Relative efficacy of micronutrient powders versus iron-folic acid tablets in controlling anemia in women in the second trimester of pregnancy.

BACKGROUND: Iron deficiency is a major cause of anemia and the most prevalent nutrient deficiency among pregnant women in developing countries. The use of iron and folic acid supplements to treat and prevent iron-deficiency anemia has limited effectiveness, mainly due to poor adherence. Home fortification with a micronutrient powder for pregnant women may be an effective and acceptable alternative to traditional drug models. OBJECTIVE: To determine whether home fortification with micronutrient powders is at least as efficacious as iron and folic acid tablets for improving hemoglobin concentration in pregnant women. METHODS: A cluster-randomized noninferiority trial was conducted in the rural subdistrict of Kaliganj in central Bangladesh. Pregnant women (gestational age 14-22 weeks, n=478), were recruited from 42 community-based Antenatal Care Centres. Each centre was randomly allocated to receive either a micronutrient powder (containing iron,folic acid, vitamin C, and zinc) or iron and folic acid tablets. Changes in hemoglobin from baseline were compared across groups using a linear mixed-effects regression model. RESULTS: At enrolment, the overall prevalence of anemia was 45% (n = 213/478). After the intervention period, the mean hemoglobin concentrations among women receiving the micronutrient powder were not inferior to those among women receiving tablets (109.5 ± 12.9 vs. 112.0 ± 11.2 g/L; 95% CI, -0.757 to 5.716). Adherence to the micronutrient powder was lower than adherence to tablets (57.5 ± 22.5% vs. 76.0 ± 13.7%; 95% CI, -22.39 to -12.94); however, in both groups, increased adherence was positively correlated with hemoglobin concentration. CONCLUSIONS: The micronutrient powder was at least as efficacious as the iron and folic acid tablets in controlling moderate to severe anemia during pregnancy.

Daily use of Sprinkles micronutrient powder for 2 months reduces anemia among children 6 to 36 months of age in the Kyrgyz Republic: a cluster-randomized trial.

BACKGROUND: Iron-deficiency anemia is widespread among young children in the Kyrgyz Republic, and there is an urgent need to identify an effective intervention to address this significant public health problem. OBJECTIVE: To test the effectiveness of a 2-month intervention with daily home fortification of complementary food using micronutrient powder (Sprinkles) in reducing anemia among children 6 to 36 months of age in the Kyrgyz Republic. METHODS: In this cluster-randomized, community-based effectiveness trial conducted in three regions of the Kyrgyz Republic, 24 clusters of children aged 6 to 36 months were randomly assigned to two groups. The intervention group (12 clusters, n = 1,103) received 60 sachets of micronutrient powder (12.5 mg elemental iron), which were taken as one sachet daily for 2 months. The control group (12 clusters, n = 1,090) did not receive micronutrient powder until after the study period. Blood hemoglobin concentration was assessed at the start and end of the intervention. RESULTS: From baseline to follow-up, the mean hemoglobin concentration in the intervention group increased by 7 g/L, whereas it decreased by 2 g/L in the control group (p < .001). The prevalence of anemia (hemoglobin < 110 g/L) in the intervention group decreased from 72% at baseline to 52% at follow-up, whereas it increased from 72% to 75% in the control group (p < .001). Compliance with the intervention was high, with children consuming on average 45 of the 60 sachets given. CONCLUSIONS: A course of 60 Sprinkles micronutrient powder sachets taken daily for 2 months is effective in improving hemoglobin levels and reducing the prevalence of anemia among young children in the Kyrgyz Republic.

Unexpectedly high early prevalence of anaemia in 6-month-old breast-fed infants in rural Bangladesh.

OBJECTIVE: To determine the prevalence of anaemia and maternal and infant factors associated with Hb values in infants at 6 months of age in rural Bangladesh. DESIGN: Infants (born to mothers supplemented with Fe-folic acid from mid-pregnancy) were visited at birth and 6 months of age. Mothers' anthropometric status, and infants' birth weight, gestational age at birth, weight and Hb concentration at 6 months were measured. Household socio-economic and demographic data, infant feeding practices and health status were collected using a pre-tested structured questionnaire. SETTING: Rural Bangladesh. SUBJECTS: Four hundred and two infants. RESULTS: For the total cohort (n 402), the range of anaemia prevalence values was from 30.6 % using a cut-off value of Hb < 95 g/l to 71.9 % using a value of Hb < 110 g/l. Birth weight and month of birth were the only factors positively associated with infant Hb in a linear regression model (P = 0.008 and 0.011, respectively). CONCLUSIONS: There was an unexpectedly high prevalence of anaemia in infants at 6 months of age, before the assumed period of vulnerability. Hb at this age tended to be higher in those with higher birth weight. We also found a season effect on Hb, as it tended to be higher as the study progressed. The high prevalence of anaemia at such an early age needs to be addressed to minimize the disease's long-term consequences.

