Micronutrient deficiency and supplements in schoolchildren and teenagers

PURPOSE OF REVIEW

The essential micronutrients are corner stones in the functional and physical development. Early deficiency has life-long consequences. While awareness about iron deficiency is relatively high, it remains lower for other micronutrients. This review aims at reporting on recent data and attracting attention to the high prevalence of micronutrient deficiencies in school-age and adolescent individuals.

RECENT FINDINGS

Iron deficiency anaemia remains highly prevalent worldwide and the most frequent deficiency but can be corrected with simple tools ranging from food fortification, nutritional intervention, and to supplements. The link between micronutrient (MN) deficiency and neurobehavioral disorders is increasingly established and is worrying even in Western countries. Paediatric individuals are prone to imbalanced diets and picky eating behaviour, and their diets may then become incomplete: the highest risk for deficiency is observed for iron, zinc and vitamin D.

SUMMARY

There is not much new information, but rather confirmation of the importance of health policies. Well conducted randomized controlled trials confirm that deficiencies can be corrected efficiently including with food fortification, and result in clinical benefits. Individual complementation should be considered in children and adolescents with proven deficiency.

Overnutrition is a risk factor for iron, but not for zinc or vitamin A deficiency in children and young people: a systematic review and meta-analysis

INTRODUCTION

Traditionally associated with undernutrition, increasing evidence suggests micronutrient deficiencies can coexist with overnutrition. Therefore, this work aimed to systematically review the associations between iron, zinc and vitamin A (VA) status and weight status (both underweight and overweight) in children and young people.

METHODS

Ovid Medline, Ovid Embase, Scopus and Cochrane databases were systematically searched for observational studies assessing micronutrient status (blood, serum or plasma levels of iron, zinc or VA biomarkers) and weight status (body mass index or other anthropometric measurement) in humans under 25 years of any ethnicity and gender. Risk of bias assessment was conducted using the American Dietetic Association Quality Criteria Checklist. Where possible, random effects restricted maximum likelihood meta-analyses were performed.

RESULTS

After screening, 83 observational studies involving 190 443 participants from 44 countries were identified, with many studies having reported on more than one micronutrient and/or weight status indicator. Iron was the most investigated micronutrient, with 46, 28 and 27 studies reporting data for iron, zinc and VA status, respectively. Synthesising 16 records of OR from seven eligible studies, overnutrition (overweight and obesity) increased odds of iron deficiency (ID) (OR (95% CI): 1.51 (1.20 to 1.82), p<0.0001, I2=40.7%). Odds appeared to be higher for children living with obesity (1.88 (1.33 to 2.43), p<0.0001, I2=20.6%) in comparison to those with overweight (1.31 (0.98 to 1.64), p<0.0001, I2=40.5%), although between group differences were not significant (p=0.08).

CONCLUSIONS

Overnutrition is associated with increased risk of ID, but not zinc or VA deficiencies, with an inverted U-shaped relationship observed between iron status and bodyweight. Our results highlight significant heterogeneity in the reporting of micronutrient biomarkers and how deficiencies were defined. Inflammation status was rarely adequately accounted for, and the burden of ID may well be under-recognised, particularly in children and young people living with overnutrition.

PROSPERO REGISTRATION NUMBER

CRD42020221523.

Iron Supplementation of Pregnant Sows to Prevent Iron Deficiency Anemia in Piglets: A Procedure of Questionable Effectiveness

In pigs, iron deficiency anemia (IDA) is a common disorder that occurs during the early postnatal period, leading to the stunted growth and increased mortality of piglets. The main cause of IDA is low iron stores in the liver of newborn piglets; these stores constitute the main source of iron needed to satisfy the erythropoietic requirements of the piglets in their first weeks of life. Insufficient iron stores in piglets are usually due to the inadequate placental iron transfer from the sow to the fetuses. Therefore, iron supplementation in pregnant sows has been implemented to enhance placental iron transfer and increase iron accumulation in the liver of the fetuses. Over the years, several oral and parenteral approaches have been attempted to supplement sows with various iron preparations, and consequently, to improve piglets' red blood cell indices. However, there is debate with regard to the effectiveness of iron supplementation in pregnant sows for preventing IDA in newborn piglets. Importantly, this procedure should be carried out with caution to avoid iron over-supplementation, which can lead to iron toxicity. This article aims to critically review and evaluate the use of iron supplementation in pregnant sows as a procedure for preventing IDA in piglets.

Association between Iron-Folic Acid Supplementation during Pregnancy and Maternal and Infant Anemia in West Java, Indonesia: A Mixed-Method Prospective Cohort Study

The Indonesian government has provided iron-folic acid (IFA) supplementation in response to maternal pregnancy iron-deficiency anemia. However, community-based cohorts on IFA's effects on maternal and infant anemia are limited. A mixed-method study design with a primary longitudinal cohort was used to observe the association between IFA and anemia in mothers and infants. Iron-folic acid supplementation was observed throughout pregnancy. Anemia status was based on a single hemoglobin assessment using HemoCue Hb 201 + in the second or third trimester of pregnancy for the mother and at birth for the infant. Qualitative data were collected via in-depth interviews (IDIs) and a forum group discussion (FGD). Iron-folic acid supplementation with > 180 tablets throughout pregnancy was associated with lower pregnancy anemia (adjusted relative risk [aRR] = 0.25, 95% CI: 0.092-0.664, P = 0.006) after adjusting for potential confounding variables. Supplementation with IFA was not associated with infant anemia (RR = 1.033, 95% CI: 0.70-1.54, P = 0.873 for 90-180 tablets and RR = 1.07, 95% CI 0.70-1.63, P = 0.774 for > 180 tablets). The IDIs and FGD suggested that IFA and multivitamin content knowledge, IFA consumption monitoring, and paternal involvement were important in IFA supplementation and effectiveness in reducing anemia. Iron-folic acid supplementation was associated with reduced maternal but not infant anemia. Because maternal anemia is associated with infant anemia, an anemia monitoring program for women in early pregnancy is vital in addressing infant health. Paternal involvement was also identified as a major factor in maternal and child health.

Role of mineral nutrients other than iron in pregnancy: under recognized opportunities to improve maternal/fetal outcomes: a literature review

BACKGROUND

Anemia during pregnancy is an important global health concern, affecting 40% of women worldwide, and iron deficiency shares a significant proportion of the burden. From conception to birth, pregnancy is a period when women undergo metabolic and physiological changes. The nutritional needs are higher during pregnancy; thus, adequate nutrition is essential to maintain fetal growth and development. However, adverse effects due to deficiency in nutrition during pregnancy can result in maternal, fetal and neonatal complications. Despite the multifactorial etiology of anemia, iron deficiency is assumed as the primary cause of anemia during pregnancy and hence, mitigation strategy pivots around it for anemia management. Therefore, excluding other contributors, a single-micronutrient approach with iron supplements remains a myopic approach and this can exacerbate iron deficiency anemia. Micronutrient deficiencies are of particular concern as they may pose a silent threat to the survival and well-being of reproductive-age women and their infants.

AIM

Micronutrients, especially trace minerals, play a myriad of roles in pregnancy, and the lack of each one causes adverse complications to both the mother and the fetus. In this review paper, we attempt to piece together available information regarding the adverse effects of abnormal trace mineral levels along with iron deficiency on the mother and the fetus.

METHOD

A non-systematic literature search in PubMed, Google Scholar, and the Cochrane databases, for publications on minerals and vitamins during pregnancy and the possible influence of supplements on pregnancy outcomes.

CONCLUSION

Micronutrient deficiency exacerbates the pregnancy-induced anemia and other adverse birth outcomes. Micronutrient supplementation during pregnancy can combat anemia as well as reduce a number of adverse pregnancy outcomes in a comprehensive manner.

Ten2Twenty-Ghana: a randomised controlled trial on the efficacy of multiple micronutrient-fortified biscuits on the micronutrient status of adolescent girls

Adolescent girls are an important target group for micronutrient interventions particularly in Sub-Saharan Africa where adolescent pregnancy and micronutrient deficiencies are common. When consumed in sufficient amounts and at levels appropriate for the population, fortified foods may be a useful strategy for this group, but little is known about their effectiveness and timing (regarding menarche), particularly in resource-poor environments. We evaluated the effect of consuming multiple micronutrient-fortified biscuits (MMB), sold in the Ghanaian market, 5 d/week for 26 weeks compared with unfortified biscuits (UB) on the micronutrient status of female adolescents. We also explored to what extent the intervention effect varied before or after menarche. Ten2Twenty-Ghana was a 26-week double-blind, randomised controlled trial among adolescent girls aged 10-17 years (n 621) in the Mion District, Ghana. Biomarkers of micronutrient status included concentrations of Hb, plasma ferritin (PF), soluble transferrin receptor (TfR) and retinol-binding protein (RBP), including body-iron stores. Intention-to-treat analysis was supplemented by protocol-specific analysis. We found no effect of the intervention on PF, TfR and RBP. MMB consumption did not affect anaemia and micronutrient deficiencies at the population level. MMB consumption increased the prevalence of vitamin A deficiency by 6·2 % (95 % CI (0·7, 11·6)) among pre-menarche girls when adjusted for baseline micronutrient status, age and height-for-age Z-score, but it decreased the prevalence of deficient/low vitamin A status by -9·6 % (95 % CI (-18·9, -0·3)) among post-menarche girls. Consuming MMB available in the market did not increase iron status in our study, but reduced the prevalence of deficient/low vitamin A status in post-menarcheal girls.

