Effects of Iron and Vitamin A Levels on Pregnant Women and Birth Outcomes: Complex Relationships Untangled Using a Birth Cohort Study in Uganda.

INTRODUCTION: Women and infants are among the most vulnerable groups for micronutrient deficiencies. Pregnancy micronutrient status can affect birth outcomes and subsequent infants' growth. METHODS: We determined the relationship between maternal iron and vitamin A status at delivery using several biomarkers (ferritin, soluble transferrin receptor [sTFR], body iron stores [BIS], hemoglobin and retinol binding protein [RBP]) and birth outcomes (body weight, Z-scores, head circumference, small-for-gestational-age and preterm birth) in rural Uganda. We investigated women who had serum results at the point of delivery and paired them to their infants at birth (n = 1244). We employed multivariable linear and logistic regression, adjusting for clustering at the subcounty level to determine the relationship between maternal micronutrients and birth outcomes. RESULTS: After adjusting for relevant factors, we found that maternal iron status (ferritin and BIS) and anemia (hemoglobin) were not significantly associated with the assessed birth outcomes. However, there was a significant association between serum sTFR and preterm births (AOR: 0.67; 95% CI 0.48-0.94). For Vitamin A, we observed a significant positive association between RBP and length-for-age (LAZ) at birth (ß = 0.12, p < 0.030). DISCUSSION: These findings indicate that the relationship between maternal iron status and birth outcomes needs to be further investigated, because depending on the biomarker used the associations were either in favor of an adverse birth outcome or not significant. Additionally, they confirm that higher maternal RBP levels could be beneficial for birth outcomes. CLINICALTRIALS: gov as NCT04233944.

Markers of Environmental Enteric Dysfunction Are Associated with Poor Growth and Iron Status in Rural Ugandan Infants.

BACKGROUND: Environmental enteric dysfunction (EED), characterized by altered intestinal permeability/inflammation, microbial translocation, and systemic inflammation (SI), may be a significant contributor to micronutrient deficiencies and poor growth in infants from low-resource settings. OBJECTIVE: We examined associations among EED, SI, growth, and iron status at 6 mo of age. METHODS: We performed a cross-sectional analysis of 6-mo-old infants (n = 548) enrolled in a Ugandan birth-cohort study (NCT04233944). EED was assessed via serum concentrations of anti-flagellin and anti- LPS immunoglobulins (Igs); SI was assessed via serum concentrations of ɑ1-acid glycoprotein (AGP) and C-reactive protein (CRP); iron status was assessed via serum concentrations of hemoglobin (Hb), soluble transferrin receptor (sTfR), and ferritin. Associations were assessed using adjusted linear regression analysis. RESULTS: At 6 mo, ∼35% of infants were stunted [length-for-age z score (LAZ) < -2] and ∼53% were anemic [hemoglobin (Hb) <11.0 g/dL]. Nearly half (∼46%) had elevated AGP (>1 g/L) and ∼30% had elevated CRP (>5 mg/L). EED and SI biomarkers were significantly correlated (r = 0.142-0.193, P < 0.001 for all). In adjusted linear regression models, which included adjustments for SI, higher anti-flagellin IgA, anti-LPS IgA, and anti-LPS IgG concentrations were each significantly associated with lower LAZ [ß (95% CI): -0.21 (-0.41, 0.00), -0.23 (-0.44, -0.03), and -0.33 (-0.58, -0.09)]. Furthermore, higher anti-flagellin IgA, anti-flagellin IgG, and anti-LPS IgA concentrations were significantly associated with lower Hb [ß (95% CI): -0.24 (-0.45, -0.02), -0.58 (-1.13, 0.00), and -0.26 (-0.51, 0.00)] and higher anti-flagellin IgG and anti-LPS IgG concentrations were significantly associated with higher sTfR [ß (95% CI): 2.31 (0.34, 4.28) and 3.13 (0.75, 5.51)]. CONCLUSIONS: EED is associated with both low LAZ and iron status in 6-mo-old infants. Further research on the mechanisms by which EED affects growth and micronutrient status is warranted.

Improving the iron status of school children through a school noon meal programme with meals prepared using a multiple micronutrient-fortified salt in Tamil Nadu, India.