A multiple-micronutrient-fortified beverage affects hemoglobin, iron, and vitamin A status and growth in adolescent girls in rural Bangladesh.

Adolescent girls have high nutrient needs and are susceptible to micronutrient deficiencies. The objective of this study was to test the effect of a multiple-micronutrient-fortified beverage on hemoglobin (Hb) concentrations, micronutrient status, and growth among adolescent girls in rural Bangladesh. A total of 1125 girls (Hb > or = 70 g/L) enrolled in a randomized, double-blind, placebo-controlled trial and were allocated to either a fortified or nonfortified beverage of similar taste and appearance. The beverage was provided at schools 6 d/wk for 12 mo. Concentrations of Hb and serum ferritin (sFt), retinol, zinc, and C-reactive protein were measured in venous blood samples at baseline, 6 mo, and 12 mo. In addition, weight, height, and mid-upper arm circumference (MUAC) measurements were taken. The fortified beverage increased the Hb and sFt and retinol concentrations at 6 mo (P < 0.01). Adolescent girls in the nonfortified beverage group were more likely to suffer from anemia (Hb <120 g/L), iron deficiency (sFt <12 microg/L), and low serum retinol concentrations (serum retinol <0.70 micromol/L) (OR = 2.04, 5.38, and 5.47, respectively; P < 0.01). The fortified beverage group had greater increases in weight, MUAC, and BMI over 6 mo (P < 0.01). Consuming the beverage for an additional 6 mo did not further improve the Hb concentration, but the sFt level continued to increase (P = 0.01). The use of multiple-micronutrient-fortified beverage can contribute to the reduction of anemia and improvement of micronutrient status and growth in adolescent girls in rural Bangladesh.

Effect of daily versus once-weekly home fortification with micronutrient Sprinkles on hemoglobin and iron status among young children in rural Bangladesh.

BACKGROUND: The effectiveness of commonly suggested public health interventions to control childhood iron-deficiency anemia has been low. OBJECTIVE: To determine whether iron provided in Sprinkles daily or in a higher dose once weekly affected hemoglobin, serum ferritin levels, and serum transferrin receptor levels, and to determine whether there were differences in the effects of the two regimens. METHODS: In this cluster-randomized, community-based trial conducted in rural areas of Bangladesh, 136 children aged 12 to 24 months with mild to moderate anemia (hemoglobin 70-109 g/L) were randomly allocated to receive Sprinkles daily (12.5 mg of elemental iron, n = 79) or once weekly (30 mg of elemental iron, n = 73) for 8 weeks. Hemoglobin, serum ferritin, and serum transferrin receptor were assessed at the start and end of the intervention. RESULTS: In both groups, there were significant increases in hemoglobin and serum ferritin and a significant decrease in serum transferrin receptor (p < .01). There were no significant differences between the groups in the increases in hemoglobin (16.1 +/- 13.2 g/L for the group receiving Sprinkles daily and 12.3 +/- 13.3 g/L for the group receiving Sprinkles once weekly) and serum ferritin (10.6 and 5.7 microg/L, respectively). The decrease in serum transferrin receptor also did not significantly differ between the groups (median, -2.5 and -1.8 mg/L, respectively). The prevalence rates of iron-deficiency anemia, depleted iron stores, and tissue iron deficiency decreased significantly within each group (p < .01), with no significant differences between the groups. CONCLUSIONS: Home fortification of complementary foods with Sprinkles given either daily or once weekly improved iron-deficiency anemia and iron status among young children.

Controlling iron deficiency anemia through the use of home-fortified complementary foods.

Iron deficiency anemia (IDA) is more common in South Asian countries including India, Bangladesh and Pakistan than anywhere else in the world. During infancy and early childhood, IDA is associated with impaired psycho-motor development and cognitive function that may be irreversible. As a consequence, there is a growing awareness that IDA is one of many factors impeding socio-economic prosperity of developing nations. The combination of unacceptably high prevalence rates and inadequate preventative programs highlights the need for new effective sustainable strategies to control IDA. The burden of iron deficiency can be reduced by taking a more holistic approach that would include promotion of healthy weaning practices and use of appropriate complementary foods, together with improving the nutritional value of such foods. There is an increasing body of peer-reviewed literature to support the contention that "micronutrient Sprinkles" is an effective strategy to improve the nutritional value of home-prepared complementary foods and thus to reduce the burden of iron deficiency among children. By combining data from recently conducted randomised control trials, Sprinkles were shown to be as efficacious as iron drops for treating childhood anemia. The iron in Sprinkles is well absorbed, and Sprinkles are easy to use and well accepted by young children and their caregivers. Integrated into existing public health programs, Sprinkles has the potential to improve the effectiveness of such programs.

Anaemia and iron deficiency during pregnancy in rural Bangladesh.

