. The metabolite composition of foods was determined with nontargeted ultra-performance LC-tandem mass spectrometry metabolomics. Results: All foods provided similar energy; CB and CP foods contained higher protein and dietary fiber contents than did the CSB food. Iron and zinc were highest in the CSB and CP foods, whereas CB and CP foods contained higher amounts of magnesium, phosphorus, and potassium. A total of 652 distinct metabolites were identified across the 3 foods, and 23, 14, and 36 metabolites were specific to the CSB, CB, and CP foods, respectively. Among the potential dietary biomarkers of intake to distinguish legume foods were pipecolic acid and oleanolic acid for CB; arabinose and serotonin for CSB; and quercetin and α- and γ-tocopherol acid for CP. No heavy metals were detected, and aflatoxin was measured only in the CSB (5.2 parts per billion). Conclusions: Legumes in the diet provide a rich source of protein, dietary fiber, essential micronutrients, and phytochemicals that may reduce EED. These food metabolite analyses identified potential dietary biomarkers of legume intake for stool, urine, and blood detection that can be used in future studies to assess the relation between the distinct legumes consumed and health outcomes. This trial was registered at clinicaltrials.gov as NCT02472262 and NCT02472301.
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Affiliation(s)
- Erica C Borresen
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO
| | - Lei Zhang
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO
| | - Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Lao People's Democratic Republic
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Pediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - Nora Jean Nealon
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO
- Program in Cell and Molecular Biology, Colorado State University, Fort Collins, CO
| | - Kenneth M Maleta
- Department of Public Health, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Public Health, University of Malawi, Blantyre, Malawi
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - Elizabeth P Ryan
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO
- Program in Cell and Molecular Biology, Colorado State University, Fort Collins, CO
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48
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Callaghan-Gillespie M, Schaffner AA, Garcia P, Fry J, Eckert R, Malek S, Trehan I, Thakwalakwa C, Maleta KM, Manary MJ, Papathakis PC. Trial of ready-to-use supplemental food and corn-soy blend in pregnant Malawian women with moderate malnutrition: a randomized controlled clinical trial. Am J Clin Nutr 2017; 106:1062-1069. [PMID: 28793991 PMCID: PMC6483045 DOI: 10.3945/ajcn.117.157198] [Citation(s) in RCA: 12] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/14/2017] [Indexed: 01/16/2023] Open
Abstract
Background Malnutrition during pregnancy in sub-Saharan Africa is associated with poor birth outcomes. Objective This study compared maternal and offspring anthropometry for moderately malnourished pregnant women receiving ready-to-use supplemental food (RUSF), a fortified corn-soy blend (CSB+) with a daily multiple micronutrient antenatal supplement [United Nations International Multiple Micronutrient Preparation (UNIMMAP)], or standard of care comprising CSB+ and iron and folic acid (IFA). Design A single-blind randomized controlled clinical trial was conducted in southern Malawi among 1828 pregnant women with moderate malnutrition, defined as a midupper arm circumference (MUAC) ≥20.6 and ≤23.0 cm. Women received 1 of 3 dietary treatment regimens that provided ∼900 kcal/d and 33-36 g protein/d. Maternal and infant anthropometry were followed until the child was 3 mo old. Results Newborns had a mean length-for-age z score of -1.3 ± 1.2 and 22% were stunted at birth. Mothers receiving RUSF had the highest weight gain during supplementation (3.4 ± 2.6, 3.0 ± 2.2, and 3.2 ± 2.4 kg for the RUSF, CSB+ with UNIMMAP, and CSB+ with IFA groups, respectively; P = 0.03). Newborn birth weights and lengths were similar across intervention groups, but the incidence of newborns with a birth weight <2.4 kg (weight-for-age z score <-2) was higher in the CSB+ with UNIMMAP group than the other groups (17%, 18%, and 24% for the CSB+ with IFA, RUSF, and CSB+ with UNIMMAP groups, respectively; P = 0.02). At birth, HIV-exposed newborns had a similar length and weight as newborns without HIV exposure, but their head circumference was smaller (34.0 ± 1.5 and 34.3 ± 1.6 cm, respectively; P = 0.02). At 3 mo of age, HIV-exposed infants had smaller weights, lengths, and head and arm circumferences than infants without HIV exposure. Conclusions RUSF improved maternal weight gain compared with CSB+ with UNIMMAP. The large amount of food given and the modest effect on linear growth in newborns suggests that stunting in utero is unlikely to be reduced by supplemental food alone. This trial was registered at clinicaltrials.gov as NCT02120599.