The medium-term impact of a micronutrient powder intervention on anemia among young children in Rural China

BACKGROUND

Poor development of young children is a common issue in developing countries and it is well established that iron deficiency anemia is one of the risk factors. Research has shown that iron deficiency is a common micronutrient deficiency among children in rural China and can result in anemia. A previous paper using data from the same trial as those used in the current study, but conducted when sample children were younger, found that after 6 months of providing caregivers of children 6-11 months of age free access to iron-rich micronutrient powder (MNP) increased the hemoglobin concentrations (Hb) of their children. However, no effects were found 12 and 18 months after the intervention. The current study followed up the children four years after the start of the original intervention (when the children were 4-5 years old) and aims to assess the medium-term impacts of the MNP program on the nutritional status of the sample pre-school-aged children, including their levels of Hb, the prevalence of anemia, and the dietary diversity of the diets of the children.

METHODS

At baseline, this study sampled 1,802 children aged 6-11 months in rural Western China. The intervention lasted 18 months. In this medium-term follow-up study that successfully followed 81% (n = 1,464) of children (aged 49-65 months) from the original study population 4 years after the start of the intervention, we used both intention-to-treat (ITT) effect and average treatment on the treated effect (ATT) analyses to assess the medium-term impacts of the MNP distribution program on the nutritional status of sample children.

RESULTS

The ITT analysis shows that the MNP intervention decreased the prevalence of anemia of young children in the medium run by 8% (4 percentage points, p < 0.1). The ATT analysis shows that consuming 100 (out of 540) MNP sachets during the initial intervention led to a decrease in anemia of 4% (2 percentage points, p < 0.1). Among children with moderate anemia at baseline (Hb < 100 g/L), the intervention reduced the probability of anemia by 45% (9 percentage points, p < 0.1), and, for those families that complied by consuming 100 (out of 540) sachets, a 25% (5 percentage points, p < 0.05) reduction in the anemia rate was found. The MNP intervention also led to a persistent increase in dietary diversity among children that were moderately anemic at baseline. The results from the quantile treatment effect analysis demonstrated that children with lower Hb levels at baseline benefited relatively more from the MNP intervention.

CONCLUSIONS

The findings of the current study reveal that the MNP intervention has medium-term effects on the nutritional status of children in rural China. The impacts of the MNP program were relatively higher for children that initially had more severe anemia levels. Hence, the implications of this study are that programs that aim to increase caregiver knowledge of nutrition and improve their feeding practices should be encouraged across rural China. Families, policymakers, and China's society overall need to continue to pay more attention to problems of childhood anemia in rural areas. This is particularly crucial for families with moderately anemic children at an early age as it can significantly contribute to improving the anemia status of children across rural areas of China.

TRIAL REGISTRATION

ISRCTN44149146 (15/04/2013).

Digital Educational Game "O Jardim do Ferro": A Tool for the Prevention of Iron Deficiency Anemia in Childhood

Objective: To create and evaluate a digital educational game (DEG) for preschool children for the prevention of iron deficiency and iron deficiency anemia. Methodology: The DEG software was developed by a multidisciplinary team, according to Chandler's methodology, in Engine Unity. The game is a 2D platformer, for Android, with three different phases. A quiz was developed for parents/caregivers about iron absorption and anemia. The quiz content was evaluated by experts. The evaluation of the game was carried out through a questionnaire applied in the school for children from 4 to 6 years of age. Results: For the construction of the game, programming, team planning, art, and soundtrack were necessary. The game was registered at the National Institute of Industrial Property. The quiz was evaluated by 14 experts and all questions had more than 80% agreement. The questionnaire was answered by 32 children with a mean age of 5.0 ± 0.7 years, and ∼70% evaluated the game positively. Thus, the acceptability of the software was favored by most players. Conclusion: The "O Jardim do Ferro" software, from its conception to evaluation, proved to be a promising tool to contribute to food and nutrition education actions, providing opportunities for the construction of knowledge about iron-rich foods for the prevention of iron deficiency and iron deficiency anemia in childhood.

The iron status of rural Nigerian women in the second and third trimesters of pregnancy: implications for the iron endowment and subsequent dietary iron needs of their babies

INTRODUCTION

The aim of the study was to determine the iron status of rural-dwelling pregnant Nigerian women in the second and third trimesters, and to predict their risk of giving birth to babies with suboptimal iron endowment.

METHODS

This was a prospective cohort study conducted between April and August 2021. A total of 174 consecutive and consenting pregnant rural dwellers, who met the inclusion criteria, were recruited by convenience sampling from the antenatal clinic of a public hospital in Nsukka, a semirural town in south-east Nigeria. The study participants were aged 21-40 years, and their iron status was determined by measuring blood haemoglobin (Hb) and serum ferritin (SF) concentration. Hb concentration was determined by the cyanmethemoglobin method and the SF concentration was determined by enzyme immunoassay method.

RESULTS

Almost half (47.7%) of the participants had Hb concentrations below 11 g/dL, while about two out of every five (40.8%) had SF concentrations less than 15 µg/L. The prevalence of iron deficiency, iron deficiency anaemia (IDA) and non-iron deficiency anaemia were 40.8%, 23.6% and 24.7%, respectively. The mean SF levels varied with maternal age, gestation stage, pregnancy intervals and the intake of iron supplements. The mean SF concentration was higher in the second trimester than in the third. The mean SF concentration ± standard deviation (37.10±3.02 µg/L) was higher in the group that took iron supplements than in the group that did not (20.76±2.11 µg/L). However, two out of five participants in both groups had SF concentrations less than 15.0 µg/L.

CONCLUSION

The prevalence of IDA was quite high among the participants in both trimesters even with the widespread intake of the recommended oral iron supplements. About four out of 10 of the participants had SF concentrations of less than 15 µg/L and were thus judged at risk of giving birth to babies with poor iron deposits. Therefore, more effective strategies are needed to monitor and prevent IDA among pregnant women in rural populations of Nigeria and, by inference, other parts of tropical Africa.

Preoperative iron infusion does not reduce the requirement for blood transfusion in colorectal cancer surgery

BACKGROUND

Allogeneic blood transfusions (BT) for patients undergoing colorectal cancer surgery have demonstrated to increase postoperative morbidity and mortality. It has been suggested that the utilization of preoperative iron infusions may reduce the requirement for allogeneic BT in these patients. The aim of this project is to ascertain whether the preoperative use of intravenous iron is significantly associated with a reduction in perioperative blood transfusion requirement.

METHODS

A retrospective study of 130 patients was conducted in Blacktown Hospital, Australia. Data pertaining to patient demographics, as well as quantity of preoperative iron infusion and perioperative blood transfusion was collected.

RESULTS

Twenty-six (20%) patients required perioperative BT. Twenty-seven underwent preoperative iron infusion, with 20 of them not requiring BT and seven requiring BT. There was no evidence to suggest preoperative iron infusion reduces blood transfusion requirement (RR 1.55, 95% CI 0.57-4.18, P=0.39). For elective procedures, no significance was also demonstrated (RR 1.20, 95% CI 0.29-4.92, P=0.80).

CONCLUSIONS

There is no evidence suggesting that preoperative iron infusion reduces the requirement for perioperative blood transfusion in colorectal cancer surgery.

Consumption Pattern of Tea Is Associated with Serum Ferritin Levels of Women of Childbearing Age in Nandi County, Kenya: A Cross-Sectional Study

INTRODUCTION

Tea consumption with meals affects iron absorption, increasing the risk of iron deficiency. Our study investigated the association between tea consumption patterns and serum ferritin levels among women of childbearing age (WCA) in Nandi County, Kenya.

METHODS

We conducted a cross-sectional analytical study among 160 WCA selected using a systematic random sampling technique from Kapsabet Ward. Information on tea consumption practices was gathered using a researcher-administered questionnaire, and serum ferritin and C-reactive protein were measured. We assessed associations between tea consumption and iron status of respondents by multivariable regression analysis, adjusting for potential confounders, including parasitic infections and recent severe blood losses.

RESULTS

The prevalence of anaemia and iron deficiency among the study participants were 86.2% and 45%, respectively. Majority (90.6%) of the respondents consumed tea or coffee, with an infusion time of more than 5 min (60.0%) and a moderate tea strength (64.1%), within 1 h before or after meals. Iron deficiency was associated the number of teacups consumed (adjusted odds ratio = 7.282, 95% CI = 3.580-14.812).

CONCLUSION

High tea consumption is positively associated with iron deficiency among WCA. Lower tea infusion strength, shorter tea infusion duration, and a lower number of teacups overall consumed, as well as consuming tea 1 h before or after meals instead of with meals, may be recommended for better outcomes in iron status among WCA.