BACKGROUND AND OBJECTIVES: To improve the iron status of school children through noon meals prepared using a multiple micronutrient-fortified salt. METHODS AND STUDY DESIGN: Children from a randomly selected school who consumed (intervention) and did not consume (reference) a noon meal prepared using a multiple micronutrient- fortified salt were studied over 1 year. A pre-post-test design for children aged 5-17years in reference (n=100) and intervention (n=128) groups was used. Levels of serum ferritin, soluble transferrin receptor (sTfR), alpha glycoprotein (AGP), and C-reactive protein (CRP) were assessed at baseline and at 1 year. In a subsample, urinary iodine was assessed. RESULTS: sTfR decreased in the intervention group (-0.80 mg/L) but increased in the reference group (0.47 mg/L) at 1 year (p=0.0001).Body iron stores (BIS) increased in the intervention group (0.09 mg/kg body weight) and decreased (-0.58 mg/kg body weight) in the reference group at 1 year (p=0.028).These findings indicate an increase in iron deficiency in the reference group and a decrease in the intervention group. However, no changes in serum ferritin and urinary iodine were observed in either group or between groups. CONCLUSIONS: Iron status can be improved in schoolchildren in Tamil Nadu by increasing the amount of micronutrients in the fortified salt used for preparing noon-time school meals.

Micronutrient status differs among Maasai and Kamba preschoolers in a supplementary feeding programme in Kenya.

Since 2001, ChildFund Kenya has supplied micronutrient fortified school meals to preschoolers from two tribes (Kamba and Maasai) attending early childhood development (ECD) centres in Emali, S.E. Kenya. Lack of information on the micronutrient status of the preschoolers prompted a cross-sectional assessment of micronutrient (iron, zinc, selenium, vitamin A, vitamin D) status and prevalence of deficiencies among the two tribes. Data on sociodemographic, health, anthropometric status, and micronutrient supply from preschool meals were collected from 287 Kamba and 213 Maasai children aged 3 to 5 years attending 23 ECD centres. Nonfasting blood samples were collected for haemoglobin and plasma biomarkers of iron, zinc, selenium, vitamin A, vitamin D, C-reactive protein (CRP), α1 -acid glycoprotein, and immunoglobin G. The prevalence of anaemia was significantly higher in Maasai children than Kamba (38%, 95% CI [31%, 45%], vs. 5%, [3%, 9%]), as well as iron deficiency and its various stages (P < 0.001). No differences were seen in the prevalence of zinc, selenium, vitamin A, or vitamin D deficiencies (all P > 0.05). Body iron, CRP, and age were significant predictors of haemoglobin concentrations for both tribes (all P < 0.006) and plasma 25-OHD for Maasai children only. The higher prevalence of iron deficiency among Maasai than Kamba children was possibly attributed to the high consumption of cow's milk (low in bioavailable iron) in place of micronutrient fortified meals together with a higher prevalence of chronic inflammation and intestinal damage.

Iron, zinc, vitamin A and selenium status in a cohort of Indonesian infants after adjusting for inflammation using several different approaches.

Inflammation confounds the interpretation of several micronutrient biomarkers resulting in estimates that may not reflect the true burden of deficiency. We aimed to assess and compare the micronutrient status of a cohort of Indonesian infants (n 230) at aged 6, 9 and 12 months by ignoring inflammation (unadjusted) and adjusting four micronutrient biomarkers for inflammation with C-reactive protein (CRP) and α-1-glycoprotein (AGP) using the following methods: (1) arithmetic correction factors with the use of a four-stage inflammation model; and (2) regression modelling. Prevalence of infants with any inflammation (CRP>5 mg/l and/or AGP>1 g/l) was about 25% at each age. Compared with unadjusted values, regression adjustment at 6, 9 and 12 months generated the lowest (P50 % across all ages. In conclusion, without inflammation adjustment, Fe deficiency was grossly under-estimated and vitamin A and Zn deficiency over-estimated, highlighting the importance of correcting for the influence of such, before implementing programmes to alleviate micronutrient malnutrition. However, further work is needed to validate the proposed approaches with a particular focus on assessing the influence of varying degrees of inflammation (i.e. recurrent acute infections and low-grade chronic inflammation) on each affected nutrient biomarker.

Prevalence and public health relevance of micronutrient deficiencies and undernutrition in pre-school children and women of reproductive age in Côte d'Ivoire, West Africa.

