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Stoffel NU, Drakesmith H. Effects of iron status on adaptive immunity and vaccine efficacy: a review. Adv Nutr 2024:100238. [PMID: 38729263 DOI: 10.1016/j.advnut.2024.100238] [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: 01/24/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024] Open
Abstract
Vaccines can prevent infectious diseases, but their efficacy varies, and factors impacting vaccine effectiveness remain unclear. Iron deficiency is the most common nutrient deficiency, affecting over 2 billion individuals. It is particularly common in areas with high infectious disease burden and in groups that are routinely vaccinated, such as infants, pregnant women, and the elderly. Recent evidence suggests that iron deficiency and low serum iron (hypoferremia) not only cause anemia, but also may impair adaptive immunity and vaccine efficacy. A report of human immunodeficiency caused by defective iron transport underscored the necessity of iron for adaptive immune responses and spurred research in this area. Sufficient iron is essential for optimal production of plasmablasts and IgG responses by human B cells in vitro and in vivo. The increased metabolism of activated lymphocytes depends on high iron acquisition, and hypoferremia, especially when occurring during lymphocyte expansion, adversely affects multiple facets of adaptive immunity, and may lead to prolonged inhibition of T cell memory. In mice, hypoferremia suppresses adaptive immune response to influenza infection, resulting in more severe pulmonary disease. In African infants, anemia and/or iron deficiency at time of vaccination predict decreased response to diphtheria, pertussis and pneumococcal vaccines, and response to measles vaccine may be increased by iron supplementation. In this review, we examine the emerging evidence that iron deficiency may limit adaptive immunity and vaccine responses. We discuss the molecular mechanisms and evidence from animal and human studies, highlight important unknowns, and propose a framework of key research questions to better understand iron-vaccine interactions.
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Affiliation(s)
- Nicole U Stoffel
- Medical Research Council Translational Immune Discovery Unit, Medical Research Council Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
| | - Hal Drakesmith
- Medical Research Council Translational Immune Discovery Unit, Medical Research Council Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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Giorgetti A, Nyilima S, Stoffel NU, Moretti D, Mwasi E, Karanja S, Zeder C, Speich C, Netland C, Jin Z, Zimmermann MB, Brittenham GM. Stable iron ( 58Fe) isotopic measurements in Kenyan toddlers during 3 months of iron supplementation demonstrate that half of the iron absorbed is lost. Br J Haematol 2024; 204:2057-2065. [PMID: 38302093 DOI: 10.1111/bjh.19319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/28/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
Increased iron loss may reduce the effectiveness of iron supplementation. The objective of this study was to determine if daily oral iron supplementation increases iron loss, measured using a stable isotope of iron (58Fe). We enrolled and dewormed 24 iron-depleted Kenyan children, 24-27 months of age, whose body iron was enriched and equilibrated with 58Fe given at least 1 year earlier. Over 3 months of supplementation (6 mg iron/kg body weight [BW]/day), mean (±SD) iron absorption was 1.10 (±0.28) mg/day. During supplementation, 0.55 (±0.36) mg iron/day was lost, equal to half of the amount of absorbed iron. Supplementation did not increase faecal haem/porphyrin or biomarkers of enterocyte damage and gut or systemic inflammation. Using individual patient data, we examined iron dose, absorption and loss among all available long-term iron isotopic studies of supplementation. Expressed in terms of body weight, daily iron loss was correlated significantly with iron absorption (Pearson's r = 0.66 [95% confidence interval 0.48-0.78]) but not with iron dose (r = 0.16 [95% CI -0.10-0.40]). The results of this study indicate that iron loss is increased with daily oral iron supplementation and may blunt the efficacy of iron supplements in children. This study was registered at ClinicalTrials.gov as NCT04721964.
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Affiliation(s)
- Ambra Giorgetti
- Laboratory of Human Nutrition, ETH, Zurich, Switzerland
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Suzane Nyilima
- Public and Community Health Department, Jomo Kenyatta University, Nairobi, Kenya
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, ETH, Zurich, Switzerland
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Diego Moretti
- Nutrition Group, Swiss Distance University of Applied Sciences, Regensdorf, Switzerland
| | - Edith Mwasi
- Paediatric Department, Msambweni District Hospital, Msambweni, Kwale County, Kenya
| | - Simon Karanja
- Public and Community Health Department, Jomo Kenyatta University, Nairobi, Kenya
| | | | | | | | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, ETH, Zurich, Switzerland
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Gary M Brittenham
- Department of Paediatrics, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Mikulic N, Uyoga MA, Stoffel NU, Derrien M, Nyilima S, Kostopoulos I, Roeselers G, Chenoll E, Mwasi E, Pironaci G, Karanja S, Bourdet-Sicard R, Zimmermann MB. Prebiotics increase iron absorption and reduce the adverse effects of iron on the gut microbiome and inflammation: a randomized controlled trial using iron stable isotopes in Kenyan infants. Am J Clin Nutr 2024; 119:456-469. [PMID: 38042412 PMCID: PMC10884607 DOI: 10.1016/j.ajcnut.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 11/18/2023] [Accepted: 11/27/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Iron fortificants tend to be poorly absorbed and may adversely affect the gut, especially in African children. OBJECTIVE We assessed the effects of prebiotic galacto-oligosaccharides/fructo-oligosaccharides (GOS/FOS) on iron absorption and gut health when added to iron-fortified infant cereal. METHODS We randomly assigned Kenyan infants (n = 191) to receive daily for 3 wk a cereal containing iron and 7.5 g GOS/FOS (7.5 g+iron group), 3 g (3-g+iron group) GOS/FOS, or no prebiotics (iron group). A subset of infants in the 2 prebiotic+iron groups (n = 66) consumed 4 stable iron isotope-labeled test meals without and with prebiotics, both before and after the intervention. Primary outcome was fractional iron absorption (FIA) from the cereal with or without prebiotics regardless of dose, before and after 3 wk of consumption. Secondary outcomes included fecal gut microbiota, iron and inflammation status, and effects of prebiotic dose. RESULTS Median (25th-75th percentiles) FIAs from meals before intervention were as follows: 16.3% (8.0%-27.6%) without prebiotics compared with 20.5% (10.4%-33.4%) with prebiotics (Cohen d = 0.53; P < 0.001). FIA from the meal consumed without prebiotics after intervention was 22.9% (8.5%-32.4%), 41% higher than from the meal without prebiotics before intervention (Cohen d = 0.36; P = 0.002). FIA from the meal consumed with prebiotics after intervention was 26.0% (12.2%-36.1%), 60% higher than from the meal without prebiotics before intervention (Cohen d = 0.45; P = 0.007). After 3 wk, compared with the iron group, the following results were observed: 1) Lactobacillus sp. abundances were higher in both prebiotic+iron groups (P < 0.05); 2) Enterobacteriaceae sp. abundances (P = 0.022) and the sum of pathogens (P < 0.001) were lower in the 7.5-g+iron group; 3) the abundance of bacterial toxin-encoding genes was lower in the 3-g+iron group (false discovery rate < 0.05); 4) fecal pH (P < 0.001) and calprotectin (P = 0.033) were lower in the 7.5-g+iron group. CONCLUSIONS Adding prebiotics to iron-fortified infant cereal increases iron absorption and reduces the adverse effects of iron on the gut microbiome and inflammation in Kenyan infants. This trial was registered at clinicaltrials.gov as NCT03894358.
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Affiliation(s)
- Nadja Mikulic
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Mary A Uyoga
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | | | - Suzane Nyilima
- Public and Community Health Department, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | | | | | - Edith Mwasi
- Paediatrics Department, Msambweni County Referral Hospital, Msambweni, Kenya
| | - Giulia Pironaci
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Simon Karanja
- Public and Community Health Department, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Michael B Zimmermann
- Medical Research Council Translational Immune Discovery Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Headington, Oxford, United Kingdom.