Iron Intake and Human Health

Iron deficiency anemia (IDA) is a global nutritional disorder affecting large population groups in varying magnitudes in different countries [...].

Reported outcomes in patients with iron deficiency or iron deficiency anemia undergoing major surgery: a systematic review of outcomes

BACKGROUND

Iron deficiency (ID) is the leading cause of anemia worldwide. The prevalence of preoperative ID ranges from 23 to 33%. Preoperative anemia is associated with worse outcomes, making it important to diagnose and treat ID before elective surgery. Several studies indicated the effectiveness of intravenous iron supplementation in iron deficiency with or without anemia (ID(A)). However, it remains challenging to establish reliable evidence due to heterogeneity in utilized study outcomes. The development of a core outcome set (COS) can help to reduce this heterogeneity by proposing a minimal set of meaningful and standardized outcomes. The aim of our systematic review was to identify and assess outcomes reported in randomized controlled trials (RCTs) and observational studies investigating iron supplementation in iron-deficient patients with or without anemia.

METHODS

We searched MEDLINE, CENTRAL, and ClinicalTrials.gov systematically from 2000 to April 1, 2022. RCTs and observational studies investigating iron supplementation in patients with a preoperative diagnosis of ID(A), were included. Study characteristics and reported outcomes were extracted. Outcomes were categorized according to an established outcome taxonomy. Quality of outcome reporting was assessed with a pre-specified tool. Reported clinically relevant differences for sample size calculation were extracted.

RESULTS

Out of 2898 records, 346 underwent full-text screening and 13 studies (five RCTs, eight observational studies) with sufficient diagnostic inclusion criteria for iron deficiency with or without anemia (ID(A)) were eligible. It is noteworthy to mention that 49 studies were excluded due to no confirmed diagnosis of ID(A). Overall, 111 outcomes were structured into five core areas including nine domains. Most studies (92%) reported outcomes within the 'blood and lymphatic system' domain, followed by "adverse event" (77%) and "need for further resources" (77%). All of the latter reported on the need for blood transfusion. Reported outcomes were heterogeneous in measures and timing. Merely, two (33%) of six prospective studies were registered prospectively of which one (17%) showed no signs of selective outcome reporting.

CONCLUSION

This systematic review comprehensively depicts the heterogeneity of reported outcomes in studies investigating iron supplementation in ID(A) patients regarding exact definitions and timing. Our analysis provides a systematic base for consenting to a minimal COS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020214247.

Sensory evaluations of a novel iron and zinc-enriched powder for the potential treatment and prevention of iron deficiency in women of reproductive age

Iron deficiency (ID) and ID with anaemia (IDA) are serious global health problems that disproportionately affect women aged 15-49 years. Although food fortification is one of the most effective and sustainable ways to combat nutritional deficiencies, iron remains one of the most difficult micronutrients to fortify, given its tendency to react strongly with food constituents. Therefore, it is important to assess the sensory properties of foods fortified with iron to determine the acceptability and palatability in target populations. We aimed to determine the palatability and acceptability of a novel iron and zinc-enriched powder fortified in tap water by conducting sensory evaluations in 35 women of reproductive age using a 9-point hedonic scale, where participants rated the sensory properties of six samples containing different amounts of the active or placebo powder. We found significant differences between samples reconstituted at 1, 2, and 3 g/L for sensory properties, including overall taste. Participants were found to be more willing to drink the mineral-enriched powder when prepared at the lowest concentration (1 g/L) compared to higher concentrations. Our results provide important insight into the sensory qualities of a novel formulation of an iron and zinc-enriched powder for at-home fortification and indicate consumer acceptability in reproductive-aged women, a key group at risk for ID/IDA. If found to improve iron status, novel treatments like this product will contribute to global efforts to develop safe, acceptable and sustainable interventions for ID and IDA.

Prenatal iron supplementation adjusted to maternal iron stores reduces behavioural problems in 4-year-old children

Prenatal iron supplementation improves children's health and cognitive performance, but few studies explore behavioural development. This study assessed the effects of adjusting prenatal iron supplementation to maternal iron stores during early pregnancy on children's behavioural problems. Randomized controlled trial conducted in Tarragona (Spain) involving 230 nonanaemic pregnant women and their children after a 4-year follow-up. Based on haemoglobin (Hb) levels before gestational week (GW) 12, women receive different iron doses: those with Hb = 110-130 g/L were randomized to receive 80 or 40 mg/day and those with Hb > 130 g/L were randomized to receive 20 or 40 mg/day. Maternal iron stores at GW12 were classified using serum ferritin (SF) as low (SF < 15 µg/L), normal (SF = 15-65 µg/L), and normal-high (SF > 65 µg/L). Children's behaviour was assessed by parents using the Child Behaviour Checklist for ages 1.5-5 years and the Behaviour Rating Inventory of Executive Function-Preschool Version, and by teachers using the Teacher's Report Form for ages 1.5-5 years. Multivariable regression models were performed. Taking 80 mg/day of iron improved child behaviour when women had low iron stores but worsened it when mothers had normal-high iron stores, except for depressive and attention/hyperactivity problems. Taking 20 mg/day of iron improved behaviour only in those children whose mothers had SF > 65 µg/L in early pregnancy. Additionally, executive functioning improved at high doses of prenatal iron when maternal baseline SF < 15 µg/L. Adjusting prenatal iron supplementation to both maternal baseline Hb levels and iron stores reduces behavioural problems in 4-year-old children.

Characterization of Oyster Protein Hydrolysate-Iron Complexes and their In Vivo Protective Effects against Iron Deficiency-Induced Symptoms in Mice

Iron is one of the trace mineral elements, and iron deficiency is a common phenomenon that negatively influences human health. Food-derived iron supplements were considered excellent candidates for improving this syndrome. In this work, oyster-protein hydrolysates (OPH) and ferrous chloride successfully formed the OPH-Fe complex (6 mg/mL, 40 °C, 30 min), where the main binding sites involved were the carboxyl and amino groups. The OPH-Fe complex showed no obvious changes in the secondary structure, while the iron changed the morphological appearance and also showed fluorescence quenching, an ultraviolet shift, and an increase in size distribution. The OPH-Fe complex showed better dynamic absorption of iron (64.11 μmol/L) than ferrous sulfate (46.90 μmol/L), and the medium dose had better protective effects against iron-deficiency anemia in vivo. Three representative peptides (DGKGKIPEE, FAGDDAPRA, and VLDSGDGVTH) that were absorbed intact were identified. This experiment provided a theoretical foundation for further study of the digestion and absorption of the OPH-Fe complex.

School-based supplementation with iron-folic acid or multiple micronutrient tablets to address anemia among adolescents in Burkina Faso: a cluster-randomized trial

BACKGROUND

Iron-deficiency anemia is a leading cause of morbidity among adolescents (aged 10-19 y), especially in low- and middle-income settings. Few policies and programs have targeted adolescent health.

OBJECTIVES

This study aimed to evaluate the effectiveness of school-based supplementation with iron-folic acid (IFA) or multiple micronutrient supplements (MMSs) in addressing anemia among adolescents in Burkina Faso.

METHODS

In this cluster-randomized trial, 3123 secondary school students aged 10 to 18 y in Burkina Faso were either supplemented with weekly IFA, daily MMSs, or received standard nutrition education as controls. Supplementation occurred between April 2021 and April 2022 over 2 supplementation periods (10 wk, then 16 wk) separated by a gap of 20 wk without supplementation. Hemoglobin was evaluated 4 times: at baseline prior to each supplementation period and at the end of each period. Anemia was categorized by the World Health Organization hemoglobin level cutoffs as none, mild, moderate, or severe. Associations between treatment arm and anemia or continuous hemoglobin (g/dL) were assessed using multilevel mixed effects generalized linear models with schools as a random effect, controlling for baseline hemoglobin or anemia status.

RESULTS

Baseline anemia prevalence was similar across study arms, with 32.7% in IFA, 31.2% in MMS, and 29.5% in the control arm. Over the full study period, adolescents provided IFA had hemoglobin levels higher than those in the control arm (adjusted β: 0.32; 95% CI: 0.02, 0.62). No significant associations were observed for MMS or for anemia outcomes; however, the direction and magnitude of nonsignificant associations indicate potential protective effects of IFA and MMSs on anemia.

CONCLUSIONS

The results do not provide strong evidence that weekly IFA or daily MMS alone is effective, but supplementation may play a role in addressing adolescent anemia if combined with cointerventions. Additional research is required to determine the best strategy to address anemia. This trial was registered at clinicaltrials.gov as NCT04657640.

Maternal gestational iron status and infant haematological and neurodevelopmental outcomes

Prevention of iron deficiency (ID), the most common micronutrient deficiency in infants and children, begins prenatally by ensuring adequate fetal loading. Adequate intrauterine iron status is crucial for normal fetal brain development, postnatal brain performance and prevention of early postnatal iron deficiency, particularly in infants fed exclusively human milk. Adequate fetal loading may be achieved in some cases through adequate maternal iron levels prior to pregnancy and oral iron supplementation during pregnancy. However, because so many women are iron-deficient leading up to pregnancy, coupled with the negative iron balance induced by pregnancy, a large number of women remain iron-deficient during pregnancy. More consistent iron-specific early screening and more effective iron delivery approaches are needed to solve this global problem.