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Affiliation(s)
| | - Andrew A Schaffner
- Department of Statistics, California Polytechnic State University, San Luis Obispo, CA
| | - Patsy Garcia
- Department of Statistics, California Polytechnic State University, San Luis Obispo, CA
| | - Jocelyn Fry
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
| | - Rachael Eckert
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
| | - Shirin Malek
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
| | - Indi Trehan
- Department of Pediatrics, Washington University, St. Louis, MO
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Chrissie Thakwalakwa
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Peggy C Papathakis
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
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49
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Alpers DH, Young GP, Tran CD, Mortimer EK, Gopalsamy GL, Krebs NF, Manary MJ, Ramakrishna BS, Binder HJ, Brown IL, Miller LV. Drug-development concepts as guides for optimizing clinical trials of supplemental zinc for populations at risk of deficiency or diarrhea. Nutr Rev 2017; 75:147-162. [PMID: 28399577 DOI: 10.1093/nutrit/nuw065] [Citation(s) in RCA: 3] [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: 11/15/2022] Open
Abstract
Studies on the efficacy of zinc supplementation for treatment or prevention of diarrhea have shown an inconsistent effect in populations at risk for zinc deficiency. Unlike drugs, which have no preexisting presence in the body, endogenous zinc must be assessed pharmacokinetically by isotope tracer studies. Although such methods have produced much data, very few studies have estimated the dose and the timing of dosing of zinc supplementation. This review examines drug kinetics used to establish the best dose, the timing of such doses, and the mechanism of action through pharmacodynamic markers and applies them, where possible, to zinc supplements. The findings reveal that little is known, especially in children at highest risk of zinc deficiency. Key data missing to inform proper dosing, whether for treatment of disease or for preventive nutrient supplementation, are noted. Addressing these uncertainties could improve study design, leading to future studies of zinc supplements that might be of greater benefit.
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Affiliation(s)
- David H Alpers
- School of Medicine, Washington University, St Louis, Missouri, USA
| | - Graeme P Young
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Cuong D Tran
- CSIRO Health and Biosecurity, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Health Sciences, The University of Adelaide, South Australia, Australia
| | - Elissa K Mortimer
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Geetha L Gopalsamy
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia.,CSIRO Health and Biosecurity, Adelaide, South Australia, Australia
| | - Nancy F Krebs
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Mark J Manary
- School of Medicine, Washington University, St Louis, Missouri, USA
| | | | - Henry J Binder
- School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Ian L Brown
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Leland V Miller
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
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50
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Stobaugh HC, Bollinger LB, Adams SE, Crocker AH, Grise JB, Kennedy JA, Thakwalakwa C, Maleta KM, Dietzen DJ, Manary MJ, Trehan I. Effect of a package of health and nutrition services on sustained recovery in children after moderate acute malnutrition and factors related to sustaining recovery: a cluster-randomized trial. Am J Clin Nutr 2017; 106:657-666. [PMID: 28615258 PMCID: PMC6482975 DOI: 10.3945/ajcn.116.149799] [Citation(s) in RCA: 19] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/15/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Children who recover from moderate acute malnutrition (MAM) have high rates of relapse in the year after nutritional recovery. Interventions to decrease these adverse outcomes are needed to maximize the overall effectiveness of supplemental feeding programs (SFPs).Objective: We evaluated the effectiveness of a package of health and nutrition interventions on improving the proportion of children who sustained recovery for 1 y after MAM treatment. We further explored factors related to sustained recovery.Design: We conducted a cluster-randomized clinical effectiveness trial involving rural Malawian children aged 6-62 mo who were enrolled on discharge from an SFP for MAM. We enrolled 718 children at 10 control sites and 769 children at 11 intervention sites. In addition to routine health and nutrition counseling, the intervention group received a package of health and nutrition interventions that consisted of a lipid nutrient supplement, deworming medication, zinc supplementation, a bed net, and malaria chemoprophylaxis. A survival analysis was used to determine the effectiveness of the intervention as well as to identify factors associated with sustained recovery.Results: Of 1383 children who returned for the full 12-mo follow-up period, 407 children (56%) and 347 children (53%) sustained recovery in the intervention and control groups, respectively. There was no significant difference in relapse-free survival curves between the treatment and control groups (P = 0.380; log-rank test). The risk factors for relapse or death after initial recovery were a smaller midupper arm circumference on SFP admission (P = 0.01) and discharge (P < 0.001), a lower weight-for-height z score on discharge (P < 0.01), and the receipt of ready-to-use supplementary food as opposed to ready-to-use therapeutic food during treatment (P < 0.05).Conclusion: The provision of a package of health and nutrition services in addition to traditional SFP treatment has no significant effect on improving sustained recovery in children after treatment of MAM. This trial was registered at clinicaltrials.gov as NCT02351687.
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Affiliation(s)
- Heather C Stobaugh
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA,Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Lucy B Bollinger
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Sara E Adams
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Audrey H Crocker
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Jennifer B Grise
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Julie A Kennedy
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | | | | | - Dennis J Dietzen
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO,School of Public Health and Family Medicine,Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO; .,Department of Pediatrics and Child Health, University of Malawi, Blantyre, Malawi.,Partners In Health, Harper, Liberia
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