OBJECTIVE: To provide nationally representative data on the prevalence of anaemia, vitamin A and Fe deficiencies among pre-school age children (pre-SAC) and non-pregnant women of reproductive age (WRA), and on vitamin B12 and folate deficiencies in WRA, and the influence of inflammation on their interpretation. DESIGN: A cross-sectional survey to measure anthropometry, malaria parasitaemia and micronutrient status. Specifically, blood samples were analysed for Hb, plasma ferritin, soluble transferrin receptors, C-reactive protein, α1-acid glycoprotein, retinol-binding protein, vitamin B12 and folate. SETTING: Côte d'Ivoire in 2007. SUBJECTS: Nine hundred and twenty-eight WRA and 879 pre-SAC. RESULTS: In WRA, prevalence of Plasmodium parasitaemia (5 %) was low, but inflammation (34 %) was higher. Anaemia was a severe public health problem and prevalence differed by residency and eco-region. Inflammation-adjusted Fe deficiency was highest in urban areas (20 %). Nationally, folate deficiency was 86 %, higher in urban areas and varied by eco-region. Prevalence of vitamin B12 deficiency was low but higher in the rural areas and the north. Inflammation-adjusted vitamin A deficiency was very low (1 %). In pre-SAC, prevalence of inflammation (67 %) and Plasmodium parasites (25 %) was high; the latter was associated with poverty, rural residency and higher ferritin concentrations. Anaemia was classified as a severe public health problem (72 %), and was higher in rural areas (76 %) and the north (87 %). A quarter of pre-SAC suffered from vitamin A deficiency (inflammation-adjusted) and prevalence of undernutrition was high. CONCLUSIONS: Prevalence of inflammation, Plasmodium parasitaemia and micronutrient deficiencies were high in Côte d'Ivoire, particularly in pre-SAC. Nutritional interventions should be accompanied by strategies to reduce exposure to infections.

Plasma ferritin and soluble transferrin receptor concentrations and body iron stores identify similar risk factors for iron deficiency but result in different estimates of the national prevalence of iron deficiency and iron-deficiency anemia among women and children in Cameroon.

Available iron status indicators reflect different aspects of metabolism. We compared the prevalence and distribution of iron deficiency (ID) and iron-deficiency anemia (IDA) among Cameroonian women and children, as measured by plasma ferritin, and soluble transferrin receptor concentrations, body iron stores (BIS), and hemoglobin, and evaluated the impact of adjustments for inflammation on these measures. In a nationally representative survey, we randomly selected 30 clusters in each of 3 zones (north, south, and large cities) and 10 households/ cluster, each with a child aged 12-59 mo and a woman 15-49 y. Ferritin and BIS were mathematically adjusted for inflammation, using plasma C-reactive protein and α(1)-acid glycoprotein both as continuous and categorical variables. Inflammation was present in 48.0% of children and 20.8% of women and anemia was diagnosed in 57.6% of children and 38.8% of women. Depending on the iron status indicator applied, the prevalence of ID ranged from 14.2 to 68.4% among children and 11.5 to 31.8% among women, and the prevalence of IDA ranged from 12.0 to 47.4% among children and 9.0 to 19.4% among women; the proportion of anemia associated with ID ranged from 20.8 to 82.3% among children and 23.2 to 50.0% among women. The different iron indicators generally identified similar groups at greatest risk of deficiency, using both conventional and derived cutoffs: younger children, pregnant women, and women and children in the north and rural areas. Research is needed to clarify the relationships between iron status indicators, particularly in the presence of inflammation, to harmonize global data on prevalence of ID.

Micronutrient status during pregnancy is associated with child immune status in rural Bangladesh.

Background: Poor immune function increases children's risk of infection and mortality. Several maternal factors during pregnancy may affect infant immune function during the postnatal period. Objectives: We aimed to evaluate whether maternal micronutrients, stress, estriol, and immune status during the first or second trimester of pregnancy were associated with child immune status in the first two years after birth. Methods: We conducted observational analyses within the water, sanitation, and hygiene (WASH) Benefits Bangladesh randomized controlled trial. We measured biomarkers in 575 pregnant women and postnatally in their children. Maternal biomarkers measured during the first and second trimester of pregnancy included nutrition status via vitamin D (25-hydroxy-D [25(OH)D]), ferritin, soluble transferrin receptor (sTfR), and retinol-binding protein (RBP); cortisol; estriol. Immune markers were assessed in pregnant women at enrollment and their children at ages 14 and 28 mo, including C-reactive protein (CRP), alpha-1-acid glycoprotein (AGP), and 13 cytokines (including IFN-γ). We generated a standardized sum score of log-transformed cytokines. We analyzed IFN-γ individually because it is a critical immunoregulatory cytokine. All outcomes were prespecified. We used generalized additive models and reported the mean difference and 95% confidence intervals at the 25th and 75th percentiles of exposure distribution. Results: At child age 14 mo, concentrations of maternal RBP were inversely associated with the cytokine sum score in children (-0.34 adjusted difference between the 25th and 75th percentile [95% confidence interval -0.61, -0.07]), and maternal vitamin A deficiency was positively associated with the cytokine sum score in children (1.02 [0.13, 1.91]). At child age of 28 mo, maternal RBP was positively associated with IFN-γ in children (0.07 [0.01, 0.14]), whereas maternal vitamin A deficiency was negatively associated with child AGP (-0.07 [-0.13, -0.02]). Maternal iron deficiency was associated with higher AGP concentrations in children at age 14 mo (0.13 [0.04, 0.23]), and maternal sTfR concentrations were positively associated with child CRP concentrations at age 28 mo (0.18 [0, 0.36]). Conclusion: Maternal deficiencies in vitamin A or iron during the first 2 trimesters of pregnancy may shape the trajectory of a child's immune status.