Review of intervention products for use in the prevention and control of anemia

Anemia remains a major public health problem, especially in low- and middle-income countries. The World Health Organization recommends several interventions to prevent and manage anemia in vulnerable population groups, including young children, menstruating adolescent girls and women, and pregnant and postpartum women. Daily iron supplementation reduces the risk of anemia in infants, children, and pregnant women, and intermittent iron supplementation reduces anemia risk in menstruating girls and women. Micronutrient powders reduce the risk of anemia in children. Fortifying wheat flour with iron reduces the risk of anemia in the overall population, whereas the effect of fortifying maize flour and rice is still uncertain. Regarding non-nutrition-related interventions, malaria treatment and deworming have been reported to decrease anemia prevalence. Promising interventions to prevent anemia include vitamin A supplementation, multiple micronutrient supplementation for pregnant women, small-quantity lipid-based supplements, and fortification of salt with iodine and iron. Future research could address the efficacy and safety of different iron supplementation formulations, identify the most bioavailable form of iron for fortification, examine adherence to supplementation regimens and fortification standards, and investigate the effectiveness of integrating micronutrient, helminth, and malaria control programs.

Impact of a school-based nutrition educational intervention on knowledge related to iron deficiency anaemia in rural Karnataka, India: A mixed methods pre-post interventional study

OBJECTIVE

To understand the extent to which adolescent awareness about anaemia and anaemia prevention can be changed by nutrition messages received at school.

DESIGN

Mixed-methods pre-post intervention study.

SETTING

Three government schools in Bagalkot, Belagavi and Raichur districts of Karnataka, India.

POPULATION

Students of grade six and seven and teachers involved in implementing the intervention.

METHODS

An educational intervention was co-developed by school teachers and nutrition experts using locally adapted resource materials that consisted of lectures, role play and practical demonstrations. Seven half-hour educational sessions were delivered by school teachers over 7 weeks to 455 students. Pre- and post-intervention tests measured changes in adolescents' knowledge about anaemia. Semi-structured in-depth interviews with teachers and focus groups with students explored their reactions to the intervention.

MAIN OUTCOME MEASURES

Knowledge score related to anaemia.

RESULTS

The percentage of children with correct scores increased by 7.3-49.0 percentage points for the tested questions after implementation of the intervention. The mean knowledge score increased by 3.67 ± 0.17 (p < 0.01). During interviews, teachers and students highlighted high acceptance of the intervention and materials, an increase in awareness, a positive attitude towards changing behaviour around diet, an increase in the demand for iron and folic acid supplements and improved sharing of messages learned with peers and families. Challenges expressed included need for further training, time limitations and hesitancy in teaching about menstruation and pregnancy.

CONCLUSIONS

Educational interventions carried out for adolescents by teachers in schools are effective in improving awareness and attitude related to anaemia and its prevention.

Biogenic engineered nanomaterials for enhancing bioavailability via developing nano-iron-fortified smart foods: advances, insight, and prospects of nanobionics in fortification of food

Iron deficiency is a significant cause of iron deficiency anemia (IDA). Treatment of IDA is challenging due to several challenges, including low target bioavailability, low palatability, poor pharmacokinetics, and extended therapeutic regimes. Nanotechnology holds the promise of revolutionizing the management and treatment of IDA. Smart biogenic engineered nanomaterials (BENMs) such as lipids, protein, carbohydrates, and complex nanomaterials have been the subject of extensive research and opened new avenues for people and the planet due to their enhanced physicochemical, rheological, optoelectronic, thermomechanical, biological, magnetic, and nutritional properties. Additionally, they show eco-sustainability, low biotoxicity, active targeting, enhanced permeation and retention, and stimuli-responsive characteristics. We examine the opportunities offered by emerging smart BENMs for the treatment of iron deficiency anemia by utilizing iron-fortified smart foods. We review the progress made so far and other future directions to maximize the impact of smart nanofortification on the global population. The toxicity effects are also discussed with commercialization challenges.

Iron supplements in pregnant women with normal iron status: A systematic review and meta-analysis

INTRODUCTION

Effects of daily iron supplementation in iron replete pregnancy are unclear. This systematic review aimed to assess benefits and harms of oral iron supplements in pregnant women without anemia and iron deficiency.

MATERIAL AND METHODS

We predefined and registered a protocol in PROSPERO (CRD42020186210) and performed the review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We searched for randomized clinical trials (RCTs) and observational studies comparing daily oral iron supplementation with no iron supplements in non-anemic iron replete pregnant women. Searches were conducted in MEDLINE (by PubMed), EMBASE (by OVID), Cochrane Library, and ClinicalTrials.gov from inception to September 2022 without language restrictions. Two authors independently screened records, extracted data, and assessed risk of bias using the revised Cochrane risk of bias tool (RoB2). One author read full-texts, assessed certainty of evidence by GRADE and conducted meta-analyses using a random-effects model. Primary outcomes included iron deficiency anemia, iron deficiency, hemoglobin >130 g/L, elevated iron status, small for gestational age newborns, low birthweight newborns, preterm birth, and congenital anomalies.

RESULTS

Eight RCTs (2822 women) but no observational studies were eligible for inclusion. Daily oral iron supplementation in pregnancy probably reduces iron deficiency anemia at term (risk ratio [RR]: 0.51, 95% confidence interval [CI]: 0.38-0.70; 4 RCTs, 1670 women; I2  = 13%; moderate-certainty evidence) and the incidence of low birthweight babies (RR: 0.30, 95% CI: 0.13-0.68; 2 RCTs, 361 infants; I2  = 0%; moderate-certainty evidence). In addition, it may reduce iron deficiency at term (RR: 0.74, 95% CI: 0.60-0.92; 4 RCTs, 1663 women; I2  = 58%; low-certainty evidence) and the incidence of small for gestational age babies (RR: 0.39, 95% CI: 0.17-0.86; 1 RCT, 213 infants; I2 not estimable; low-certainty evidence).

CONCLUSIONS

Daily iron supplementation in iron replete non-anemic pregnant women probably reduces the risk of maternal iron deficiency anemia at term and low birthweight.

Iron-fortified water: a new approach for reducing iron deficiency anemia in resource-constrained settings

A new approach for fortification of drinking water is presented for combating iron deficiency anemia (IDA) worldwide. The idea is to leach Fe from a bed containing granular metallic iron (Fe0), primarily using ascorbic acid (AA). AA forms very stable and bioavailable complexes with ferrous iron (FeII). Calculated amounts of the FeII-AA solution can be added daily to the drinking water of households or day-care centers for children and adults (e.g. hospitals, kindergartens/schools, refugee camps) to cover the Fe needs of the populations. Granular Fe0 (e.g., sponge iron) in filters is regarded as a locally available Fe carrier in low-income settings, and, AA is also considered to be affordable in low-income countries. The primary idea of this concept is to stabilize FeII from the Fe0 filter by using an appropriate AA solution. An experiment showed that up to 12 mg Fe can be daily leached from 1.0 g of a commercial sponge iron using a 2 mM AA solution. Fe fortification of safe drinking water is a practicable, affordable and efficient method for reducing IDA in low-income communities.

[Analysis on the iron status and associated factors during the first trimester of pregnancy]

OBJECTIVE

To investigate the impact of dietary and underlying factors on the iron status of women in early pregnancy and to provide evidence for preventing iron deficiency and iron deficiency anemia, thereby reducing the incidence of associated adverse outcomes.

METHODS

From November to December 2018, women in the first trimester of pregnancy (< 12 weeks gestation) who established prenatal records at the Shunyi District Maternal and Child Health Hospital, Beijing, were enrolled in this study, in which 388 participants were accessed for data including demographic characteristics, anthropometric measurements, parity, biomarkers reflecting iron status, and food-frequency questionnaire. SPSS 26.0 were used for statistical analysis. Dietary patterns were extracted using principal component analysis, and factor scores of each dietary pattern were calculated. Two-sided Fisher exact probability test and one-way ANOVA were conducted to access differences in iron status among the groups, and the differences were significant if P < 0.05. Iron deficiency was defined as serum ferritin(SF) < 30 μg/L. To analyze the potential role of dietary factors on iron deficiency during the first trimester, the collected data listed above were adopted as independent factors for the cross-sectional Logistic regression. We used Logistic regression to analyze the potential effects of baseline characteristics and dietary factors on iron status.

RESULTS

Among the 388 participants included in the analysis, 121 (32.2%) were iron deficient, in which 107 (27.6%) were iron depletion (ID), 8 (2.1%) were iron deficiency erythropoiesis (IDA), 6(1.5%) were iron deficiency anemia. The mean SF concentration was (50.4±35.3) μg/L. Multiparity(OR=3.9, 95%CI: 1.81-8.42, P=0.001)was a risk factor for iron deficiency during early pregnancy. No significant iron status differences were found among the participants with different educational levels and anthropometric measurements. In contrast, age (OR =0.96, 95%CI: 0.94-0.97, P < 0.001) was a protective factor. For multiparas, taking iron-containing supplements might have a protective effect for iron deficiency (OR=0.27, 95%CI: 0.09-0.83, P=0.022). The balance-diet pattern (OR=0.81, 95%CI: 0.66-1.00, P=0.054) only showed a marginally significant effect.