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Berger MM, Amrein K, Barazzoni R, Bindels L, Bretón I, Calder PC, Cappa S, Cuerda C, D'Amelio P, de Man A, Delzenne NM, Forbes A, Genton L, Gombart AF, Joly F, Laviano A, Matthys C, Phyo PP, Ravasco P, Serlie MJ, Shenkin A, Stoffel NU, Talwar D, van Zanten ARH. The science of micronutrients in clinical practice - Report on the ESPEN symposium. Clin Nutr 2024; 43:268-283. [PMID: 38104489 DOI: 10.1016/j.clnu.2023.12.006] [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: 11/05/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND & AIMS The European Society for Clinical Nutrition and Metabolism published its first clinical guidelines for use of micronutrients (MNs) in 2022. A two-day web symposium was organized in November 2022 discussing how to apply the guidelines in clinical practice. The present paper reports the main findings of this symposium. METHODS Current evidence was discussed, the first day being devoted to clarifying the biology underlying the guidelines, especially regarding the definition of deficiency, the impact of inflammation, and the roles in antioxidant defences and immunity. The second day focused on clinical situations with high prevalence of MN depletion and deficiency. RESULTS The importance of the determination of MN status in patients at risk and diagnosis of deficiencies is still insufficiently perceived, considering the essential role of MNs in immune and antioxidant defences. Epidemiological data show that deficiencies of several MNs (iron, iodine, vitamin D) are a global problem that affects human health and well-being including immune responses such as to vaccination. Clinical conditions frequently associated with MN deficiencies were discussed including cancer, obesity with impact of bariatric surgery, diseases of the gastrointestinal tract, critical illness, and aging. In all these conditions, MN deficiency is associated with worsening of outcomes. The recurrent problem of shortage of MN products, but also lack of individual MN-products is a worldwide problem. CONCLUSION Despite important progress in epidemiology and clinical nutrition, numerous gaps in practice persist. MN depletion and deficiency are frequently insufficiently searched for in clinical conditions, leading to inadequate treatment. The symposium concluded that more research and continued education are required to improve patient outcome.
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Affiliation(s)
- Mette M Berger
- Lausanne University, Faculty of Biology & Medicine, 1005 Lausanne, Switzerland.
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Laure Bindels
- Faculty of Pharmacy and Biomedical Sciences, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Irene Bretón
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Philip C Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK.
| | - Stefano Cappa
- IUSS Cognitive Neuroscience (ICoN) Center, University School for Advanced Studies (IUSS-Pavia), 27100 Pavia, Italy.
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Patrizia D'Amelio
- Service de gériatrie et réadaptation gériatrique, Département de Médecine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Angélique de Man
- Department of Intensive Care Medicine, Research VUMC Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands.
| | - Nathalie M Delzenne
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Laurence Genton
- Clinical Nutrition Unit, Department of Endocrinology, Geneva University Hospitals, Geneva, Switzerland.
| | - Adrian F Gombart
- Linus Pauling Institute, Department of Biochemistry and Biophysics, Oregon State University, Corvallis, OR 97331, USA.
| | - Francisca Joly
- Beaujon Hospital, APHP, Clichy, University of Paris VII, France.
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, University La Sapienza, Rome, Italy.
| | | | - Pyi Pyi Phyo
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe, Copenhagen, Denmark.
| | - Paula Ravasco
- Coordinator of the Curricular Units Diabetes, Obesity and Lifestyle, Digestion and Defence, University of Lisbon - Católica Medical School, Lisbon, Portugal.
| | - Mireille J Serlie
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Alan Shenkin
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
| | - Dinesh Talwar
- Department of Biochemistry, Glasgow Royal Infirmary, Glasgow, UK.
| | - Arthur R H van Zanten
- Gelderse Vallei Hospital, Ede and Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, the Netherlands.
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von Siebenthal HK, Gessler S, Vallelian F, Steinwendner J, Kuenzi UM, Moretti D, Zimmermann MB, Stoffel NU. Alternate day versus consecutive day oral iron supplementation in iron-depleted women: a randomized double-blind placebo-controlled study. EClinicalMedicine 2023; 65:102286. [PMID: 38021373 PMCID: PMC10659995 DOI: 10.1016/j.eclinm.2023.102286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Background Guidelines to treat iron deficiency recommend daily provision of oral iron, but this may decrease fractional iron absorption and increase side effects. Our objective was to compare consecutive-day versus alternate-day iron supplementation. Methods In a double-masked, randomized, placebo-controlled trial, young Swiss women (n = 150; serum ferritin ≤30 μg/L) were assigned to: daily 100 mg iron for 90 d, followed by daily placebo for another 90 d (consecutive-day group) or the same daily dose of iron and placebo on alternate days for 180 d (alternate-day group). The study period was 24/11/2021-10/8/2022. Co-primary outcomes, at equal total iron doses, were serum ferritin and gastrointestinal side effects; secondary outcomes were iron deficiency and serum hepcidin. Compliance and side effects were recorded daily using a mobile application. Data were analysed using mixed models and longitudinal prevalence ratios (LPR). The trial was registered at ClinicalTrials.gov (NCT05105438). Findings 75 women were assigned to each group and included in the intention-to-treat analysis. Capsule adherence and side effect reporting was >97% in both groups. At equal total iron doses, comparing consecutive-day and alternate-day groups, median serum ferritin was 43.8 μg/L (31.7-58.2) versus 44.8 μg/L (33.8-53.6) (P = 0.98), the LPR for gastrointestinal side effects on days of iron intake was 1.56 (95% CI: 1.38, 1.77; P < 0.0001), and median serum hepcidin was 3.0 nM (IQR 2.0-5.0) versus 1.9 nM (1.4-2.9) (P < 0.0001). Iron deficiency prevalence after 3 months was 5.5% versus 4.3% (P = 0.74) and after 6 months was 11.4% and 3.0% (P = 0.049). Interpretation At equal total iron doses, compared to consecutive day dosing of iron, alternate day dosing did not result in higher serum ferritin but reduced iron deficiency at 6 months and triggered fewer gastrointestinal side effects. Funding Swiss National Science Foundation, Bern, Switzerland.
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Affiliation(s)
- Hanna K. von Siebenthal
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Sara Gessler
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Joachim Steinwendner
- Laboratory of Web Science, Swiss Distance University of Applied Sciences, Zürich, Switzerland
| | - Urs-Martin Kuenzi
- Laboratory of Web Science, Swiss Distance University of Applied Sciences, Zürich, Switzerland
| | - Diego Moretti
- Nutrition Research, Department of Health, Swiss Distance University of Applied Sciences, Zürich, Switzerland
| | - Michael B. Zimmermann
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
- Medical Research Council Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nicole U. Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
- Medical Research Council Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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von Siebenthal HK, Moretti D, Zimmermann MB, Stoffel NU. Effect of dietary factors and time of day on iron absorption from oral iron supplements in iron deficient women. Am J Hematol 2023; 98:1356-1363. [PMID: 37357807 DOI: 10.1002/ajh.26987] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/02/2023] [Accepted: 05/23/2023] [Indexed: 06/27/2023]
Abstract
Guidelines generally recommend taking iron supplements in the morning away from meals and with ascorbic acid (AA) to increase iron absorption. However, there is little direct evidence on the effects of dietary factors and time of day on absorption from iron supplements. In iron-depleted women (n = 34; median serum ferritin 19.4 μg/L), we administered 100 mg iron doses labeled with 54 Fe, 57 Fe, or 58 Fe in each of six different conditions with: (1) water (reference) in the morning; (2) 80 mg AA; (3) 500 mg AA; (4) coffee; (5) breakfast including coffee and orange juice (containing ~90 mg AA); and (6) water in the afternoon. Fractional iron absorption (FIA) from these n = 204 doses was calculated based on erythrocyte incorporation of multiple isotopic labels. Compared to the reference: 80 mg AA increased FIA by 30% (p < .001) but 500 mg AA did not further increase FIA (p = .226); coffee decreased FIA by 54% (p = .004); coffee with breakfast decreased FIA by 66% (p < .001) despite the presence of ~90 mg of AA. Serum hepcidin was higher (p < .001) and FIA was 37% lower (p = .059) in the afternoon compared to the morning. Our data suggest that to maximize efficacy, ferrous iron supplements should be consumed in the morning, away from meals or coffee, and with an AA-rich food or beverage. Compared to consuming a 100 mg iron dose in the morning with coffee or breakfast, consuming it with orange juice alone results in a ~ 4-fold increase in iron absorption, and provides ~20 more mg of absorbed iron per dose. The trial was registered at Clinicaltrials.gov(NCT04074707).