Micronutrient status in lactating mothers before and after introduction of fortified flour: cross-sectional surveys in Maela refugee camp.

BACKGROUND: Deficiency of micronutrients is common in refugee populations. OBJECTIVES: Identify deficiencies and whether provided supplements and wheat flour fortified with 10 micronutrients impacts upon status among breast-feeding women from Maela refugee camp. METHODS: Two sequential cross-sectional studies were conducted in different groups of lactating mothers at 12 weeks postpartum. The first survey was before and the second 4-5 months after micronutrient fortified flour (MFF) had been provided to the camp (in addition to the regular food basket). Iron status and micronutrients were measured in serum, whole blood, and in breast milk samples. RESULTS: Iron and zinc deficiency and anemia were highly prevalent while low serum retinol and thiamine deficiency were rarely detected. Iron and zinc deficiency were associated with anemia, and their proportions were significantly lower after the introduction of MFF (21 vs. 35% with soluble transferrin receptor (sTfR) >8.5 mg/L, P = 0.042, and 50 vs. 73% with serum zinc <0.66 mg/L, P = 0.001). Serum sTfR, whole-blood thiamine diphosphate (TDP) and serum ß-carotene were significant predictors (P < 0.001) of milk iron, thiamine and ß-carotene, respectively. Lower prevalence of iron deficiency in the MFF group was associated with significantly higher iron and thiamine in breast milk. CONCLUSIONS: High whole-blood TDP and breast milk thiamine reflected good compliance to provided thiamine; high prevalence of iron deficiency suggested insufficient dietary iron and low acceptance to ferrous sulfate supplements. MFF as an additional food ration in Maela refugee camp seemed to have an effect in reducing both iron and zinc deficiency postpartum.

A Study to Improve the Vitamin A and Iodine Status of Pregnant Women through a Multiple Micronutrient Fortified Salt.

Background: To study the efficacy of a multiple micronutrient fortified salt enriched with iron, iodine, vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, niacin, and folic acid in improving serum retinol and iodine status of pregnant women. Methods: It was a randomized control trial in the antenatal clinic of a hospital. 151 women in the experimental group received a multiple micronutrient fortified salt to cook all their meals, and 150 women in the control group did not receive the fortified salt. Blood was collected in the three trimesters. Urine was collected in their first and third trimesters. Serum retinol, CRP (C-reactive protein), and AGP (Alpha glycoprotein) in blood were assessed, and iodine was assessed in urine. All the women were dewormed once. Results: The inflammation adjusted mean serum retinol in three trimesters in the experimental group was 24.51, 27.29, and 25.68 µg/dL, and it was 28.97, 27.63, and 22.72 µg/dL in the control group. Over the study period of 6 months, the increase in serum retinol in the experimental group was 1.17 µg/dL whereas in the control group serum retinol decreased by 6.25 µg/dL. The experimental group increase in serum retinol is significantly more (p=0.0001) than the changes in retinol in the control group. The prevalence of serum retinol deficiency in the three trimesters was 39.1%,25.8%, and 37.7% in the experimental group and 14%, 22.7%, and 39.3% in the control group, and the change in the experimental group was significant (p=0.001) compared to the control group by binary logistic regression. Over the study period of 6 months there is a significant increase in urinary iodine concentration in the experimental group (p=0.030), showing absorption of iodine from the fortified salt whereas there is a significant decline in the iodine values in the control group (p=0.008). At the end of the study, the urinary iodine concentration of the experimental group was significantly more (p=0.0001) than that of the control group. Conclusion: The fortified salt was able to improve serum retinol levels and urinary iodine levels in pregnant women. Trial Registration. This trial was registered retrospectively on 19/02/2022 in the ISRCTN registry with trial ID ISRCTN17782574.