CONCLUSION

Increasing attention should be paid to the iron status of pregnant multiparas and young pregnant women. For those women of reproductive age with the risk factors listed above, especially for multiparas, iron-containing supplements should be recommended to prevent gestational iron deficiency. The effect of the "balance" dietary pattern on iron status in the first trimester and following requires further research and discussion.

Prevention and Management of Iron Deficiency/Iron-Deficiency Anemia in Women: An Asian Expert Consensus

The lack of standardized clinical practice impeding the optimal management of iron deficiency (ID) and iron deficiency anemia (IDA) in women is a global concern, particularly in the Asia-Pacific region. The aim of this study was to determine best practices through a Delphi consensus process. In Round 1, panelists were asked to rate their level of agreement with 99 statements across four domains: identification, diagnosis and assessment, prevention, and treatment of ID/IDA in women. In Round 2, panelists reappraised their ratings in view of the collective feedback and responses to Round 1. After two rounds, consensus (≥85% agreement) was reached for 84% of the Delphi statements. Experts agreed on the role of presenting symptoms and risk factors in prompting assessments of anemia and iron status in women. Experts repeatedly called for prevention, recommending preventive iron supplementation for pregnant women irrespective of anemia prevalence levels, and for non-pregnant adult women, adolescent girls, and perimenopausal women living in areas with a high prevalence of anemia. Experts unanimously agreed to prescribing oral ferrous iron as first-line therapy for uncomplicated ID/IDA. The recommendations and clinical pathway algorithms generated should be used to inform clinical practice and standardize the care of women at risk or presenting with ID/IDA in the Asia-Pacific region.

The Effect of Prebiotics on Human Iron Absorption: A Review

Iron deficiency remains the most common nutritional deficiency. Oral iron supplementation is the recommended first-line treatment and used as a preventive measure as well. Enhancers of iron absorption are highly sought after to improve supplementation outcomes. Evidence from animal and human studies exists that prebiotics can enhance iron absorption. The purpose of this present narrative review of the literature is to summarize the existing evidence on the effects of prebiotics on human iron absorption. Relevant articles were identified from PUBMED, Scopus, and Web of Science from inception to November 2021. Only human trials investigating the effect of prebiotics on iron absorption were included. Eleven articles were identified and included for review. There are promising findings supporting an enhancing effect of certain prebiotics, but inconsistencies between the studies and results exist. The most convincing evidence exists for the prebiotics galacto-oligosaccharides and fructo-oligosaccharides combined with the commonly used iron compound ferrous fumarate, from studies in adult women with low iron stores and in anemic infants. Many factors seem to play a role in the enhancing effect of prebiotics on iron absorption such as type of prebiotic, dose, acute (single-dose) or chronic (long-term) prebiotic consumption, iron compound, iron status, inflammatory status, and age of the population studied. More research investigating the optimal combination of prebiotic, iron compound, and dose as well as the effect of long-term application on iron status outcomes is needed.

Childhood and Adolescent Anemia Burden in India: The Way Forward

The burden of anemia in Indian children, based on capillary blood sampling, is believed to be profound and worsening (67.1%) according to the successive National Family Health Surveys (NFHS). This might be an overestimate. The recent Comprehensive National Nutrition Survey of Indian children, that used venous blood sampling, found only less than half (30.7%) the NFHS prevalence, of which only one third was due to iron deficiency (ID). Unfortunately, the apparently worsening NFHS anemia burden estimate has been interpreted as an inadequacy of the present iron supplementation policy. This has led to additional iron supply through mandatory rice fortification. However, the lack of efficacy of iron supplementation appears inevitable, if the true prevalence of iron deficiency anemia is only about 10%. Thus, etiology is a critical consideration when devising appropriate and effective prevention policies. Future policies must focus on precision, thoughtfulness, restraint, and community engagement.

Fundamental Aspects of the Development of a Model of an Integrated Health Care System for the Prevention of Iron Deficiency Anemia among Adolescent Girls: A Qualitative Study

Iron deficiency anemia (IDA) in adolescent girls is a problem that has not been resolved. This study aimed to explore the critical aspects of an integrated health care system model for preventing IDA in adolescent girls in a rural area of Indonesia. This qualitative research employed a grounded theory approach in order to build a substantive theory. This study used in-depth interviews with adolescents, parents, teachers, health workers, and persons in charge of adolescent programs at the health office, education office, and ministry of religion. Purposive sampling was performed until data saturation was achieved. Codes, categories, and themes were generated through thematic data analysis to develop a substantive theory. Data analysis was performed using MAXQDA 2022 software. A total of 41 people participated in this study. This investigation generated twenty-two categories and seven themes. These themes relate to policymaker commitments, stakeholder governance, quality, adolescents' lifestyles, adolescents' self-factors, adolescents' access to health services, and social support. The themes identified become fundamental aspects of the integrated health care system model for preventing IDA in adolescent girls. The model of the integrated health care system consists of several essential points, which include awareness and efforts from policymakers and adolescent girls, supported by parents, teachers, and the community.

Benefits and Risks of Early Life Iron Supplementation

Infants are frequently supplemented with iron to prevent iron deficiency, but iron supplements may have adverse effects on infant health. Although iron supplements can be highly effective at improving iron status and preventing iron deficiency anemia, iron may adversely affect growth and development, and may increase risk for certain infections. Several reviews exist in this area; however, none has fully summarized all reported outcomes of iron supplementation during infancy. In this review, we summarize the risks and benefits of iron supplementation as they have been reported in controlled studies and in relevant animal models. Additionally, we discuss the mechanisms that may underly beneficial and adverse effects.

Iron Deficiency in the United States: Limitations in Guidelines, Data, and Monitoring of Disparities

Iron deficiency and the more severe sequela, iron deficiency anemia, are public health problems associated with morbidity and mortality, particularly among pregnant women and younger children. The 1998 Centers for Disease Control and Prevention recommendations for prevention and control of iron deficiency in the United States is old and does not reflect recent evidence but is a foundational reference for many federal, clinical, and program guidelines. Surveillance data for iron deficiency are sparse at all levels, with critical gaps for pregnant women and younger children. Anemia, iron deficiency, and iron deficiency anemia are often conflated but should not be. Clinical guidelines for anemia, iron deficiency, and iron deficiency anemia give inconsistent recommendations, causing nonsystematic assessment of iron deficiency. Screening for iron deficiency typically relies on identifying anemia, despite anemia's low sensitivity for iron deficiency. In the National Health and Nutrition Examination Survey, more than 70% of iron deficiency is missed among pregnant women and children by relying on hemoglobin for iron deficiency screening. To improve assessment and diagnosis and strengthen surveillance, better and more complete data and updated foundational guidance on iron deficiency and anemia are needed that consider new evidence for measuring and interpreting laboratory results. (Am J Public Health. 2022;112(S8):S826-S835. https://doi.org/10.2105/AJPH.2022.306998).

Effectiveness of Dietary Intervention with Iron and Vitamin C Administered Separately in Improving Iron Status in Young Women

In order to maintain an adequate iron status in young women, effective dietary interventions should provide sufficient amounts of iron in everyday meals and improve the bioavailability of non-heme iron by providing vitamin C. While some intervention studies administering products rich in vitamin C in conjunction with iron sources showed improved iron status, it is unknown whether a separate administration of products rich in iron and vitamin C may be a successful strategy as well. The aim of this study was to assess the effectiveness of dietary intervention with iron and vitamin C administered separately in improving iron status in young women to prevent iron deficiency anemia. The study was conducted in a group of 29 women aged 18-30, and an 8-week dietary intervention was performed. Study participants with an adequate iron status received 50 g of iron-fortified oat flakes (as a source of non-heme iron) with breakfast and 200 mL of orange juice (as a source of vitamin C) in the second part of the day. Iron status was analyzed based on red blood cells, hemoglobin, hematocrit, serum ferritin, and serum iron, and it was assessed at baseline, after 4 weeks, and after 8 weeks of the intervention. The intakes of iron, vitamin C, and folate were controlled throughout the study period, and menstrual blood loss was estimated. After 8 weeks of intervention, statistically significant differences compared with baseline were observed only for hematocrit, as its level after 8 weeks of intervention was higher than the baseline (p = 0.0491). Comparing subsamples within the dietary intervention considered effective and ineffective for red blood cell levels, it was indicated that lower baseline vitamin C intake may result in a more effective dietary intervention (p = 0.0231). Comparing subsamples within the dietary intervention considered effective and ineffective for hemoglobin, hematocrit, iron, and serum ferritin levels, it was indicated that higher baseline levels of hemoglobin (p = 0.0143), hematocrit (p = 0.0497), iron (p = 0.0101), and serum ferritin (p = 0.0343) respectively may result in a more effective dietary intervention. It was concluded that dietary intervention with iron and vitamin C administered separately may be effective in improving iron status in young women to prevent iron deficiency anemia. It may be concluded that in the studied group, a better baseline iron status and lower baseline vitamin C intake may result in a more effective dietary intervention with iron and vitamin C administered separately to improve iron status in young women.