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Affiliation(s)
- Hanna K von Siebenthal
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland
| | - Diego Moretti
- Department of Health, Swiss Distance University of Applied Sciences, Zürich, Switzerland
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Rachmühl C, Lacroix C, Giorgetti A, Stoffel NU, Zimmermann MB, Brittenham GM, Geirnaert A. Validation of a batch cultivation protocol for fecal microbiota of Kenyan infants. BMC Microbiol 2023; 23:174. [PMID: 37403024 DOI: 10.1186/s12866-023-02915-9] [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: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND The combination of cultivation studies with molecular analysis approaches allows characterization of the complex human gut microbiota in depth. In vitro cultivation studies of infants living in rural sub-Saharan Africa are scarce. In this study, a batch cultivation protocol for Kenyan infant fecal microbiota was validated. METHODS Fresh fecal samples were collected from 10 infants living in a rural area of Kenya. Samples were transported under protective conditions and subsequently prepared for inoculation within less than 30 h for batch cultivation. A diet-adapted cultivation medium was used that mimicked the daily intake of human milk and maize porridge in Kenyan infants during weaning. 16 S rRNA gene amplicon sequencing and HPLC analyses were performed to assess the composition and metabolic activity, respectively, of the fecal microbiota after 24 h of batch cultivation. RESULTS High abundance of Bifidobacterium (53.4 ± 11.1%) and high proportions of acetate (56 ± 11% of total metabolites) and lactate (24 ± 22% of total metabolites) were detected in the Kenyan infant fecal microbiota. After cultivation started at an initial pH 7.6, the fraction of top bacterial genera (≥ 1% abundant) shared between fermentation and fecal samples was high at 97 ± 5%. However, Escherichia-Shigella, Clostridium sensu stricto 1, Bacteroides and Enterococcus were enriched concomitant with decreased Bifidobacterium abundance. Decreasing the initial pH to 6.9 lead to higher abundance of Bifidobacterium after incubation and increased the compositional similarity of fermentation and fecal samples. Despite similar total metabolite production of all fecal microbiota after cultivation, inter-individual differences in metabolite profiles were apparent. CONCLUSIONS Protected transport and batch cultivation in host and diet adapted conditions allowed regrowth of the top abundant genera and reproduction of the metabolic activity of fresh Kenyan infant fecal microbiota. The validated batch cultivation protocol can be used to study the composition and functional potential of Kenyan infant fecal microbiota in vitro.
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Affiliation(s)
- Carole Rachmühl
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Christophe Lacroix
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland.
| | - Ambra Giorgetti
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, USA
| | - Annelies Geirnaert
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland.
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von Siebenthal HK, Galetti V, Zimmermann MB, Stoffel NU. Regulation of iron absorption in infants. Am J Clin Nutr 2023; 117:607-615. [PMID: 36811475 DOI: 10.1016/j.ajcnut.2022.10.003] [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: 07/01/2022] [Revised: 10/14/2022] [Accepted: 10/28/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Iron programs in low- and middle-income countries often target infants and young children. Limited data from human infants and mouse models suggest that homeostatic control of iron absorption is incomplete in early infancy. Excess iron absorption during infancy may have detrimental effects. OBJECTIVES Our aims were to 1) investigate determinants of iron absorption in infants aged 3-15 mo and assess whether regulation of iron absorption is fully mature during this period and 2) define the threshold ferritin and hepcidin concentrations in infancy that trigger upregulation of iron absorption. METHODS We performed a pooled analysis of standardized, stable iron isotope absorption studies performed by our laboratory in infants and toddlers. We used generalized additive mixed modeling (GAMM) to examine relationships between ferritin, hepcidin, and fractional iron absorption (FIA). RESULTS Kenyan and Thai infants aged 2.9-15.1 mo (n = 269) were included; 66.8% were iron deficient and 50.4% were anemic. In regression models, hepcidin, ferritin, and serum transferrin receptor were significant predictors of FIA, whereas C-reactive protein was not. In the model including hepcidin, hepcidin was the strongest predictor of FIA (β = -0.435). In all models, interaction terms, including age, were not significant predictors of FIA or hepcidin. The fitted GAMM trend of ferritin versus FIA showed a significant negative slope until ferritin of 46.3 μg/L (95% CI: 42.1, 50.5 μg/L), which corresponded to an FIA decrease from 26.5% to 8.3%; above this ferritin value, FIA remained stable. The fitted GAMM trend of hepcidin versus FIA showed a significant negative slope until hepcidin of 3.15 nmol/L (95% CI: 2.67, 3.63 nmol/L), above which FIA remained stable. CONCLUSIONS Our findings suggest that the regulatory pathways of iron absorption are intact in infancy. In infants, iron absorption begins to increase at threshold ferritin and hepcidin values of ∼46 μg/L and ∼3 nmol/L, respectively, similar to adult values.
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Affiliation(s)
- Hanna K von Siebenthal
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Switzerland.
| | - Valeria Galetti
- VMMT Research, Cagiallo, Switzerland; GroundWork, Fläsch, Switzerland
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
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Derrien M, Mikulic N, Uyoga MA, Chenoll E, Climent E, Howard-Varona A, Nyilima S, Stoffel NU, Karanja S, Kottler R, Stahl B, Zimmermann MB, Bourdet-Sicard R. Gut microbiome function and composition in infants from rural Kenya and association with human milk oligosaccharides. Gut Microbes 2023; 15:2178793. [PMID: 36794816 PMCID: PMC9980514 DOI: 10.1080/19490976.2023.2178793] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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] [Indexed: 02/17/2023] Open
Abstract
The gut microbiota evolves rapidly after birth, responding dynamically to environmental factors and playing a key role in short- and long-term health. Lifestyle and rurality have been shown to contribute to differences in the gut microbiome, including Bifidobacterium levels, between infants. We studied the composition, function and variability of the gut microbiomes of 6- to 11-month-old Kenyan infants (n = 105). Shotgun metagenomics showed Bifidobacterium longum to be the dominant species. A pangenomic analysis of B. longum in gut metagenomes revealed a high prevalence of B. longum subsp. infantis (B. infantis) in Kenyan infants (80%), and possible co-existence of this subspecies with B. longum subsp. longum. Stratification of the gut microbiome into community (GMC) types revealed differences in composition and functional features. GMC types with a higher prevalence of B. infantis and abundance of B. breve also had a lower pH and a lower abundance of genes encoding pathogenic features. An analysis of human milk oligosaccharides (HMOs) classified the human milk (HM) samples into four groups defined on the basis of secretor and Lewis polymorphisms revealed a higher prevalence of HM group III (Se+, Le-) (22%) than in most previously studied populations, with an enrichment in 2'-fucosyllactose. Our results show that the gut microbiome of partially breastfed Kenyan infants over the age of six months is enriched in bacteria from the Bifidobacterium community, including B. infantis, and that the high prevalence of a specific HM group may indicate a specific HMO-gut microbiome association. This study sheds light on gut microbiome variation in an understudied population with limited exposure to modern microbiome-altering factors.
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Affiliation(s)
- Muriel Derrien
- Advanced Health & Science, Danone Nutricia Research, Palaiseau, France,CONTACT Muriel Derrien Advanced Health & Science, Danone Nutricia Research, Palaiseau, France
| | - Nadja Mikulic
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Mary A Uyoga
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Empar Chenoll
- ADM-Biopolis, ADM, Parc Cientific Universitat de Valencia, Paterna, Valencia, Spain
| | - Eric Climent
- ADM-Biopolis, ADM, Parc Cientific Universitat de Valencia, Paterna, Valencia, Spain
| | - Adrian Howard-Varona
- ADM-Biopolis, ADM, Parc Cientific Universitat de Valencia, Paterna, Valencia, Spain
| | - Suzane Nyilima
- Public and Community Health Department, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Simon Karanja
- Public and Community Health Department, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Bernd Stahl
- Advanced Health & Science, Danone Nutricia Research, Utrecht, The Netherlands,Department of Chemical Biology & Drug Discovery, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Raphaëlle Bourdet-Sicard
- Advanced Health & Science, Danone Nutricia Research, Palaiseau, France,Raphaëlle Bourdet-Sicard Advanced Health & Science, Danone Nutricia Research, Palaiseau, France
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10
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Uyoga MA, Mzembe G, Stoffel NU, Moretti D, Zeder C, Phiri K, Sabatier M, Hays NP, Zimmermann MB, Mwangi MN. Iron Bioavailability from Infant Cereals Containing Whole Grains and Pulses: A Stable Isotope Study in Malawian Children. J Nutr 2021; 152:826-834. [PMID: 34958374 PMCID: PMC8891185 DOI: 10.1093/jn/nxab406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/29/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Compared with infant cereals based on refined grains, an infant cereal containing whole grains (WGs) and pulses with adequate amounts of ascorbic acid to protect against absorption inhibitors could be a healthier source of well-absorbed iron. However, iron absorption from such cereals is uncertain. OBJECTIVE We measured iron bioavailability from ferrous fumarate (Fefum) added to commercial infant cereals containing 1) refined wheat flour (reference meal), 2) WG wheat and lentil flour (WG-wheat-lentil), 3) WG wheat and chickpea flour (WG-wheat-chickpeas), and 4) WG oat flour (WG-oat) and from ferrous bisglycinate (FeBG) added to the same oat-based cereal (WG-oat-FeBG). METHODS In a prospective, single-blinded randomized crossover study, 6- to 14-mo-old Malawian children (n = 30) consumed 25-g servings of all 5 test meals containing 2.25 mg stable isotope-labeled iron and 13.5 mg ascorbic acid. Fractional iron absorption (FIA) was assessed by erythrocyte incorporation of isotopes after 14 d. Comparisons were made using linear mixed models. RESULTS Seventy percent of the children were anemic and 67% were iron deficient. Geometric mean FIA percentages (-SD, +SD) from the cereals were as follows: 1) refined wheat, 12.1 (4.8, 30.6); 2) WG-wheat-lentil, 15.8 (6.6, 37.6); 3) WG-wheat-chickpeas, 12.8 (5.5, 29.8); and 4) WG-oat, 9.2 (3.9, 21.5) and 7.4 (2.9, 18.9) from WG-oat-FeBG. Meal predicted FIA (P ≤ 0.001), whereas in pairwise comparisons, only WG-oat-FeBG was significantly different compared with the refined wheat meal (P = 0.02). In addition, FIAs from WG-wheat-lentil and WG-wheat-chickpeas were significantly higher than from WG-oat (P = 0.002 and P = 0.04, respectively) and WG-oat-FeBG (P < 0.001 and P = 0.004, respectively). CONCLUSION In Malawian children, when given with ascorbic acid at a molar ratio of 2:1, iron bioavailability from Fefum-fortified infant cereals containing WG wheat and pulses is ≈13-15%, whereas that from FeBG- and Fefum-fortified infant cereals based on WG oats is ≈7-9%.
