Safety and Efficacy of Antenatal Iron Supplementation in a Malaria-endemic Area in Kenya: A Randomised Trial.

Objectives: Whereas coverage of antenatal iron supplementation is low and benefits are uncertain, there are concerns that it can increase the burden of malaria, with potentially devastating effects on maternal and neonatal health outcomes. We aimed to measure the effect of iron supplementation during pregnancy on maternal Plasmodium infection assessed at delivery, birth weight, gestational age, fetal growth and maternal and infant iron status. Methods: Rural Kenyan women (n=470) with singleton pregnancies, gestational age 13─23 weeks and haemoglobin concentration ≥ 90 g/L were randomised to supervised daily supplementation with iron (60 mg as ferrous fumarate) or placebo until 1 month postpartum. To prevent severe anaemia, all women additionally received 5.7 mg iron/day through flour fortification. Intermittent preventive treatment against malaria was given as usual. Plasmodium infection was assessed at birth by dipstick tests, PCR and histological examination of placental biopsies. Results: There was no evident effect on Plasmodium infection (both intervention groups: 45%; difference, 95% CI: 0%, ─9% to 9%). Iron supplementation increased birth weight by 143g (95% CI: 58─228g) and reduced the prevalence of low birth weight (<2,500g) by 65% (95% CI: 13%─86%). The effect on birth weight was larger in women who were initially iron-deficient than in those who were iron-replete (250 g versus ─13 g; p-interaction=0.008), and the improved birth weight seemed achieved mostly through improved fetal growth. Iron supplementation resulted in improved maternal iron status at 1 month postpartum, and improved infant iron stores. Conclusions: Coverage of universal antenatal iron supplementation must be increased.

Optical Brain Imaging as an Assessment Tool for Nutrition Related Cognitive Development in Rural Gambia: Studies from Birth to 24 Months of Age.

Objectives: Appropriate nutrition in the first 1000 days of life is essential for optimal brain development and function. Neurobehavioral assessments of cognitive function can only detect effects of nutritional deficiencies once they reach the point of observable behaviour, thus reducing the efficacy of early intervention strategies. The aim of this study was to demonstrate the use of optical imaging as an assessment tool for cognitive function in the first two years of life for nutrition based studies in a resource poor settings. Methods: Near infrared spectroscopy (NIRS) is an optical imaging technique which has been widely used to study cognitive function in infants in the developed world. Systems are portable and easy to setup, protocols are tolerant of participant motion, and non experts can easily be trained to perform the studies. We transported an NIRS system to a field station in rural Gambia to study infants from three age groups (4-8 month-olds n = 24; 9-13 month olds n = 26; 18-24 month-olds, n = 20) and used it to measure brain activation to visual and auditory social and non social stimuli. Results: Significant localised brain activation was seen during auditory social (e.g., laughter) compared to auditory non social (e.g., toy rattles) conditions - as well as to visual social (human peek-a-boo) compared to visual non social (transport images). Conclusions: These results confirm the viability of optical neuroimaging in resource poor settings, and its potential as an assessment tool for nutrition related studies of cognitive function.

Hepcidin Screening to Guide Iron Supplementation in African Children.

Objectives: Hematologic and non-hematologic benefits from iron supplementation are chiefly seen in iron deficient individuals; concerns that iron might promote infection especially in non-iron deficient individuals have complicated global anemia control policies, particularly in malaria-endemic settings. Iron homeostasis, including intestinal absorption, is controlled by hepcidin. Hepcidin is regulated by iron, erythropoietic drive, and inflammation, suggesting its potential utility to appraise iron status and thus guide iron supplementation. Methods: In 1338 African pre-school children we evaluated the Area Under the ROC Curve (AUCROC) for plasma hepcidin concentration as a diagnostic test of iron status, anemia type and erythrocyte incorporation of oral iron, determining and modeling the effects of cutoffs. Results: Hepcidin detected iron deficiency with an AUCROC = 0.85 (optimal sensitivity/ specificity at a cutoff of 5.5 ng/ml); this was not significantly affected by gender, wasting, malaria or carriage of inherited red cell disorders. In anemic children, hepcidin distinguished iron deficiency anemia from anemia of inflammation (AUCROC=0.89, optimal sensitivity/specificity cutoff 5.4 ng/ml). Hepcidin was the best predictor for >20% incorporation into erythrocytes of orally-administered 57Fe (AUCROC=0.90, optimal sensitivity/ specificity cutoff <6.9 ng/ml). If a hepcidin cutoff of 5.5 ng/ml had been used to guide iron supplementation in this population, 77% of iron deficient children would have received supplements while 80% of children with P. falciparum and 86% of children with anemia of inflammation would have avoided iron. Conclusions: In African children, hepcidin ascertains iron status, distinguishes iron deficiency anemia from anemia of inflammation, and hence could guide iron supplementation toward groups in whom it will likely be beneficial and safe.