Effect of Picture-based health education and counselling on knowledge and adherence to preconception Iron-folic acid supplementation among women planning to be pregnant in Eastern Ethiopia: a randomized controlled trial

The present study examined the effect of picture-based nutrition education on knowledge and adherence to pre-conception iron-folic acid supplement (IFAS) in Ethiopia, a country where there is a high burden of neural tube defects (NTDs) and anaemia. In eastern Ethiopia, a parallel randomised controlled trial design was employed among women planning to get pregnant. The interventional arm (n 122) received a preconception picture-based nutrition education and counselling along with an IFAS and the control arm (n 122) received only a preconception IFAS. The effects of the intervention between-group differences were assessed using a χ 2 and independent sample t-test. Bivariate and multivariable linear regression model was fitted to detect independent variables affecting the outcome. The outcome measures regarding the knowledge and adherence to the IFAS intake during the three months of the intervention period were deteremined. It was observed that large proportion of women in the intervention group (42⋅6 %) had an adherence to IFAS compared to the control group (3⋅3 %); (P < 0⋅0001). Based on bivariate and multivariable linear regression analyses, among NTDs affecting pregnancy, the history of spontaneous abortion and knowledge were independently associated with adherence to the IFAS (P < 0⋅05). Preconception nutrition education with regular follow-ups could be effective in improving knowledge and adherence to the IFAS intake. This intervention is very short, simple, cost-effective and has the potential for adaptation development to a large-scale implementation in the existing healthcare system in Ethiopia to prevent NTDs and adverse birth outcomes among women who plan to get pregnant. This clinical trial was registered on 6 April 2021 under the ClinicalTrials.gov with an identifier number PACTR202104543567379.

Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status

BACKGROUND

Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low-resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large-scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double-fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted.  OBJECTIVES: To assess the effect of double-fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies.

SELECTION CRITERIA

All prospective randomised controlled trials (RCTs), including cluster-randomised controlled trials (cRCTs), and controlled before-after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible.

DATA COLLECTION AND ANALYSIS

Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear).  MAIN RESULTS: We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint.  With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low-certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD -96.86 μg/L, 95% CI -164.99 to -28.73; 7 studies, 1594 participants; low-certainty evidence), although both salts increased mean urinary iodine concentration above the cut-off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI -0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD -17.27 µg/L, 95% CI -49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD -3.94 µg/L, 95% CI -20.65 to 12.77; 5 studies, 1419 participants; low-certainty evidence) or transferrin receptor concentration (MD -4.68 mg/L, 95% CI -11.67 to 2.31; 5 studies, 1256 participants; low-certainty evidence) compared to IS. However, DFS may reduce zinc protoporphyrin concentration (MD -27.26 µmol/mol, 95% CI -47.49 to -7.03; 3 studies, 921 participants; low-certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low-certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate-certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low-certainty evidence).  Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration.

AUTHORS' CONCLUSIONS

Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free-living population (non-research population), where there could be an added cost to purchase double-fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status.

Dietary Approaches to Iron Deficiency Prevention in Childhood—A Critical Public Health Issue

Iron is an essential nutrient, and individual iron status is determined by the regulation of iron absorption, which is driven by iron requirements. Iron deficiency (ID) disproportionately affects infants, children, and adolescents, particularly those who live in areas with unfavorable socioeconomic conditions. The main reason for this is that diet provides insufficient bioavailable iron to meet their needs. The consequences of ID include poor immune function and response to vaccination, and moderate ID anemia is associated with depressed neurodevelopment and impaired cognitive and academic performances. The persistently high prevalence of ID worldwide leads to the need for effective measures of ID prevention. The main strategies include the dietary diversification of foods with more bioavailable iron and/or the use of iron-fortified staple foods such as formula or cereals. However, this strategy may be limited due to its cost, especially in low-income countries where biofortification is a promising approach. Another option is iron supplementation. In terms of health policy, the choice between mass and targeted ID prevention depends on local conditions. In any case, this remains a critical public health issue in many countries that must be taken into consideration, especially in children under 5 years of age.

A randomized trial of iron- and zinc-biofortified pearl millet-based complementary feeding in children aged 12 to 18 months living in urban slums

BACKGROUND & AIMS

Biofortification of staple crops with higher levels of micronutrients via traditional breeding methods is a sustainable strategy and can possibly complement fortification and other interventions to target micronutrient deficiencies in low resource settings, particularly among vulnerable populations such as children. We aimed to determine if iron- and zinc-biofortified pearl millet (FeZnPM, Dhanashakti, ICTP-8203Fe)-based complementary feeding improves nutritional status, including iron biomarkers and growth, in children living in urban slums of Mumbai.

METHODS

We conducted a randomized controlled trial of FeZnPM among 223 children aged 12-18 months who were not severely anemic at baseline (hemoglobin ≥9.0 g/dL). Children were randomized to receive either FeZnPM or conventional non-biofortified pearl millet (CPM) daily for 9 months. Iron status (hemoglobin, serum ferritin), plasma zinc, and anthropometric indicators (length, weight, mid-upper arm circumference, triceps and subscapular skinfolds) were evaluated at enrollment and throughout the trial. World Health Organization (WHO) anthropometric z-scores were calculated using WHO growth standards. Primary outcomes were hemoglobin and serum ferritin concentrations, and growth, defined as WHO z-scores. An intent to treat approach was used for analyses. We used the Hodges-Lehmann-Sen test to assess the change in primary outcomes between baseline and the last visit and report corresponding 95% confidence intervals.

RESULTS

At baseline, 67.7% of children were anemic (hemoglobin <11.0 g/dL) and 59.6% were iron deficient (serum ferritin <12.0 μg/L). FeZnPM did not significantly increase iron biomarkers or improve growth, compared to CPM. In subgroup analyses, FeZnPM improved hemoglobin concentrations in male children, and in children with iron deficiency or iron depletion (serum ferritin <25.0 μg/L) at baseline, relative to CPM.

CONCLUSIONS

Daily consumption of FeZnPM-based complementary foods did not significantly impact iron and zinc status or growth in children living in Mumbai's urban slums. However, the intervention significantly improved hemoglobin concentrations among male children and among individuals who were iron-deficient or iron-depleted at baseline.

TRIAL REGISTRATION

This trial is registered with Clinicaltrials.gov (ID: NCT02233764), and Clinical Trials Registry of India (ID: REF/2014/10/007731).

Ferritin-guided iron supplementation in whole blood donors: optimal dosage, donor response, return and efficacy (FORTE)-a randomised controlled trial protocol

BACKGROUND

Frequent whole blood donors have an increased risk of developing iron deficiency. Iron deficiency can have detrimental health effects when left untreated. Donation intervals are commonly too short to replenish iron stores and extending these reduces donor availability. Oral iron supplementation is known to shorten iron store recovery time but may also induce gastrointestinal complaints. We aim to optimise the effectiveness of iron supplements while minimising the risks of side effects. Therefore, we will evaluate the impact of different iron supplementation protocols in terms of dosage and frequency on ferritin and haemoglobin levels, gastrointestinal side effects, iron deficiency-related symptoms and donor return compared with placebo supplementation.

METHODS

Twelve hundred whole blood donors with ferritin levels ≤30 µg/L are included into a double-blind, randomised controlled trial. Participants are randomly allocated to one of six arms, administering capsules containing 0 mg, 30 mg or 60 mg of iron, either on alternate days or daily for 56 days. At baseline and 56, 122 and 182 days of follow-up, ferritin and haemoglobin levels are measured, and compliance, donor return, dietary iron intake, gastrointestinal, iron deficiency-related symptoms and general health are assessed by questionnaire.

ETHICS AND DISSEMINATION

This study will provide a comprehensive overview of the effects of different frequencies and dosages of administration of iron supplements on iron status and health effects, thereby considering individual differences in treatment adherence and lifestyle. The outcome will provide scientific evidence to guide the debate if and how oral iron supplements may support the recovery of whole blood donors with low ferritin levels.

TRIAL REGISTRATION NUMBER

NL8590; The Dutch trial registry.