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Affiliation(s)
| | - Glory Mzembe
- Training and Research Unit of Excellence (TRUE), Blantyre, Malawi,School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Diego Moretti
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland,Swiss Distance University of Applied Sciences, Zurich, Switzerland
| | - Christophe Zeder
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Kamija Phiri
- Training and Research Unit of Excellence (TRUE), Blantyre, Malawi,School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Magalie Sabatier
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., Vers-Chez-Les-Blanc, Lausanne, Switzerland
| | - Nicholas P Hays
- Nestlé Product Technology Center—Nutrition, Société des Produits Nestlé S.A., Vevey, Switzerland
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Martin N Mwangi
- Training and Research Unit of Excellence (TRUE), Blantyre, Malawi,School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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11
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Stoffel NU, Zimmermann MB, Cepeda-Lopez AC, Cervantes-Gracia K, Llanas-Cornejo D, Zeder C, Tuntipopipat S, Moungmaithong S, Densupsoontorn N, Quack Loetscher K, Gowachirapant S, Herter-Aeberli I. Maternal iron kinetics and maternal-fetal iron transfer in normal-weight and overweight pregnancy. Am J Clin Nutr 2021; 115:1166-1179. [PMID: 34910118 PMCID: PMC8970997 DOI: 10.1093/ajcn/nqab406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/07/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Inflammation during pregnancy may aggravate iron deficiency (ID) by increasing serum hepcidin and reducing iron absorption. This could restrict iron transfer to the fetus, increasing risk of infant ID and its adverse effects. OBJECTIVES We aimed to assess whether iron bioavailability and/or iron transfer to the fetus is impaired in overweight/obese (OW) pregnant women with adiposity-related inflammation, compared with normal-weight (NW) pregnant women. METHODS In this prospective study, we followed NW (n = 43) and OW (n = 40) pregnant women who were receiving iron supplements from the 14th week of gestation to term and followed their infants to age 6 mo. We administered 57Fe and 58Fe in test meals mid-second and mid-third trimester, and measured tracer kinetics throughout pregnancy and infancy. RESULTS In total, 38 NW and 36 OW women completed the study to pregnancy week 36, whereas 30 NW and 27 OW mother-infant pairs completed the study to 6 mo postpartum. Both groups had comparable iron status, hemoglobin, and serum hepcidin throughout pregnancy. Compared with the NW, the OW pregnant women had 1) 43% lower fractional iron absorption (FIA) in the third trimester (P = 0.033) with median [IQR] FIA of 23.9% [11.4%-35.7%] and 13.5% [10.8%-19.5%], respectively; and 2) 17% lower maternal-fetal iron transfer from the first tracer (P = 0.051) with median [IQR] maternal-fetal iron transfer of 4.8% [4.2%-5.4%] and 4.0% [3.6%-4.6%], respectively. Compared with the infants born to NW women, infants born to OW women had lower body iron stores (BIS) with median [IQR] 7.7 [6.3-8.8] and 6.6 [4.6-9.2] mg/kg body weight at age 6 mo, respectively (P = 0.024). Prepregnancy BMI was a negative predictor of maternal-fetal iron transfer (β = -0.339, SE = 0.144, P = 0.025) and infant BIS (β = -0.237, SE = 0.026, P = 0.001). CONCLUSIONS Compared with NW, OW pregnant women failed to upregulate iron absorption in late pregnancy, transferred less iron to their fetus, and their infants had lower BIS. These impairments were associated with inflammation independently of serum hepcidin.This trial was registered at clinicaltrials.gov as NCT02747316.
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Affiliation(s)
- Nicole U Stoffel
- Laboratory of Human Nutrition, Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland,Medical Research Council Human Immunology Unit, Medical Research Council Weatherall Institute of Molecular Medicine, University of Oxford and John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Karla Cervantes-Gracia
- Department of Basic Sciences, School of Medicine, Universidad de Monterrey, Monterrey, Mexico
| | - Daniel Llanas-Cornejo
- Department of Basic Sciences, School of Medicine, Universidad de Monterrey, Monterrey, Mexico
| | - Christophe Zeder
- Laboratory of Human Nutrition, Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland
| | | | | | | | | | | | - Isabelle Herter-Aeberli
- Laboratory of Human Nutrition, Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland
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12
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Lazrak M, El Kari K, Stoffel NU, Elammari L, Al-Jawaldeh A, Loechl CU, Yahyane A, Barkat A, Zimmermann MB, Aguenaou H. Tea Consumption Reduces Iron Bioavailability from NaFeEDTA in Nonanemic Women and Women with Iron Deficiency Anemia: Stable Iron Isotope Studies in Morocco. J Nutr 2021; 151:2714-2720. [PMID: 34038558 DOI: 10.1093/jn/nxab159] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/06/2021] [Accepted: 04/29/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Available data suggest that polyphenols from tea can inhibit iron absorption from ferric sodium EDTA (NaFeEDTA), but previous studies were done in small groups of mostly nonanemic adults. Morocco recently introduced national wheat flour fortification with NaFeEDTA, but tea is the national beverage and is consumed with most meals. OBJECTIVES Our objective was to quantify bioavailability of iron from NaFeEDTA when added to a wheat flour-based meal in both nonanemic women and women with iron deficiency anemia (IDA), when consumed with and without traditional Moroccan green tea. METHODS We recruited 2 groups of healthy Moroccan women (n = 46): women with IDA (n = 25; hemoglobin <12 g/dL, serum ferritin <15 μg/L) and nonanemic women (n = 21). Each group received in random order 2 standardized test meals containing 6 mg Fe as isotopically labeled NaFeEDTA and either 300 mL of tea or water. Fractional iron absorption (FIA) was measured by the erythrocyte incorporation of stable iron isotopes after 14 d. We performed linear mixed-model analysis and post hoc sample t tests to assess the effects of group and tea on FIA. RESULTS The polyphenol content of the tea serving was 492 mg. Tea consumption reduced iron absorption from NaFeEDTA by >85% in both IDA and nonanemic women. There were group (P < 0.001) and tea (P < 0.001) effects on FIA, but no group by tea interaction (P = 0.312). Median (IQR) FIA (%) in women with IDA from test meals consumed without and with tea was 36.7 (24.2-39.8) and 4.1 (2.8-6.1), respectively (P < 0.001). Median (IQR) FIA (%) in nonanemic women from test meals consumed without and with tea was 16.7 (9.2-24.2) and 1.4 (0.8-2.9), respectively (P < 0.001). CONCLUSIONS FIA from wheat flour-based meals without and with tea was ∼2-fold higher in women with IDA than in nonanemic women. Providing fortificant iron as NaFeEDTA cannot overcome the inhibition of tea polyphenols on iron absorption, even in IDA, where iron absorption is strongly upregulated. This trial was registered at www.clinicaltrials.gov as NCT02175888.