OBJECTIVE: To study the prevalence of anaemia and its association with measures of iron deficiency (ID) among a group of pregnant women. DESIGN: Cross-sectional survey. SETTING: Pregnant women identified through house-to-house visits and participating in community-based antenatal care activities in a rural location of Mymensingh, Bangladesh. SUBJECTS: The estimates are based on 214 reportedly healthy pregnant women in their second trimester. Information on socio-economic status and reproductive history were obtained through home visits and venous blood samples were collected at antenatal care centres. Haemoglobin concentration (Hb) was measured by HemoCue, serum ferritin (sFt) by radioimmunoassay and serum transferrin receptor (sTfR) by enzyme-linked immunosorbent assay methods. ID was defined as presence of either low sFt (<12 microg l(-1)) or high sTfR (>8.5 mg l(-1)). RESULTS: The prevalence of anaemia (Hb <110 g l(-1)) was 50%, but severe anaemia (Hb <70 g l(-1)) was absent. Low sFt was observed in 42%, high sTfR in 25%, either low sFt or high TfR in 54% and both low sFt and high TfR in 13% of the pregnant women. Two out of three anaemic women had an indication of ID, which was present in 80% of women with moderate (Hb 70-99 g l(-1)) and 50% with mild (Hb 100-109 g l(-1)) anaemia. Four out of 10 non-anaemic women (Hb >/=110 g l(-1)) also had ID, but the prevalence was significantly lower than that observed in anaemic women (P=0.001). CONCLUSIONS: Despite the high prevalence of anaemia, severe cases were absent. The prevalence of ID increased at lower Hb. However, an increased prevalence was also found among women in the highest category of Hb.

Efficacy and trial effectiveness of weekly and daily iron supplementation among pregnant women in rural Bangladesh: disentangling the issues.

BACKGROUND: According to our current understanding, iron absorption with weekly iron supplements is not higher than that with daily supplements (ie, there is no mucosal block). However, community-based trials have repeatedly shown that a weekly regimen is as effective as a daily one. Furthermore, when differences in absorption are found, they are commonly smaller than would be expected on the basis of differences in the amount of iron provided. The possibility of differential compliance between the regimens needs to be evaluated to explain these findings. OBJECTIVE: Taking compliance into account, we compared the efficacy and trial effectiveness of weekly and daily iron supplementation during pregnancy. DESIGN: In Bangladesh, 50 antenatal centers were randomly assigned to prescribe either 2 doses of 60 mg Fe once weekly or 1 dose of 60 mg Fe/d. Compliance was monitored by using a pill bottle equipped with an electronic counting device. Hemoglobin concentrations were measured at baseline and after 4, 8, and 12 wk of supplementation. RESULTS: There was no differential effect per iron tablet between weekly and daily regimens. A 12-wk daily regimen (68% compliance) produced a small but significantly greater hemoglobin response than did the weekly regimen (104% compliance). The first 20 tablets consumed produced most of the effect; after 40 tablets, there was no further response. CONCLUSIONS: There was no evidence of a mucosal block in the daily regimen. Over 12 wk, 50% of the amount of iron in a daily regimen was sufficient for maximum hemoglobin effect. The weekly regimen provided a large part of this amount, explaining the limited difference in effect. It appears that the current international recommendation for iron supplementation in pregnancy is higher than necessary.

Do side-effects reduce compliance to iron supplementation? A study of daily- and weekly-dose regimens in pregnancy.

Side-effects of iron supplementation lead to poor compliance. A weekly-dose schedule of iron supplementation rather than a daily-dose regimen has been suggested to produce fewer side-effects, thereby achieving a higher compliance. This study compared side-effects of iron supplementation and their impact on compliance among pregnant women in Bangladesh. These women were assigned to receive either weekly doses of 2 x 60 mg iron (one tablet each Friday morning and evening) or a daily dose of 1 x 60 mg iron. Fifty antenatal care centres were randomly assigned to prescribe either a weekly- or a daily-supplementation regimen (86 women in each group). Side-effects were assessed by recall after one month of supplementation and used for predicting compliance in the second and third months of supplementation. Compliance was monitored using a pill bottle equipped with an electronic counting device that recorded date and time whenever the pill bottle was opened. Of five gastrointestinal side-effects (heartburn, nausea, vomiting, diarrhoea, or constipation) assessed, vomiting occurred more frequently in the weekly group (21%) than in the daily group (11%, p<0.05). Compliance (ratio between observed and recommended tablet intake) was significantly higher in the weekly-supplementation regimen (93%) than in the daily-supplementation regimen (61%, p<0.05). Overall, gastrointestinal side-effects were not significantly associated with compliance. However, the presence of nausea and/or vomiting reduced compliance in both the regimens-but only among women from the lower socioeconomic group. In conclusion, weekly supplementation of iron in pregnancy had a higher compliance compared to daily supplementation of iron despite a higher frequency of side-effects. The findings support the view that gastrointestinal side-effects generally have a limited influence on compliance, at least in the dose ranges studied. Efforts to further reduce side-effects of iron supplementation may not be a successful strategy for improving compliance and effectiveness of antenatal iron supplementation.