High-dose intravenous iron supplementation after preoperative autologous blood donation is useful to prevent post-donation/preoperative anemia

To estimate the effectiveness of high-dose intravenous (IV) iron supplementation for iron deficiency anemia after preoperative autologous blood donation (PAD), 155 donors who visited the donation office of the University of Tokyo Hospital from December 2020 to June 2021 and showed suspected post-donation anemia were analyzed. The participants were treated with high-dose intravenous (IV) iron supplementation (high-dose group, n = 30) or a combination of low-dose IV iron and oral iron supplementation (low-dose group, n = 125). The preoperative hemoglobin (Hb) and Hb decreasing ratios during PAD (ΔHb) were compared between the two groups. Multivariate linear regression analyses were also performed to identify the confounding factors associated with preoperative Hb and ΔHb as well as high-dose IV iron supplementation. Preoperative Hb level was slightly higher in the high-dose group than in the low-dose group (12.1 ± 1.1 vs. 11.9 ± 1.1 g/dL, p = 0.27). ΔHb was significantly higher in the high-dose group than in the low-dose group (3.7 % ± 8.8 % vs. 7.7 % ± 6.5 %, p = 0.011). On the multivariate linear regression analyses, high-dose IV iron supplementation was significantly associated with higher preoperative Hb and lower ΔHb levels (p = 0.021 and 0.017, respectively) as well as the donation available period (period from the first visit to the donation office to the operation) and administration of erythropoiesis-stimulating agents. High-dose IV iron supplementation after PAD will be useful in the treatment of post-donation anemia.

Effect of educational program based on theory of planned behavior on promoting nutritional behaviors preventing Anemia in a sample of Iranian pregnant women

BACKGROUND

Iron deficiency anemia (IDA) is one of the most common problems during pregnancy. The aim of this research was to determine the effect of educational program based on Theory of Planned Behavior (TPB) on promoting nutritional behaviors preventing anemia in a pregnant woman in Shiraz city, Iran.

METHODS

This quasi-experimental study was done on 150 pregnant women (75 experimental and 75 control groups) who were selected using randomly sampling method in in Shiraz city, Iran, in 2020-2021. The educational intervention for the experimental group included six educational sessions for 50 or 55 min-based TPB model. A questionnaire consisted of items about demographic information, TPB constructs (attitude, perceived behavioral control, subjective norms and behavioral intention) was used to measure the nutritional behaviours preventing iron deficiency anemia in pregnancy women before and 3 months after the intervention.

RESULTS

The results showed that before the educational intervention, there was no significant difference between the two groups in terms of knowledge, attitude, perceived behavioral control, subjective norms, behavioral intention and nutritional performance; however, three months after the educational intervention, the experimental group showed a significant increase in each of the mentioned variables. For example the mean and standard deviation score of behavioral intention after intervention in the experimental group was significantly increased (25.57 ± 1.66, P = 0.001),and the mean and standard deviation score of performance after intervention in the experimental group was significantly increased (31.03 ± 2.19, P = 0.001), (P < 0.05).

CONCLUSIONS

After the educational intervention, the experimental group showed a significant increase in of the knowledge, attitude, perceived behavioral control, subjective norms, behavioral intention and nutritional performance. Therefore the results of the study showed positive effect of nutrition educational intervention program base on TPB model on improvement of iron deficiency anemia preventive behaviours in the pregnancy women.

Complementary Feeding and Iron Status: "The Unbearable Lightness of Being" Infants

The complementary feeding (CF) period that takes place between 6 and 24 months of age is of key importance for nutritional and developmental reasons during the transition from exclusively feeding on milk to family meals. In 2021, a multidisciplinary panel of experts from four Italian scientific pediatric societies elaborated a consensus document on CF, focusing in particular on healthy term infants. The aim was to provide healthcare providers with useful guidelines for clinical practice. Complementary feeding is also the time window when iron deficiency (ID) and iron deficiency anemia (IDA) are most prevalent. Thus, it is appropriate to address the problem of iron deficiency through nutritional interventions. Adequate iron intake during the first two years is critical since rapid growth in that period increases iron requirements per kilogram more than at any other developmental stage. Complementary foods should be introduced at around six months of age, taking into account infant iron status.

Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews

BACKGROUND

Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling).

OBJECTIVES

To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle.

METHODS

In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting).

MAIN RESULTS

We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus).

AUTHORS' CONCLUSIONS

Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.

Benefits and Risks of Iron Interventions in Infants in Rural Bangladesh

BACKGROUND

Universal provision of iron supplements (drops or syrup) or multiple micronutrient powders to young children in low-to-middle-income countries where anemia is prevalent is recommended by the World Health Organization and widely implemented. The functional benefits and safety of these interventions are unclear.

METHODS

We conducted a three-group, double-blind, double-dummy, individually randomized, placebo-controlled trial to assess the immediate and medium-term benefits and risks of 3 months of daily supplementation with iron syrup or iron-containing multiple micronutrient powders, as compared with placebo, in 8-month-old children in rural Bangladesh. The primary outcome was cognitive development, as assessed by the cognitive composite score on the Bayley Scales of Infant and Toddler Development, third edition, immediately after completion of the assigned 3-month regimen; scores range from 55 to 145, with higher scores indicating better cognitive performance. Secondary outcomes included the cognitive composite score at 9 months after completion of the assigned regimen; behavioral, language, and motor development, as well as growth and hematologic markers, immediately after completion and at 9 months after completion; and safety.

RESULTS

We randomly assigned 3300 infants to receive iron syrup (1101 infants), multiple micronutrient powders (1099), or placebo (1100) daily. After completion of the assigned 3-month regimen, no apparent effect on the cognitive composite score was observed with iron syrup as compared with placebo (mean between-group difference in change in score from baseline, -0.30 points; 95% confidence interval [CI], -1.08 to 0.48) or with multiple micronutrient powders as compared with placebo (mean between-group difference in change in score from baseline, 0.23 points; 95% CI, -0.55 to 1.00). No apparent effect on any other developmental or growth outcome was observed immediately after completion of the assigned regimen or at 9 months after completion. At 9 months after completion of the assigned regimen, the prevalences of anemia, iron deficiency, and iron deficiency anemia increased in all three trial groups but remained lower among the children who received iron syrup or multiple micronutrient powders than among those who received placebo. The risk of serious adverse events and incidence of symptoms of infection were similar in the three trial groups.

CONCLUSIONS

In this trial involving infants in Bangladesh, 3 months of daily supplementation with iron syrup or multiple micronutrient powders did not appear to have an effect on child development or other functional outcomes as compared with placebo. (Funded by the National Health and Medical Research Council of Australia; BRISC Australian New Zealand Clinical Trials Registry number, ACTRN12617000660381.).

Can the supplementary consumption of baobab (Adansonia digitata L.) fruit pulp improve the hemoglobin levels and iron status of schoolchildren in Kenya? Findings of a randomized controlled intervention trial

PURPOSE

In the rural Kenyan diet, the bioavailability of iron is low and predisposes the population to iron deficiency. Fruit pulp of the indigenous baobab tree contains significant amounts of vitamin C, which enhances non-heme iron bioavailability. We studied the impact of baobab fruit pulp (BFP) consumption on the hemoglobin (Hb) and iron status of Kenyan schoolchildren.

METHODS

The single-blind randomized controlled intervention trial was implemented daily among apparently healthy schoolchildren aged 6-12 years with hemoglobin level < 12.2 g/dl. For 12 weeks, children in the intervention group (n = 29) received a drink with BFP, while the control group (n = 29) received an isoenergy drink without BFP. At baseline and endline, blood samples were taken.

RESULTS

The development of hemoglobin, ferritin (FER) and soluble transferrin receptor (sTfR) did not differ significantly between the intervention and control groups. However, in the intervention group, Hb levels improved slightly (2.2%), while they decreased slightly (1.2%) in the control group. Levels of geometric means of sTfR remained almost unchanged (0.7%) in the intervention group and slightly worsened (2.7%) in the control group. In both the groups, geometric mean of FER levels decreased, yet to a smaller extent in the intervention (17.3%) than in the control (26.0%) group.

CONCLUSION

Even though no significant effects of BFP could be detected in this study, the identification of products such as BFP remains pertinent to help improve non-heme iron absorption in the most vulnerable populations.

A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency

BACKGROUND

Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools.

OBJECTIVES

This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity.

METHODS

We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools.

RESULTS

At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity.

CONCLUSIONS

Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.

Effect of Fortification with Multiple Micronutrient Powder on the Prevention and Treatment of Iron Deficiency and Anaemia in Brazilian Children: A Randomized Clinical Trial

Fortification with multiple micronutrient powder has been proposed as a public health intervention able to reduce micronutrient deficiencies in children. Our objective was to compare the effectiveness of fortification with multiple micronutrient powder with drug supplementation in the prevention and treatment of iron deficiency and anaemia. This was a cluster trial with anemic and non-anaemic children between six and 42 months old, in randomization data. Non anaemic children received fortification with multiple micronutrient powder or standard drug supplementation of ferrous sulfate associated with folic acid in a prevention dose. Anaemic children who were randomized to receive multiple micronutrient powder also received the recommended iron complementation for anaemia treatment. A total of 162 children were evaluated. The prevalence of anaemia decreased from 13.58 to 1.85%. Iron deficiency decreased from 21.74% to 7.89% (by serum ferritin) and iron deficiency decreased from 66.81 to 38.27% (by soluble transferrin receptor). No difference was identified between interventions for hemoglobin (p = 0.142), serum ferritin (p = 0.288), and soluble transferrin receptor (p = 0.156). Fortification with multiple micronutrient powder was effective in preventing iron deficiency and anaemia in children aged six to 48 months. In anaemic children; it was necessary to supplement the dose of multiple micronutrient powder with ferrous sulfate.