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Affiliation(s)
- Meryem Lazrak
- Ibn Tofail University- National Center for Energy, Nuclear Sciences and Techniques,Joint Research Unit in Nutrition and Food, RDC-Nutrition "Regional Designated Center of Nutrition Associated to AFRA/IAEA", Rabat-Kénitra, Morocco
| | - Khalid El Kari
- Ibn Tofail University- National Center for Energy, Nuclear Sciences and Techniques,Joint Research Unit in Nutrition and Food, RDC-Nutrition "Regional Designated Center of Nutrition Associated to AFRA/IAEA", Rabat-Kénitra, Morocco
| | - Nicole U Stoffel
- ETH Zürich, Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, Department of Health Sciences and Technology, Zurich, Switzerland
| | | | | | - Cornelia U Loechl
- International Atomic Energy Agency, Division of Human Health, Vienna International Center, Vienna, Austria
| | | | - Amina Barkat
- Unit of Research on Nutrition and Health of Mother and Nutrition, Faculty of Medicine and Pharmacy, Mohamed V University, Rabat, Morocco
| | - Michael B Zimmermann
- ETH Zürich, Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, Department of Health Sciences and Technology, Zurich, Switzerland
| | - Hassan Aguenaou
- Ibn Tofail University- National Center for Energy, Nuclear Sciences and Techniques,Joint Research Unit in Nutrition and Food, RDC-Nutrition "Regional Designated Center of Nutrition Associated to AFRA/IAEA", Rabat-Kénitra, Morocco
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13
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Galetti V, Stoffel NU, Sieber C, Zeder C, Moretti D, Zimmermann MB. Threshold ferritin and hepcidin concentrations indicating early iron deficiency in young women based on upregulation of iron absorption. EClinicalMedicine 2021; 39:101052. [PMID: 34401687 PMCID: PMC8350021 DOI: 10.1016/j.eclinm.2021.101052] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Plasma ferritin is a widely used indicator to detect iron deficiency, but the threshold ferritin that defines iron deficiency remains uncertain. Our aim was to define the ferritin concentration at which the body begins to upregulate iron absorption from the diet; this could provide a functionally-defined threshold of incipient iron deficiency. We hypothesized this threshold ferritin concentration would correspond to the threshold hepcidin concentration at which iron absorption begins to increase. METHODS We performed a pooled analysis of our stable iron isotope studies (n = 1058) conducted from 2006 to 2019 in healthy women (age 18-50 years; mean±SD ferritin 33.7 ± 27.1 μg/L) that measured iron absorption from labeled test meals providing physiological amounts of iron. To fit relationships between iron absorption, ferritin and hepcidin, we used generalized additive modeling, and to identify thresholds, we estimated the first derivatives of the fitted trend to assess inflection points in these relationships. FINDINGS Hepcidin increased linearly with increasing ferritin over the entire range of ferritin values. Iron absorption began to increase below a threshold hepcidin value of 3.09 (95%CI: 2.80, 3.38) nmol/l, above which iron absorption remained stable. Iron absorption began to increase below a threshold ferritin value of 51.1 (95%CI: 49.1, 53.1) µg/l, above which iron absorption remained stable. The latter two findings were internally consistent in that, in the relationship between hepcidin and ferritin, a hepcidin of ~3 nmol/l corresponded to a ferritin of ~51 µg/l. INTERPRETATION Based on physiological upregulation of iron absorption, a threshold ferritin of <50 µg/L, corresponding to a threshold hepcidin of <3 nmol/l, indicates incipient iron deficiency in young women.
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Affiliation(s)
- Valeria Galetti
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Schmelzbergstrasse 7, Zurich CH-8092, Switzerland
| | - Nicole U. Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Schmelzbergstrasse 7, Zurich CH-8092, Switzerland
| | - Chloé Sieber
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, Zurich CH-8006, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, Zurich CH-8006, Switzerland
| | - Christophe Zeder
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Schmelzbergstrasse 7, Zurich CH-8092, Switzerland
| | - Diego Moretti
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Schmelzbergstrasse 7, Zurich CH-8092, Switzerland
- Nutrition Group, Health Department, Swiss Distance University of Applied Sciences, Regensdorf CH-8105, Switzerland
| | - Michael B. Zimmermann
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Schmelzbergstrasse 7, Zurich CH-8092, Switzerland
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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14
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Mikulic N, Uyoga MA, Paganini D, Mwasi E, Stoffel NU, Zeder C, Karanja S, Zimmermann MB. Consumption of a Single Dose of Prebiotic Galacto-Oligosaccharides Does Not Enhance Iron Absorption from Micronutrient Powders in Kenyan Infants: A Stable Iron Isotope Study. J Nutr 2021; 151:1205-1212. [PMID: 33693741 DOI: 10.1093/jn/nxab007] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/04/2020] [Accepted: 01/07/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Long-term feeding of prebiotic galacto-oligosaccharides (GOS) increases iron absorption in African infants, but the underlying mechanism and how long GOS need to be fed to infants to achieve an increase in absorption is uncertain. OBJECTIVES In Kenyan infants, we tested whether the addition of GOS to a single test meal would affect iron absorption from a micronutrient powder (MNP) containing ferrous sulfate (FeSO4) and another MNP containing ferrous fumarate (FeFum) and sodium iron ethylenediaminetetraacetate (NaFeEDTA). METHODS In a randomized-entry, prospective crossover study, iron deficient (87%) and anemic (70%) Kenyan infants (n = 23; mean ± SD age, 9.9 ± 2.1 months) consumed 4 stable iron isotope-labeled maize porridge meals fortified with MNPs containing 5 mg iron as FeFum + NaFeEDTA, or FeSO4, either without or with 7.5 g GOS. The primary outcome, fractional iron absorption (FIA), was assessed by erythrocyte incorporation of isotopic labels. Data were analyzed using a 2-way repeated-measures ANOVA. RESULTS There was no significant interaction between GOS and the iron compounds on FIA, and the addition of GOS did not have a significant effect on FIA. There was a statistically significant difference in FIA between the meals fortified with FeSO4 and with FeFum + NaFeEDTA (P < 0.001).Given with GOS, FIA from FeSO4 was 40% higher than from FeFum + NaFeEDTA (P < 0.001); given without GOS, it was 51% higher (P < 0.01). CONCLUSIONS The addition of GOS to a single iron-fortified maize porridge test meal in Kenyan infants did not significantly increase iron absorption, suggesting long-term feeding of GOS may be needed to enhance iron absorption at this age. This study was registered at clinicaltrials.gov as NCT02666417.
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Affiliation(s)
- Nadja Mikulic
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Mary A Uyoga
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Daniela Paganini
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Edith Mwasi
- Pediatrics Department, Msambweni County Referral Hospital, Msambweni, Kenya
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Christophe Zeder
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Simon Karanja
- Public and Community Health Department, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
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15
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Frost JN, Tan TK, Abbas M, Wideman SK, Bonadonna M, Stoffel NU, Wray K, Kronsteiner B, Smits G, Campagna DR, Duarte TL, Lopes JM, Shah A, Armitage AE, Arezes J, Lim PJ, Preston AE, Ahern D, Teh M, Naylor C, Salio M, Gileadi U, Andrews SC, Dunachie SJ, Zimmermann MB, van der Klis FR, Cerundolo V, Bannard O, Draper SJ, Townsend AR, Galy B, Fleming MD, Lewis MC, Drakesmith H. Hepcidin-Mediated Hypoferremia Disrupts Immune Responses to Vaccination and Infection. Med 2021; 2:164-179.e12. [PMID: 33665641 PMCID: PMC7895906 DOI: 10.1016/j.medj.2020.10.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/26/2020] [Accepted: 10/16/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND How specific nutrients influence adaptive immunity is of broad interest. Iron deficiency is the most common micronutrient deficiency worldwide and imparts a significant burden of global disease; however, its effects on immunity remain unclear. METHODS We used a hepcidin mimetic and several genetic models to examine the effect of low iron availability on T cells in vitro and on immune responses to vaccines and viral infection in mice. We examined humoral immunity in human patients with raised hepcidin and low serum iron caused by mutant TMPRSS6. We tested the effect of iron supplementation on vaccination-induced humoral immunity in piglets, a natural model of iron deficiency. FINDINGS We show that low serum iron (hypoferremia), caused by increased hepcidin, severely impairs effector and memory responses to immunizations. The intensified metabolism of activated lymphocytes requires the support of enhanced iron acquisition, which is facilitated by IRP1/2 and TFRC. Accordingly, providing extra iron improved the response to vaccination in hypoferremic mice and piglets, while conversely, hypoferremic humans with chronically increased hepcidin have reduced concentrations of antibodies specific for certain pathogens. Imposing hypoferremia blunted the T cell, B cell, and neutralizing antibody responses to influenza virus infection in mice, allowing the virus to persist and exacerbating lung inflammation and morbidity. CONCLUSIONS Hypoferremia, a well-conserved physiological innate response to infection, can counteract the development of adaptive immunity. This nutrient trade-off is relevant for understanding and improving immune responses to infections and vaccines in the globally common contexts of iron deficiency and inflammatory disorders. FUNDING Medical Research Council, UK.