Plasma retinol-binding protein predicts plasma retinol concentration in both infected and uninfected Cameroonian women and children.

Variation in the relationship between plasma retinol-binding protein (RBP) and retinol (ROH) has implications for vitamin A (VA) status assessment using RBP. Our objectives were to identify factors affecting the RBP:ROH relationship and to derive and evaluate population-specific RBP cutoffs for VA deficiency (VAD) in Cameroon. Plasma RBP, C-reactive protein (CRP), α1-acid-glycoprotein (AGP), and ROH concentrations were compared in a subsample of women 15-49 y (n = 121) and children 12-59 mo (n = 123) included in a national survey conducted in 2009. Plasma RBP and ROH were highly correlated (r = 0.94 for women; r = 0.96 for children; P < 0.001). Pregnancy and lactation altered the RBP:ROH relationship in women, but obesity, elevated CRP and AGP, age, and VA status did not. Among children, age altered the RBP:ROH relationship, but sex, stunting, VA status, and elevated CRP and AGP did not. Cutoffs for VAD derived using regression analysis were <1.17 µmol RBP/L for women (corresponding to <1.05 µmol ROH/L) and <0.83 µmol RBP/L for children (corresponding to <0.70 µmol ROH/L). The sensitivity and specificity of derived cutoffs were 81.8 and 93.0% for women and 94.7 and 88.9% for children, respectively. The infection-adjusted prevalence of low VA status (<1.17 µmol RBP/L) was 21.9% (95% CI = 18.7-25.0%) among women. Among children, the infection-adjusted prevalence of VAD (<0.83 µmol RBP/L) was 35.0% (95% CI = 31.1-39.0%). In conclusion, VAD remains a public health problem in Cameroon. The RBP:ROH relationship should be considered in surveys using RBP to assess VA status, and use of population-specific cutoffs may be advisable.

Fermented soyabean and vitamin C-rich fruit: a possibility to circumvent the further decrease of iron status among iron-deficient pregnant women in Indonesia.

OBJECTIVE: Increasing the consumption of Fe-rich foods and thus improving Fe bioavailability without significantly increasing diet cost is the most sustainable intervention for improving Fe intake. We assessed the effect of supplementary food consisting of fermented soyabean (tempeh) and vitamin C-rich fruit consumed during pregnancy on maternal iron deficiency (ID). DESIGN: Pregnant women were randomly allocated by village into optimized diet and control groups. Supplementary food was given 6 d/week at home. The average weekly food provided comprised 600 g of tempeh, 30 g of meat, 350 g of guava, 300 g of papaya and 100 g of orange. Hb, ferritin and transferrin receptor (TfR) concentrations were measured at 12-20 and at 32-36 weeks of gestation. SETTING: Thirty-nine villages in Indonesia. SUBJECTS: Pregnant women (12-20 weeks of gestation, n 252). RESULTS: At baseline, mean Hb, ferritin and TfR concentrations and body Fe concentration were within the normal range and did not differ between groups. At near term, mean Hb, ferritin and body Fe decreased, whereas mean TfR increased significantly in both groups. The mean changes in Fe status were similar in both groups. In Fe-deficient women, consumption of an optimized diet was associated with smaller decreases in Hb (1·02 (95% CI 0·98, 1·07) g/l; P = 0·058), ferritin (1·42 (95% CI 1·16, 1·75) µg/l; P = 0·046) and body Fe (2·57 (95% CI 1·71, 3·43) mg/kg; P = 0·073) concentrations, compared with a state of no intervention. Fe-deficient women at baseline benefited more from supplementary food compared with Fe-replete women. CONCLUSIONS: Daily supplementary food containing tempeh and vitamin C-rich fruits during pregnancy might have positive effects on maternal ID.

Improving Micronutrient Status of Children and Women in Rural Communities in India Using Crystal Salt Enriched with Multiple Micronutrients.