Antropometría como predictor de diabetes gestacional: Estudio de cohorte / Anthropometry as predictor of gestational diabetes mellitus

Background: Gestational diabetes mellitus (GDM) is a high incidence disease. Easily measured predictor factors could help to implement preventive policies and early detection tests. Aim: To measure recognizable risk factors for GDM such as skinfolds and analyze the association between these factors and the development of GDM in a cohort of pregnant women. Material and Methods: Evaluation of 76 mothers that developed gestational diabetes, aged 32.2 ± 0.6 years and 324 control mothers that did not develop the disease, aged 30.1 ± 0.3 years. Weight, height, arm circumference, tricipital, bicipital, subscapular, suprailiac, knee, costal and mid-thigh skinfolds were measured in the pre-diseased stage. History of diabetes, fasting glucose and insulin levels were also evaluated. Results: Age, body mass index (BMI), fasting blood glucose, the homeostasis model assessment of insulin resistance (HOMA), bi-cipital, tricipital, costal, subscapular, suprailiac, and knee skinfolds were associated with GDM development. Age, fasting blood glucose and subscapular skinfolds were independent predictors in the logistic regression model. The odds ratio for a subs-capular skinfold over percentile 90 was 1.7 (95 percent confdence intervals: 1.07-3.04). Conclusions: Age and fasting blood glucose are independent risk factors for GDM. Subscapular skinfold is also an independent risk factor and could be used to detect high risk pregnant women and implement preventive policies.

Determinants of Appropriate Child Health and Nutrition Practices among Women in Rural Gambia.

Health education and awareness involves providing knowledge about causes of illness and choices to promote a change in individual behaviour and, thus, improves survival of individuals. Studies have, however, shown that improved knowledge and awareness is not always translated into appropriate actions. This study aimed at exploring the factors determining mothers’ choices of appropriate child health and nutrition practices in the Gambia. Eight focus-group discussions (FGDs) were held with 63 women whose children had been seen at the Keneba MRC Clinic within the 12 months preceding the study. The FGDs were analyzed using a thematic framework. Gender inequality, presence or absence of support networks, alternative explanatory models of malnutrition, and poverty were identified as the main factors that would determine the ability of a mother to practise what she knows about child health and nutrition. The findings highlight the need to consider the broader social, cultural and economic factors, including the value of involving men in childcare, when designing nutritional interventions.

Gestational diabetes, comparison of women diagnosed in second and third trimester of pregnancy with non GDM women: Analysis of a cohort study / Diabetes gestational, comparación entre mujeres diagnosticadas en el segundo y tercer trimestre del embarazo con mujeres sin diabetes gestacional: Análisis de un estudio de cohorte

Pregnant women are normally screenedfor Gestational diabetes (GDM) at week 24 of pregnancy. Howeversome women develop the disease later on their pregnancies. No study has analyzed women developing GDM later in pregnancy. Objective: To analyze data on a cohort study and compare women diagnosed with GDM in second and third trimester of pregnancy with women without GDM. Results: GDM women diagnosed during their first two trimesters of pregnancy were older (p = 0.0008) and had higher body mass Índex (BMI) (p = 0.0007) than non GDM women. However, the only risk factor in women diagnosed in their third trimester of pregnancy was having first degree relatives with type 2 DM and this was independent of age and BMI (OR of2.7, 95 percent CI 1.2 - 6.0). Conclusions: Women who develop GDM in their second trimester of pregnancy have known risk factors for diabetes mellitus such as age and higher BMI, however, the only recognised risk factor between non GDM women and women developing GDM late in pregnancy is family history of type 2 DM. Two populations ofGDM may exist andfuture studies should focus on analysing short and long term complications ofthese women to support the need to diagnosed and treat them all.

La pesquisa para diabetes gestacional (DG) se realiza normalmente en la semana 24 de embarazo. Sin embargo, muchas mujeres desarrollan la enfermedad más tardíamente durante el embarazo. No hay estudios analizando DG en tercer trimestre del embarazo. Objetivo: Analizar los datos de una cohorte para comparar mujeres con DG diagnosticada en segundo y tercer trimestre del embarazo con mujeres sin DG. Resultados: Las mujeres diagnosticadas en los primeros dos trimestres del embarazo eran mayores (p = 0,0008) y tenían mayor índice de masa corporal (IMC) (p = 0,0007) que las mujeres sin DG. El único factor de riesgo en mujeres diagnosticadas en el tercer trimestre del embarazo fue tener antecedentes familiares de DM, lo cual fue independiente de la edad e IMC (OR: 2,7, 95 por ciento CI 1,2 - 6,0). Conclusiones: Mujeres con DG diagnosticada en el segundo trimestre del embarazo tienen distintos factores de riesgo que mujeres diagnosticadas más tardíamente. Es posible que existan dos poblaciones de DG según el período de diagnóstico, por lo que debiera estudiarse si las complicaciones de estos dos subgrupos justifican el diagnóstico y tratamiento de ambos.

Early-life risk factors for adult chronic disease: follow-up of a cohort born during 1964-1978 in an urban slum of Lahore, Pakistan.

Evidence suggests that risk of chronic diseases may be programmed during the foetal and early life of the infant. With high rates of low birthweight coupled with a rapid nutritional transition, low-income countries are facing an epidemic of chronic diseases. Follow-up of a cohort of adults born during 1964-1978 in an urban slum in Lahore, Pakistan, is presented in this paper. In 695 of these adults (mean age=29.0 years, males=56%), blood pressure, fasting blood glucose, and body mass index (BMI) were measured to assess early-life predictors of risk of chronic diseases. Sixteen percent of the study population was born with a low birthweight (<2,500 g). A significant positive association (p=0.007) was observed between birthweight and BMI; additionally, adjusting for age and gender, the association with BMI was highly significant (p=0.000). Conversely, a significant negative association (p=0.016) was observed between birthweight and adult levels of fasting plasma glucose; after adjustment for age and gender, the association was more significant (p=0.005) No association was observed between birthweight and adult blood pressure. The results suggest that low birthweight may increase later risk of impaired glucose tolerance in urban Pakistani adults. Further research in this area is warranted.