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Affiliation(s)
- Joe N. Frost
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Tiong Kit Tan
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Munawar Abbas
- Food and Nutritional Sciences, School of Chemistry, Food, and Pharmacy, University of Reading, Reading, UK
| | - Sarah K. Wideman
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Michael Bonadonna
- Division of Virus-Associated Carcinogenesis (F170), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Nicole U. Stoffel
- ETH Zurich, Human Nutrition Laboratory, Institute of Food, Nutrition, and Health, Zurich, Switzerland
| | - Katherine Wray
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Barbara Kronsteiner
- Centre for Tropical Medicine and Global Health, and Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Gaby Smits
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Dean R. Campagna
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Tiago L. Duarte
- Instituto de Biologia Molecular e Celular & Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal
| | - José M. Lopes
- Faculty of Medicine (FMUP) and Institute of Molecular Pathology and Immunology (IPATIMUP), University of Porto, Porto, Portugal
| | - Akshay Shah
- Radcliffe Department of Medicine, University of Oxford and John Radcliffe Hospital, Oxford, UK
| | - Andrew E. Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - João Arezes
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Pei Jin Lim
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Alexandra E. Preston
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - David Ahern
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Megan Teh
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Caitlin Naylor
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Mariolina Salio
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Uzi Gileadi
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Simon C. Andrews
- School of Biological Sciences, University of Reading, Reading, UK
| | - Susanna J. Dunachie
- Centre for Tropical Medicine and Global Health, and Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Michael B. Zimmermann
- ETH Zurich, Human Nutrition Laboratory, Institute of Food, Nutrition, and Health, Zurich, Switzerland
| | - Fiona R.M. van der Klis
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Vincenzo Cerundolo
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Oliver Bannard
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Alain R.M. Townsend
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Bruno Galy
- Division of Virus-Associated Carcinogenesis (F170), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Mark D. Fleming
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Marie C. Lewis
- Food and Nutritional Sciences, School of Chemistry, Food, and Pharmacy, University of Reading, Reading, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- Haematology Theme, Oxford Biomedical Research Centre, Oxford, UK
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Mikulic N, Uyoga MA, Mwasi E, Stoffel NU, Zeder C, Karanja S, Zimmermann MB. Iron Absorption is Greater from Apo-Lactoferrin and is Similar Between Holo-Lactoferrin and Ferrous Sulfate: Stable Iron Isotope Studies in Kenyan Infants. J Nutr 2020; 150:3200-3207. [PMID: 32886113 DOI: 10.1093/jn/nxaa226] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/14/2020] [Accepted: 07/09/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Whether lactoferrin (Lf) binds iron to facilitate its absorption or to sequester iron from potential enteropathogens remains uncertain. Bovine Lf is added to many infant formulas, but previous studies in infants reported that Lf had no effect on or inhibited iron absorption. The effects of the apo (iron-free) or the holo (iron-loaded) forms of Lf on iron absorption are unclear. OBJECTIVES Our objective was to compare iron absorption from a maize-based porridge containing: 1) labeled ferrous sulfate (FeSO4) alone; 2) labeled FeSO4 given with bovine apo-Lf; and 3) intrinsically labeled bovine holo-Lf. METHODS In a crossover study, we measured iron absorption in Kenyan infants (n = 25; mean ± SD age 4.2 ± 0.9 months; mean ± SD hemoglobin 109 ± 11 g/L) from maize-based test meals containing: 1) 1.5 mg of iron as 54Fe-labeled FeSO4; 2) 1.42 mg of iron as 58Fe-labeled FeSO4, given with 1.41 g apo-Lf (containing 0.08 mg iron); and 3) 1.41 g holo-Lf carrying 1.5 mg iron as 57Fe. The iron saturation levels of apo- and holo-Lf were 0.56% and 47.26%, respectively primary outcome was fractional iron absorption (FIA), assessed by erythrocyte incorporation of isotopic labels. RESULTS The FIA from the meal containing apo-Lf + FeSO4 (geometric mean, 9.8%; -SD and +SD, 5.4% and 17.5%) was higher than from the meals containing FeSO4 (geometric mean, 6.3%; -SD and +SD, 3.2% and 12.6%; P = 0.002) or holo-Lf (geometric mean, 5.0%; -SD and +SD, 2.8% and 8.9%; P <0.0001). There was no significant difference in FIA when comparing the meals containing holo-Lf versus FeSO4 alone (P = 0.24). CONCLUSIONS The amount of iron absorbed from holo-Lf was comparable to that of FeSO4, and the addition of apo-Lf to a test meal containing FeSO4 significantly increased (+56%) iron absorption. These findings suggest that Lf facilitates iron absorption in young infants. Because Lf binds iron with high affinity, it could be a safe way to provide iron to infants in low-income countries, where iron fortificants can adversely affect the gut microbiome and cause diarrhea. This study was registered at clinicaltrials.gov as NCT03617575.
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Affiliation(s)
- Nadja Mikulic
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Mary A Uyoga
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Edith Mwasi
- Pediatrics Department, Msambweni County Referral Hospital, Msambweni, Kenya
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Christophe Zeder
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Simon Karanja
- Public and Community Health Department, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
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Uyoga MA, Mikulic N, Paganini D, Mwasi E, Stoffel NU, Zeder C, Karanja S, Zimmermann MB. The effect of iron dosing schedules on plasma hepcidin and iron absorption in Kenyan infants. Am J Clin Nutr 2020; 112:1132-1141. [PMID: 32678434 DOI: 10.1093/ajcn/nqaa174] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 02/05/2020] [Accepted: 06/11/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In adults, oral iron doses increase plasma hepcidin (PHep) for 24 h, but not for 48 h, and there is a circadian increase in PHep over the day. Because high PHep decreases fractional iron absorption (FIA), alternate day iron dosing in the morning may be preferable to consecutive day dosing. Whether these effects occur in infants is uncertain. OBJECTIVE Using stable iron isotopes in Kenyan infants, we compared FIA from morning and afternoon doses and from consecutive, alternate (every second day) and every third day iron doses. METHODS In prospective studies, we measured and compared FIA and the PHep response from 1) meals fortified with a 12-mg iron micronutrient powder given in the morning or afternoon (n = 22); 2) the same given on consecutive or alternate days (n = 21); and 3) a 12-mg iron supplement given on alternate days or every third day (n = 24). RESULTS In total, 65.7% of infants were anemic. In study 1, PHep did not differ between morning and afternoon (P = 0.072), and geometric mean FIA[-SD, +SD](%) did not differ between the morning and afternoon doses [15.9 (8.9, 28.6) and 16.1 (8.7, 29.8), P = 0.877]. In study 2, PHep was increased 24 h after oral iron (P = 0.014), and mean FIA [±SD](%) from the baseline dose [23.3 (10.9)] was greater than that from the consecutive day dose (at 24 h) [20.1 (10.4); P = 0.042] but did not differ from the alternate day dose (at 48 h) [20.9 (13.4); P = 0.145]. In study 3, PHep was not increased 48 and 72 h after oral iron (P = 0.384), and the geometric mean FIA[-SD, +SD](%) from doses given at baseline, alternate days, and every third day did not differ [12.7 (7.3, 21.9), 13.8 (7.8, 24.2), and 14.8 (8.8, 24.8), respectively; P = 0.080]. CONCLUSIONS In Kenyan infants given 12 mg oral iron, morning and afternoon doses are comparably absorbed, dosing on consecutive days increases PHep and modestly decreases iron absorption compared with alternate day dosing, and dosing on alternate days or every third day does not increase PHep or decrease absorption. This trial was registered at clinicaltrials.gov as NCT02989311 and NCT03617575.