To demonstrate that fortified crystal salt enriched with iron, iodine, vitamin B12, folic acid and zinc can combat multi-micronutrient deficiencies. A randomized controlled study was conducted in 6 villages in Tiruvallur district, in Tamilnadu, South India. All the women and children aged 5-17 y in households in the experimental villages (n=117) were provided the fortified salt for 8 mo. Similar demographic group in the control villages (n=95) used regular non-fortified salts for the same time period. Blood from study subjects were analysed for hemoglobin, serum ferritin, serum transferrin receptor, AGP, CRP, and serum zinc, at the beginning and end of the study. Urine was analyzed for iodine at the same times. The experimental group showed a statistically significant increase in hemoglobin (>1.05 g/dL), serum zinc (>12.23 µg/dL), ferritin (>6.97 µg/L) and body iron stores (>0.73 mg/kg body weight), compared to the control group. A significant decrease in the prevalence of anaemia from 67.5% to 29.1% and zinc deficiency from 32.7% to 12.4% was observed in the experimental group relative to control group, using Binary logistic regression. There was no change in urinary iodine in the experimental group while it decreased significantly in the control. The fortified crystal salt was effective in decreasing multi-micronutrient deficiencies.

Association of maternal diet, micronutrient status, and milk volume with milk micronutrient concentrations in Indonesian mothers at 2 and 5 months postpartum.

BACKGROUND: Maternal micronutrient deficits during preconception and pregnancy may persist during lactation and compromise human milk composition. OBJECTIVE: We measured micronutrient concentrations in human milk and investigated their association with maternal micronutrient intakes, status, and milk volume. METHODS: Infant milk intake (measured via a deuterium dose-to-mother technique), milk micronutrient and fat concentrations, and maternal micronutrient intakes were assessed at 2 and 5 mo postpartum in 212 Indonesian lactating mother-infant pairs. Maternal hemoglobin, ferritin, transferrin receptors, retinol binding protein (RBP), zinc, selenium, and vitamin B-12 were measured at 5 mo (n = 163). Multivariate or mixed effects regression examined associations of milk micronutrient concentrations with maternal micronutrient intakes, status, and milk volume. RESULTS: Prevalence of anemia (15%), and iron (15% based on body iron), selenium (2.5%), and vitamin B-12 deficiency (0%) were low compared with deficiencies of zinc (60%) and vitamin A (34%). The prevalence of inadequate intakes was >50% for 7 micronutrients at 2 and 5 mo. Median milk concentrations for most micronutrients were below reference values, and nearly all declined between 2 and 5 mo postpartum and were not associated substantially with milk volume (except for ß-carotene, α-carotene, and ß-cryptoxanthin). At 5 mo postpartum, associations between maternal micronutrient status and corresponding milk concentrations reported as mean percentage difference in human milk concentration for each unit higher maternal biomarker were significant for hemoglobin (1.9%), iron biomarkers (ranging from 0.4 to 7%), RBP (35%), selenium (70%), and vitamin B-12 (0.1%), yet for maternal intakes only a positive association with ß-carotene existed. CONCLUSIONS: Most milk micronutrient concentrations declined during lactation, independent of changes in human milk production, and few were associated with maternal micronutrient intakes. The significant associations between maternal biomarkers and milk micronutrient concentrations at 5 mo warrant further study to investigate whether the declines in milk micronutrients are linked to shifts in maternal status.

Impact of a multiple-micronutrient fortified salt on the nutritional status and memory of schoolchildren.

OBJECTIVE: This study was conducted to test the efficacy of a multiple micronutrient-fortified cooking salt. METHODS: A randomized controlled trial with a pre- and post-test design was used to study children 5 to 18 years of age, with an experimental (n=213) and control group (n=189). The children were sampled from 3 residential schools and were studied for 9 months. The experimental group received a multiple micronutrient-fortified salt containing vitamins A, B(1), B(2), B(6), B(12), as well as folic acid, niacin, iron, iodine, and zinc. The control group received iodized salt. Biochemical measurements [hemoglobin, serum ferritin (SF), serum transferrin receptor (sTfR), C-reactive protein (CRP), alpha-1 acid glycoprotein (AGP), serum retinol, serum vitamin B(12), serum folic acid, serum zinc, and urinary iodine (UI)] were measured at baseline and post-intervention. Hemoglobin was measured in all the children three times during the study period, while the remaining biochemical measurements were performed in a subsample of children. Children between 11 and 18 years of age were given cognitive tests to assess memory and attention. RESULTS: There was a significant improvement (p<0.05) in all the biochemical measurements and memory tests in the experimental group when compared with the control group. Post-intervention in the experimental group, the increase in hemoglobin was 0.67 g/dL (p<0.05). Iron status and body iron stores increased significantly (p<0.05) in the experimental group compared to the control group, while serum zinc increased by 50 mug/dL (p<0.05), and the prevalence of retinol deficiency decreased from 57.1 % at baseline to 16 % post-intervention (p<0.05). CONCLUSION: The multiple micronutrients from the multiple micronutrient-fortified cooking salt were absorbed in the children and helped in combating micronutrient deficiencies.