Periconceptional iron supplementation and risk of gestational diabetes mellitus: A prospective cohort study

AIMS

Iron supplementation has been recommended for healthy pregnancy, but concerns have been raised regarding the potential adverse effects. We sought to examine the impact of periconceptional iron supplement use on subsequent gestational diabetes mellitus (GDM) risk.

METHODS

Participants (N = 5101) with information on periconceptional micronutrient supplementation and diagnosis of GDM were involved. Information on iron supplementation and general characteristics were collected at enrollment and follow-up visits. GDM was diagnosed by oral glucose tolerance tests (OGTT) conducted at 24-28 weeks of gestation. Robust Poisson regression model was used to estimate the relative risks (RRs) and 95% confidence intervals (CI) for the effect of iron supplement use on GDM.

RESULTS

10.5% of the participants were diagnosed with GDM and the incidence was significantly higher in users with iron >30 mg/d for more than 3 months (Iron >30-L) than in nonusers. Adjusted RRs (95% CI) were 1.53 (1.21, 1.93) in Iron >30-L group, 1.14 (0.80, 1.61) in users with iron >30 mg/d for<3 months (Iron > 30-S) and 1.15 (0.86, 1.54) in users with iron ≤30 mg/d for any duration (Iron ≤30) respectively, compared to nonusers. This link in Iron >30-L group was even stronger (adjusted RR: 1.70, 95% CI: 1.25, 2.31) when restricting the analysis among primiparous and iron-replete participants without family history of diabetes. There were no significant differences in birth outcomes among groups.

CONCLUSIONS

Periconceptional iron supplementation >30 mg/d for long-term was associated with increased GDM risk. The need and safety of prophylactic iron supplement in iron-replete pregnant women should be reconsidered.

Effect of mass deworming with antihelminthics for soil-transmitted helminths during pregnancy

BACKGROUND

Helminthiasis is an infestation of the human body with parasitic worms. It is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis (hookworm infestation) is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron-deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries (LMIC) suffer from iron-deficiency anaemia. Though iron-deficiency anaemia is multifactorial, hookworm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious, but evidence of their beneficial effect and safety when given during pregnancy has not been established. This is an update of a Cochrane Review last published in 2015.

OBJECTIVES

To determine the effects of mass deworming with antihelminthics for soil-transmitted helminths (STH) during the second or third trimester of pregnancy on maternal and pregnancy outcomes.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (8 March 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

We included all prospective randomised controlled trials evaluating the effect of administration of antihelminthics versus placebo or no treatment during the second or third trimester of pregnancy; both individual-randomised and cluster-randomised trials were eligible. We excluded quasi-randomised trials and studies that were only available as abstracts with insufficient information.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, checked accuracy and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included a total of six trials (24 reports) that randomised 7873 pregnant women. All of the included trials were conducted in antenatal clinics within hospitals in LMICs (Uganda, Nigeria, Peru, India, Sierra Leone and Tanzania). Among primary outcomes, five trials reported maternal anaemia, one trial reported preterm birth and three trials reported perinatal mortality. Among secondary outcomes, included trials reported maternal worm prevalence, low birthweight (LBW) and birthweight. None of the included studies reported maternal anthropometric measures or infant survival at six months. Overall, we judged the included trials to be generally at low risk of bias for most domains, while the certainty of evidence ranged from low to moderate. Analysis suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia by 15% (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.72 to 1.00; I²= 86%; 5 trials, 5745 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on preterm birth (RR 0.84, 95% CI 0.38 to 1.86; 1 trial, 1042 participants; low-certainty evidence) or perinatal mortality (RR 1.01, 95% CI 0.67 to 1.52; 3 trials, 3356 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on hookworm (average RR 0.31, 95% CI 0.05 to 1.93; Tau² = 1.76, I² = 99%; 2 trials, 2488 participants; low-certainty evidence). Among other secondary outcomes, findings suggest that administration of antihelminthics during pregnancy may reduce the prevalence of trichuris (average RR 0.68, 95% CI 0.48 to 0.98; I²=75%; 2 trials, 2488 participants; low-certainty evidence) and ascaris (RR 0.24, 95% CI 0.19 to 0.29; I²= 0%; 2 trials, 2488 participants; moderate-certainty evidence). Antihelminthics during pregnancy probably make little or no difference to LBW (RR 0.89, 95% CI 0.69 to 1.16; 3 trials, 2960 participants; moderate-certainty evidence) and birthweight (mean difference 0.00 kg, 95% CI -0.03 kg to 0.04 kg; 3 trials, 2960 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia and worm prevalence when used in settings with high prevalence of maternal helminthiasis. Further data is needed to establish the benefit of antihelminthic treatment on other maternal and pregnancy outcomes. Future research should focus on evaluating the effect of these antihelminthics among various subgroups in order to assess whether the effect varies. Future studies could also assess the effectiveness of co-interventions and health education along with antihelminthics for maternal and pregnancy outcomes.

Multi-Nutrient Fortified Dairy-Based Drink Reduces Anaemia without Observed Adverse Effects on Gut Microbiota in Anaemic Malnourished Nigerian Toddlers: A Randomised Dose-Response Study

Prevalence of anaemia among Nigerian toddlers is reported to be high, and may cause significant morbidity, affects brain development and function, and results in weakness and fatigue. Although, iron fortification can reduce anaemia, yet the effect on gut microbiota is unclear. This open-label randomised study in anaemic malnourished Nigerian toddlers aimed to decrease anaemia without affecting pathogenic gut bacteria using a multi-nutrient fortified dairy-based drink. The test product was provided daily in different amounts (200, 400 or 600 mL, supplying 2.24, 4.48 and 6.72 mg of elemental iron, respectively) for 6 months. Haemoglobin, ferritin, and C-reactive protein concentrations were measured to determine anaemia, iron deficiency (ID) and iron deficiency anaemia (IDA) prevalence. Faecal samples were collected to analyse gut microbiota composition. All three dosages reduced anaemia prevalence, to 47%, 27% and 18%, respectively. ID and IDA prevalence was low and did not significantly decrease over time. Regarding gut microbiota, Enterobacteriaceae decreased over time without differences between groups, whereas Bifidobacteriaceae and pathogenic E. coli were not affected. In conclusion, the multi-nutrient fortified dairy-based drink reduced anaemia in a dose-dependent way, without stimulating intestinal potential pathogenic bacteria, and thus appears to be safe and effective in treating anaemia in Nigerian toddlers.

Iron deficiency in infancy: current insights

PURPOSE OF REVIEW

Iron deficiency is the most common micronutrient deficiency and infants are at particular risk. The purpose of this review is to summarize recent studies that explored the metabolism of iron in infants as well as the risks and benefits of iron supplementation in different populations.

RECENT FINDINGS

The ability of infants to regulate iron homeostasis is not fully known but most likely different from adults. Reducing iron deficiency has beneficial effects on neurodevelopment but iron overload may have adverse functional effects including diarrhea and even poor neurodevelopment. Recent studies have confirmed benefits of delayed cord clamping and supplementation of infants in risk groups while iron supplementation to pregnant women has shown limited effect in the offspring with regard to iron status and neurodevelopment. Further support is given to the recommendation that exclusive breast feeding, without supplementation, is safe for normal birth weight infants until 6 months whereafter an iron-rich diet should be given.

SUMMARY

Iron deficiency negatively impacts global health but efforts to identify optimal interventions are progressing. Yet, questions remain, particularly regarding long-term risks, benefits and optimal interventions for low birth weight infants as well as the level of iron fortification in infant formula.

Review of the Micronutrient Situation in Rwanda

BACKGROUND

Rwanda's commitment to reducing malnutrition is evident in their multisectoral nutrition policy and wide array of nutrition partners. However, the prevalence of micronutrient deficiencies and the suitability of current strategies to address existing deficiencies is unclear.

OBJECTIVE

To review the available evidence related to the prevalence of micronutrient deficiencies across the life cycle and strategies in place to address them.

METHODS

We reviewed scientific and grey literature on nutritional problems in Rwanda, emphasizing micronutrient deficiencies and anemia, and current strategies to address micronutrient malnutrition.

RESULTS

Overall, there is scant evidence related to the types and prevalence of micronutrient deficiencies among populations across the life cycle in Rwanda. Existing evidence is primarily limited to outdated or small regional surveys focusing on iron or vitamin A among women and young children. Surveys have assessed the prevalence of anemia and indicate that anemia is very high among young children and moderately high among other age-groups. However, there are limited data on the context-specific causes of anemia in Rwanda across population groups. Current nutrition strategies mainly target women and young children and are primarily designed to reduce vitamin A deficiency and/or anemia caused by micronutrient deficiencies.

CONCLUSIONS

Rwanda has many nutrition programs in place that address micronutrient deficiencies in young children and a few for women of reproductive age. However, gaps exist in knowledge of the extent of different types of micronutrient deficiencies among all populations across the life cycle and whether the delivery of nutrients through current programs is meeting actual needs.