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Affiliation(s)
- Mary A Uyoga
- Laboratory of Human Nutrition, ETH Zurich, Switzerland
| | - Nadja Mikulic
- Laboratory of Human Nutrition, ETH Zurich, Switzerland
| | | | - Edith Mwasi
- Pediatric Department, Msambweni County Referral Hospital, Msambweni, Kenya
| | | | | | - Simon Karanja
- Public and Community Health Department, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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Stoffel NU, Uyoga MA, Mutuku FM, Frost JN, Mwasi E, Paganini D, van der Klis FRM, Malhotra IJ, LaBeaud AD, Ricci C, Karanja S, Drakesmith H, King CH, Zimmermann MB. Iron Deficiency Anemia at Time of Vaccination Predicts Decreased Vaccine Response and Iron Supplementation at Time of Vaccination Increases Humoral Vaccine Response: A Birth Cohort Study and a Randomized Trial Follow-Up Study in Kenyan Infants. Front Immunol 2020; 11:1313. [PMID: 32754150 PMCID: PMC7369313 DOI: 10.3389/fimmu.2020.01313] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [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: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Iron deficiency may impair adaptive immunity and is common among African infants at time of vaccination. Whether iron deficiency impairs vaccine response and whether iron supplementation improves humoral vaccine response is uncertain. Methods: We performed two studies in southern coastal Kenya. In a birth cohort study, we followed infants to age 18 mo and assessed whether anemia or iron deficiency at time of vaccination predicted vaccine response to three-valent oral polio, diphtheria-tetanus-whole cell pertussis-Haemophilus influenzae type b vaccine, ten-valent pneumococcal-conjugate vaccine and measles vaccine. Primary outcomes were anti-vaccine-IgG and seroconversion at age 24 wk and 18 mo. In a randomized trial cohort follow-up, children received a micronutrient powder (MNP) with 5 mg iron daily or a MNP without iron for 4 mo starting at age 7.5 mo and received measles vaccine at 9 and 18 mo; primary outcomes were anti-measles IgG, seroconversion and avidity at age 11.5 mo and 4.5 y. Findings: In the birth cohort study, 573 infants were enrolled and 303 completed the study. Controlling for sex, birthweight, anthropometric indices and maternal antibodies, hemoglobin at time of vaccination was the strongest positive predictor of: (A) anti-diphtheria and anti-pertussis-IgG at 24 wk (p = 0.0071, p = 0.0339) and 18 mo (p = 0.0182, p = 0.0360); (B) anti-pertussis filamentous hemagglutinin-IgG at 24 wk (p = 0.0423); and (C) anti-pneumococcus 19 IgG at 18 mo (p = 0.0129). Anemia and serum transferrin receptor at time of vaccination were the strongest predictors of seroconversion against diphtheria (p = 0.0484, p = 0.0439) and pneumococcus 19 at 18 mo (p = 0.0199, p = 0.0327). In the randomized trial, 155 infants were recruited, 127 and 88 were assessed at age 11.5 mo and 4.5 y. Compared to infants that did not receive iron, those who received iron at time of vaccination had higher anti-measles-IgG (p = 0.0415), seroconversion (p = 0.0531) and IgG avidity (p = 0.0425) at 11.5 mo. Interpretation: In Kenyan infants, anemia and iron deficiency at time of vaccination predict decreased response to diphtheria, pertussis and pneumococcal vaccines. Primary response to measles vaccine may be increased by iron supplementation at time of vaccination. These findings argue that correction of iron deficiency during early infancy may improve vaccine response.
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Affiliation(s)
- Nicole U Stoffel
- Department of Health Sciences and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, ETH Zürich, Zurich, Switzerland
| | - Mary A Uyoga
- Department of Health Sciences and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, ETH Zürich, Zurich, Switzerland
| | - Francis M Mutuku
- Department of Environment and Health Sciences, Technical University Mombasa, Mombasa, Kenya
| | - Joe N Frost
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, United Kingdom
| | - Edith Mwasi
- Pediatrics Department, Msambweni County Referral Hospital, Msambweni, Kenya
| | - Daniela Paganini
- Department of Health Sciences and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, ETH Zürich, Zurich, Switzerland
| | - Fiona R M van der Klis
- Centre for Infectious Disease Control, National Institute for Public Health and Environment (RIVM), Bilthoven, Netherlands
| | - Indu J Malhotra
- Center for Global Health and Diseases, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - A Desiráe LaBeaud
- Division of Infectious Diseases, Department of Pediatrics, Lucille Packard Children's Hospital at Stanford School of Medicine, Stanford, CA, United States
| | - Cristian Ricci
- Pediatric Epidemiology, Department of Pediatrics, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Simon Karanja
- Department of Medical Epidemiology, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, United Kingdom.,Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Charles H King
- Center for Global Health and Diseases, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Michael B Zimmermann
- Department of Health Sciences and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, ETH Zürich, Zurich, Switzerland
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Stoffel NU, Zeder C, Brittenham GM, Moretti D, Zimmermann MB. Iron absorption from supplements is greater with alternate day than with consecutive day dosing in iron-deficient anemic women. Haematologica 2019; 105:1232-1239. [PMID: 31413088 PMCID: PMC7193469 DOI: 10.3324/haematol.2019.220830] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [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: 03/01/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022] Open
Abstract
In iron-depleted women without anemia, oral iron supplements induce an increase in serum hepcidin (SHep) that persists for 24 hours, decreasing iron absorption from supplements given later on the same or next day. Consequently, iron absorption from supplements is highest if iron is given on alternate days. Whether this dosing schedule is also beneficial in women with iron-deficiency anemia (IDA) given high-dose iron supplements is uncertain. The primary objective of this study was to assess whether, in women with IDA, alternate-day administration of 100 and 200 mg iron increases iron absorption compared to consecutive-day iron administration. Secondary objectives were to correlate iron absorption with SHep and iron status parameters. We performed a cross-over iron absorption study in women with IDA (n=19; median hemoglobin 11.5 mg/dL; mean serum ferritin 10 mg/L) who received either 100 or 200 mg iron as ferrous sulfate given at 8 AM on days 2, 3 and 5 labeled with stable iron isotopes 57Fe, 58Fe and 54Fe; after a 16-day incorporation period, the other labeled dose was given at 8 AM on days 23, 24 and 26 (days 2, 3 and 5 of the second period). Iron absorption on days 2 and 3 (consecutive) and day 5 (alternate) was assessed by measuring erythrocyte isotope incorporation. For both doses, SHep was higher on day 3 than on day 2 (P<0.001) or day 5 (P<0.01) with no significant difference between days 2 and 5. Similarly, for both doses, fractional iron absorption (FIA) on days 2 and 5 was 40-50% higher than on day 3 (P<0.001), while absorption on day 2 did not differ significantly from day 5. There was no significant difference in the incidence of gastrointestinal side effects comparing the two iron doses (P=0.105). Alternate day dosing of oral iron supplements in anemic women may be preferable because it sharply increases FIA. If needed, to provide the same total amount of iron with alternate day dosing, twice the daily target dose should be given on alternate days, as total iron absorption from a single dose of 200 mg given on alternate days was approximately twice that from 100 mg given on consecutive days (P<0.001). In IDA, even if hepatic hepcidin expression is strongly suppressed by iron deficiency and erythropoietic drive, the intake of oral iron supplements leads to an acute hepcidin increase for 24 hours. The study was funded by ETH Zürich, Switzerland. This study has been registered at www.clinicaltrials.gov as #NCT03623997.
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Affiliation(s)
- Nicole U Stoffel
- ETH Zurich, Department of Health Science and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, Zürich, Switzerland
| | - Christophe Zeder
- ETH Zurich, Department of Health Science and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, Zürich, Switzerland
| | - Gary M Brittenham
- Columbia University, Department of Pediatrics, College of Physicians and Surgeons, New York, NY, USA
| | - Diego Moretti
- ETH Zurich, Department of Health Science and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, Zürich, Switzerland
| | - Michael B Zimmermann
- ETH Zurich, Department of Health Science and Technology, Institute of Food, Nutrition and Health, Laboratory of Human Nutrition, Zürich, Switzerland
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20
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Stoffel NU, Lazrak M, Bellitir S, Mir NE, Hamdouchi AE, Barkat A, Zeder C, Moretti D, Aguenaou H, Zimmermann MB. The opposing effects of acute inflammation and iron deficiency anemia on serum hepcidin and iron absorption in young women. Haematologica 2019; 104:1143-1149. [PMID: 30630976 PMCID: PMC6545852 DOI: 10.3324/haematol.2018.208645] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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: 10/08/2018] [Accepted: 01/02/2019] [Indexed: 01/19/2023] Open
Abstract
Hepatic hepcidin synthesis is stimulated by inflammation but inhibited during iron deficiency anemia (IDA). In humans, the relative strength of these opposing signals on serum hepcidin and the net effect on iron absorption and systemic iron recycling is uncertain. In this prospective, 45-day study, in young women (n=46; age 18-49 years) with or without IDA, we compared iron and inflammation markers, serum hepcidin and erythrocyte iron incorporation from 57Fe-labeled test meals, before and 8, 24 and 36 hours (h) after influenza/DPT vaccination as an acute inflammatory stimulus. Compared to baseline, at 24-36 h after vaccination: 1) interleukin-6 increased 2-3-fold in both groups (P<0.001); 2) serum hepcidin increased >2-fold in the non-anemic group (P<0.001), but did not significantly change in the IDA group; 3) serum iron decreased in the non-anemic group (P<0.05) but did not change in the IDA group; and 4) erythrocyte iron incorporation did not change in either of the two groups, but was approximately 2-fold higher in the IDA group both before and after vaccination (P<0.001). In this study, mild acute inflammation did not increase serum hepcidin in women with IDA, suggesting low iron status and erythropoietic drive offset the inflammatory stimulus on hepcidin expression. In non-anemic women, inflammation increased serum hepcidin and produced mild hypoferremia, but did not reduce dietary iron absorption, suggesting iron-recycling macrophages are more sensitive than the enterocyte to high serum hepcidin during inflammation. The study was registered as a prospective observational trial at clinicaltrials.gov identifier: 02175888 The study was funded by the International Atomic Energy Agency.