An HPLC Ultraviolet Method Using Low Sample Volume and Protein Precipitation for the Measurement of Retinol in Human Serum Suitable for Laboratories in Low- and Middle-Income Countries.

BACKGROUND: Assessing vitamin A status in populations remains a high public health priority for low- and middle-income countries. However, analytical difficulties with serum retinol measurements persist in international laboratories. Nearly all participants in a Centers for Disease Control and Prevention external quality assessment program use HPLC to measure serum retinol, but round-to-round results failing to meet acceptable criteria suggest the need to provide a straightforward stable HPLC ultraviolet (UV) method that can be adopted by these laboratories to improve performance. We present a protein precipitation HPLC-UV method that measures serum retinol below the deficiency cutoff value (<0.7 µmol/L or 20 µg/dL) that is suitable for low- and middle-income countries and uses commercially available materials. METHODS: Serum (25 µL) added to retinyl acetate was precipitated with acetonitrile (125 µL) to extract retinol. Solvent-based calibration solutions required no extraction. Calibration used either single-point (50 µg/dL) or multipoint solutions (0.52-100 µg/dL). C18 column (4.6 × 100 mm) and acetonitrile with 0.1% triethylamine/water (83/17, v/v) as isocratic mobile phase (1.1 mL/min), achieved baseline separation (7 minutes). RESULTS: With only 25 µL of serum, the limit of detection was 0.52 µg/dL. Single- and multipoint calibration generated equivalent results. Over several years, between-run imprecision was ≤7.1% in multiple quality-control materials. Overall mean (CV) method bias for NIST-certified reference materials (e-series) was -0.2% (5.8%). Maximally, 180 samples were processed within 24 h. CONCLUSIONS: This method was robust and stable over years and accurately measured serum retinol with low-volume samples. Thus, it may be of interest to low- and middle-income countries and to pediatric and finger stick applications.

Multiple micronutrient status and predictors of anemia in young children aged 12-23 months living in New Delhi, India.

Anemia has been identified as a severe public health concern among young children in India, however, information on the prevalence of anemia attributed to micronutrient deficiencies is lacking. We aimed to assess multiple micronutrient status (iron, zinc, selenium, vitamin A, vitamin D, folate and vitamin B12) in young Indian children and to investigate the role of these seven micronutrients and other non-nutritional factors on hemoglobin concentrations and anemia. One-hundred and twenty children aged 12 to 23 months were included in a cross-sectional nutritional assessment survey, of which 77 children provided a blood sample. Hemoglobin (Hb), serum ferritin, soluble transferrin receptor (sTfR), total body iron, zinc, selenium, retinol binding protein (RBP), folate, vitamin B12 and 25-hydroxyvitamin D (25(OH)D) were measured, and adjusted for inflammation using C-reactive protein (CRP) and α-1-acid glycoprotein (AGP), where appropriate. Predictors for hemoglobin and anemia were identified in multiple regression models. Most of the children were classified as anemic, of which 86 to 93% was associated with iron deficiency depending on the indicator applied. Deficiencies of folate (37%), and notably vitamin D (74%) were also common; fewer children were classified with deficiencies of vitamin B12 (29%), zinc (25%), and vitamin A (17%) and selenium deficiency was nearly absent. Multiple micronutrient deficiencies were common with over half (57%) deficient in three or more micronutrients, and less than 10% of children were classified with adequate status for all the micronutrients measured. Iron status was found to be the only nutritional factor statistically significantly inversely associated with anemia (P = 0.003) in multivariate analysis after controlling for sex. A coordinated multi-micronutrient program is urgently needed to combat the co-existing micronutrient deficiencies in these young children to improve micronutrient status and reduce the high burden of childhood anemia.

Effect of vitamin A supplementation with BCG vaccine at birth on vitamin A status at 6 wk and 4 mo of age.