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Affiliation(s)
- Nicole U Stoffel
- ETH Zürich, Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Zürich, Switzerland
| | - Meryem Lazrak
- Ibn Tofaïl University-CNESTEN, Joint Research Unit in Nutrition and Food, RDC-Nutrition AFRA/IAEA, Rabat-Kénitra, Morocco
| | - Souhaila Bellitir
- Ibn Tofaïl University-CNESTEN, Joint Research Unit in Nutrition and Food, RDC-Nutrition AFRA/IAEA, Rabat-Kénitra, Morocco
| | - Nissrine El Mir
- Ibn Tofaïl University-CNESTEN, Joint Research Unit in Nutrition and Food, RDC-Nutrition AFRA/IAEA, Rabat-Kénitra, Morocco
| | - Asmaa El Hamdouchi
- Ibn Tofaïl University-CNESTEN, Joint Research Unit in Nutrition and Food, RDC-Nutrition AFRA/IAEA, Rabat-Kénitra, Morocco
| | - Amina Barkat
- Mohamed V University, Unit of Research on Nutrition and Health of Mother and Nutrition, Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Christophe Zeder
- ETH Zürich, Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Zürich, Switzerland
| | - Diego Moretti
- ETH Zürich, Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Zürich, Switzerland
| | - Hassan Aguenaou
- Ibn Tofaïl University-CNESTEN, Joint Research Unit in Nutrition and Food, RDC-Nutrition AFRA/IAEA, Rabat-Kénitra, Morocco
| | - Michael B Zimmermann
- ETH Zürich, Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Zürich, Switzerland
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Stoffel NU, Cercamondi CI, Brittenham G, Zeder C, Geurts-Moespot AJ, Swinkels DW, Moretti D, Zimmermann MB. Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials. Lancet Haematol 2017; 4:e524-e533. [PMID: 29032957 DOI: 10.1016/s2352-3026(17)30182-5] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/07/2017] [Accepted: 09/08/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current guidelines to treat iron deficiency recommend daily provision of ferrous iron divided through the day to increase absorption. However, daily dosing and split dosing might increase serum hepcidin and decrease iron absorption from subsequent doses. Our study aim was to compare iron absorption from oral iron supplements given on consecutive versus alternate days and given as single morning doses versus twice-daily split dosing. METHODS We did two prospective, open-label, randomised controlled trials assessing iron absorption using (54Fe)-labelled, (57Fe)-labelled, or (58Fe)-labelled ferrous sulfate in iron-depleted (serum ferritin ≤25 μg/L) women aged 18-40 years recruited from ETH Zurich and the University of Zurich, Switzerland. In study 1, women were randomly assigned (1:1) to two groups. One group was given 60 mg iron at 0800 h (±1 h) on consecutive days for 14 days, and the other group was given the same doses on alternate days for 28 days. In study 2, women were assigned to two groups, stratified by serum ferritin so that two groups with similar iron statuses could be formed. One group was given 120 mg iron at 0800 h (±1 h) and the other was given the dose split into two divided doses of 60 mg at 0800 h (±1 h) and 1700 h (±1 h) for three consecutive days. 14 days after the final dose, the groups were each crossed over to the other regimen. Within-individual comparisons were done. The co-primary outcomes in both studies were iron bioavailability (total and fractional iron absorption), assessed by measuring the isotopic label abundance in erythrocytes 14 days after administration, and serum hepcidin. Group allocations in both studies were not masked and primary and safety analyses were done on an intention-to-treat basis. The studies were registered at ClinicalTrials.gov, numbers NCT02175888 (study 1) and NCT02177851 (study 2) and are complete. FINDINGS For study 1, 40 women were enrolled on Oct 15-29, 2015. 21 women were assigned to the consecutive-day group and 19 to the alternate-day group. At the end of treatment (14 days for the consecutive-day group and 28 days for the alternate-day group), geometric mean (-SD, +SD) cumulative fractional iron absorptions were 16·3% (9·3, 28·8) in the consecutive-day group versus 21·8% (13·7, 34·6) in the alternate-day group (p=0·0013), and cumulative total iron absorption was 131·0 mg (71·4, 240·5) versus 175·3 mg (110·3, 278·5; p=0·0010). During the first 14 days of supplementation in both groups, serum hepcidin was higher in the consecutive-day group than the alternate-day group (p=0·0031). In study 2, 20 women were enrolled between Aug 13 and 18, 2015. Ten women were assigned to receive once-daily dosing and ten were assigned to receive twice-daily divided dosing. No significant differences were seen in fractional (day 1-3 geometric mean: 11·8% [7·1, 19·4] once daily vs 13·1% [8·2, 20·7] twice daily; p=0·33) or total iron absorption (day 1-3: 44·3 mg [29·4, 66·7] once daily vs 49·4 [35·2, 69·4] twice daily; p=0·33) between the two dosing regimens. Twice-daily divided doses resulted in a higher serum hepcidin concentration than once-daily dosing (p=0·013). No grade 3 or 4 adverse events were reported in either study. INTERPRETATION In iron-depleted women, providing iron supplements daily as divided doses increases serum hepcidin and reduces iron absorption. Providing iron supplements on alternate days and in single doses optimises iron absorption and might be a preferable dosing regimen. These findings should be confirmed in iron-deficient anaemic patients. FUNDING Swiss National Science Foundation, Bern, Switzerland.
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Affiliation(s)
- Nicole U Stoffel
- Department of Health Science and Technology, ETH Zürich, Zürich, Switzerland
| | - Colin I Cercamondi
- Department of Health Science and Technology, ETH Zürich, Zürich, Switzerland
| | - Gary Brittenham
- Department of Pediatrics, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Christophe Zeder
- Department of Health Science and Technology, ETH Zürich, Zürich, Switzerland
| | | | - Dorine W Swinkels
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Diego Moretti
- Department of Health Science and Technology, ETH Zürich, Zürich, Switzerland
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Stoffel NU, Zeder C, Fort E, Swinkels DW, Zimmermann MB, Moretti D. Prediction of human iron bioavailability using rapid c-ELISAs for human plasma hepcidin. Clin Chem Lab Med 2017. [PMID: 28628474 DOI: 10.1515/cclm-2017-0097] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hepcidin is the central systemic regulator of iron metabolism, but its quantification in biological fluids is challenging. Rapid, accurate and user-friendly methods are needed. Our aim was to assess the ability of hepcidin as measured by three different c-ELISA assays to predict iron bioavailability in humans. METHODS The three assays used were commercially available DRG and Peninsula assays and the c-ELISA method performed at Radboud University Medical Centre, Nijmegen, The Netherlands (Hepcidinanalysis.com), validated by comparative measurements with time-of-flight mass spectrometry. We analyzed plasma samples (n=37) selected to represent a broad range of hepcidin concentrations from a subgroup of healthy, iron-depleted women in a study assessing fractional absorption from iron supplements. RESULTS In single regressions, all three c-ELISA assays were predictors of fractional iron absorption: R2=0.363 (DRG), R2=0.281 (Peninsula) and R2=0.327 (Hepcidinanalysis.com). In multiple regressions, models including hepcidin measured with either DRG-, Peninsula or Hepcidinanalysis.com explained 55.7%, 44.5% and 52.5% of variance in fractional absorption, and hepcidin was a strong predictor of fractional absorption irrespective of the hepcidin assays used. However, we found significant differences in absolute values for hepcidin between different methods. Both the DRG assay's (y=0.61x+0.87; R2=0.873) and the Peninsula assay's measurements (y=1.88x+0.62; R2=0.770) were correlated with Hepcidinanalysis.com. CONCLUSIONS The biological variability in plasma hepcidin, (inter-sample CV) was 5-10-fold higher for both the Peninsula and DRG assay than the analytical variably (inter-run within-sample CV) suggesting substantial discriminatory power to distinguish biological hepcidin variation. Between methods, prediction of iron bioavailability in generally healthy iron depleted subjects appears comparable.
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