BACKGROUND: The effect of vitamin A supplementation (VAS) at birth on subsequent vitamin A status has not been studied. OBJECTIVE: The objective was to study the effect of 50,000 IU vitamin A administered with BCG vaccine at birth on vitamin A status in both sexes. DESIGN: Within a randomized placebo-controlled trial of VAS, we obtained blood from 614 children at 6 wk of age and from 369 mother-infant pairs at 4 mo of age. We assessed vitamin A status on the basis of serum retinol-binding protein (RBP) and measured serum C-reactive protein to monitor for concurrent infections. RESULTS: RBP concentrations indicated vitamin A deficiency in 32% of the children at age 6 wk and in 16% at age 4 mo. VAS was not associated with higher RBP concentrations overall or in either sex. However, the effect of VAS varied with maternal education (P for interaction = 0.004): At age 6 wk, VAS was associated with higher (9%; 95% CI: 2, 17%) RBP concentrations in children of noneducated mothers but not in children of educated mothers. Overall, RBP concentrations increased between 6 wk and 4 mo of age. The increase correlated inversely with the number of diphtheria-tetanus-pertussis (DTP) vaccines received in the interval (P = 0.009), particularly in girls (P for interaction = 0.01) and in vitamin A recipients (P = 0.01). CONCLUSIONS: Overall, VAS at birth had no effect on vitamin A status. However VAS may temporarily improve vitamin A status in the subgroup of children of noneducated mothers. In vitamin A recipients, subsequent DTP vaccines affected vitamin A status negatively. The main trial was registered at clinicaltrials.gov as NCT00168597.

Effect of daily or weekly multiple-micronutrient and iron foodlike tablets on body iron stores of Indonesian infants aged 6-12 mo: a double-blind, randomized, placebo-controlled trial.

BACKGROUND: There is still uncertainty about the best procedure to alleviate iron deficiency. Additionally more reliable methods are needed to assess the effect of iron intervention. OBJECTIVE: We examined the efficacy of daily iron (10 mg), daily and weekly multiple-micronutrient supplementation (10 and 20 mg Fe, respectively) in improving body iron stores of Indonesian infants. DESIGN: Infants aged 6-12 mo were randomly allocated to 1 of 4 groups: daily multiple-micronutrients (DMM) foodlike tablets (foodLETs), weekly multiple-micronutrient (WMM) foodLETs, daily iron (DI) foodLETs, or daily placebo. Hemoglobin, ferritin, transferrin receptors, and C-reactive protein data were obtained at baseline and 23 wk. RESULTS: Body iron estimated from the ratio of transferrin receptors to ferritin was analyzed for 244 infants. At baseline, mean iron stores (0.5 +/- 4.1 mg/kg) did not differ among the groups, and 45.5% infants had deficits in tissue iron (body iron < 0). At week 23, the group DI had the highest increment in mean body iron (4.0 mg/kg), followed by the DMM group (2.3 mg/kg; P < 0.001 for both). The iron stores in the WMM group did not change, whereas the mean body iron declined in the daily placebo group (-2.2 mg/kg; P < 0.001). Compared with the daily placebo group, the DMM group gained 4.55 mg Fe/kg, the DI group gained 6.23 mg Fe/kg (both P < 0.001), and the WMM group gained 2.54 mg Fe/kg (P = 0.001). CONCLUSIONS: When compliance can be ensured, DI and DMM foodLETs are efficacious in improving and WMM is efficacious in maintaining iron stores among Indonesian infants.

Malian children with moderate acute malnutrition who are treated with lipid-based dietary supplements have greater weight gains and recovery rates than those treated with locally produced cereal-legume products: a community-based, cluster-randomized trial.

BACKGROUND: Moderate acute malnutrition (MAM), defined as weight-for-length z score between -3 and -2 or midupper arm circumference between 11.5 and 12.5 cm, affects ∼33 million children aged <5 y worldwide. OBJECTIVE: The objective was to compare the effects of 4 dietary supplements for the treatment of MAM. DESIGN: Twelve community health centers in rural Mali were randomly assigned to provide to 1264 MAM children aged 6-35 mo one of 4 dietary supplements containing ∼500 kcal/d for 12 wk: 1) ready-to-use, lipid-based supplementary food (RUSF); 2) special corn-soy blend (CSB++); 3) locally processed, fortified flour (Misola); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). RESULTS: In total, 1178 children (93.2%) completed the study. The adjusted mean (95% CI) change in weight (kg) from baseline was greater with RUSF than with the locally processed blends and was intermediate with CSB++ [1.16 (1.08, 1.24) for RUSF, 1.04 (0.96, 1.13) for CSB++, 0.91 (0.82, 0.99) for Misola, and 0.83 (0.74, 0.92) for LMF; P < 0.001]. For length change, RUSF and CSB++ differed significantly from LMF. Sustained recovery rates were higher with RUSF (73%) than with Misola (61%) and LMF (58%), P < 0.0001; CSB++ recovery rates (68%) did not differ from any of the other groups. CONCLUSIONS: RUSF was more effective, but more costly, than other dietary supplements for the treatment of MAM; CSB++ yielded intermediate results. The benefits of treatment should be considered in relation to product costs and availability.