South East Asian Nutrition Surveys (SEANUTS) II - a multi-country evaluation of nutrition and lifestyle indicators in children aged 12 years and below: Rationale and Design.

OBJECTIVE: To assess the nutritional status, growth parameters and lifestyle behaviours of children between 0.5-12 years in nationally representative samples in Malaysia, Indonesia, Thailand, and Vietnam. DESIGN: A cross-sectional study was conducted in the four countries, between May 2019 and April 2021. Data collected can be categorized into four categories: (1) Growth - anthropometry, body composition, development disorder, (2) Nutrient intake and dietary habits - 24-hour dietary recall, child food habits, breast feeding and complementary feeding, (3) Socio-economic status - food insecurity and child health status/environmental, and (4) Lifestyle behaviours - physical activity patterns, fitness, sunlight exposure, sleep patterns, body image and behavioural problems. Blood samples were also collected for biochemical and metabolomic analyses. With the pandemic emerging during the study, a COVID-19 questionnaire was developed and implemented. SETTING: Both rural and urban areas in Malaysia, Indonesia, Thailand, and Vietnam. PARTICIPANTS: Children who were well, with no physical disability or serious infections/injuries and between the age of 0.5-12 years old were recruited. RESULTS: The South East Asian Nutrition Surveys II recruited 13,933 children. Depending on the country, data collection from children were conducted in schools and commune health centres, or temples, or sub-district administrative organizations. CONCLUSIONS: The results will provide up-to-date insights into nutritional status and lifestyle behaviours of children in the four countries. Subsequently, these data will facilitate exploration of potential gaps in dietary intake among Southeast Asian children and enable local authorities to plan future nutrition and lifestyle intervention strategies.

South East Asian Nutrition Surveys II (SEANUTS II) Thailand: Triple burden of malnutrition among Thai children aged 6 months to 12 years.

OBJECTIVE: This study assessed nutritional status among Thai children using anthropometry, dietary intakes, and micronutrient status. DESIGN: Cross-sectional survey with multi-stage cluster sampling. Body weight and height were measured in all children. Dietary intakes were assessed using 24-hour dietary recall. Biochemical assessment was performed in one-third of the children. SETTING: The study was conducted in Thailand's four geographical regions and Bangkok. PARTICIPANTS: 3478 Thai children aged 0.5-12.9 years. RESULTS: Stunting showed a downward trend by age group and was most prevalent among infants and toddlers. Overweight and obesity showed a significant upward trend by age group, location, and sex, and was highest among children aged 7-12.9 years. Risks of inadequate micronutrient intakes (calcium, iron, zinc, vitamins A, C, and D) were high (53.2-93.6%). Prevalence of zinc and mild vitamin A deficiencies were low; vitamin D and B12 deficiencies were nil. Vitamin D insufficiency was significantly higher in the urban area and among girls aged 7-12.9 years. Anemia was very high in infants and toddlers (56.6 and 35.2%), but showed a significant downward trend by age group. There was an overall high prevalence of iron deficiency without anemia (25%) versus iron deficiency anemia (4.2%) among children aged 4-12.9 years old. CONCLUSIONS: The high prevalence of stunting and anemia among children aged 1-3.9 years and overweight and obesity among children aged 7-12.9 years requires continued attention. While prevalence of biochemical micronutrient deficiencies was not high (except for iron), high prevalence of dietary inadequacies for several micronutrients warrants further in-depth investigations.

Discordance in exclusive breastfeeding between maternal recall and deuterium dose-to-mother technique during the first 6 months of infants: A multi-country study in Asia.

PURPOSE: This study aimed to assess the agreement in EBF between maternal recall and the dose-to-mother (DTM) technique. METHODS: Indonesia, Malaysia, Mongolia, Pakistan, Sri Lanka, Thailand, and Vietnam participated in the study. A total of 207 and 118 mother-infant pairs were assessed at 3 and 6 months of child's age. Using a standardized questionnaire, mothers were asked to recall child feeding during the previous 24 h, at 3 and 6 months. Those recalled to be EBF proceeded to be assessed using DTM technique. Non-milk oral intake (NMOI) cutoff of 86.6 g/d was used to classify EBF. RESULTS: According to DTM, 66% of infants were EBF at 3 months, while only 22% were EBF at 6 months. At 3 months, the overall % agreement between maternal recall and DTM method was 68%, kappa 0.06 (95% CI: 0.07-0.20), and at 6 months, the % agreement was only 21%, kappa -0.031 (95% CI -0.168 to 0.107). Human milk intakes were similar at 3 months and 6 months when expressed as g/d, but decreased when expressed as g/kg/d, with a large variation within and between countries; Pakistan being the lowest. CONCLUSION: This study showed there were declining levels of EBF from 3 to 6 months in the participating countries from Asia and the agreement between maternal recall and DTM technique to classify EBF was low. To ensure that the DTM technique can be more widely used in evaluating breastfeeding promotion programs, consensus on the appropriate NMOI cutoff and simplification of the DTM protocol is necessary.

Performance of the Global Diet Quality Score (GDQS) App in Predicting Nutrient Adequacy and Metabolic Risk Factors among Thai Adults.

BACKGROUND: The Global Diet Quality Score (GDQS) was developed for monitoring nutrient adequacy and diet-related noncommunicable disease risk in diverse populations. A software application (GDQS app) was recently developed for the standardized collection of GDQS data. The application involves a simplified 24-h dietary recall (24HR) where foods are matched to GDQS-food groups using an onboard database, portion sizes are estimated at the food group level using cubic models, and the GDQS is computed. OBJECTIVES: The study aimed to estimate associations between GDQS scores collected using the GDQS app and nutrient adequacy and metabolic risks. METHODS: In this cross-sectional study of 600 Thai males and nonpregnant/nonlactating females (40-60 y), we collected 2 d of GDQS app and paper-based 24HR, food-frequency questionnaires (FFQs), anthropometry, body composition, blood pressure, and biomarkers. Associations between application scores and outcomes were estimated using multiple regression, and application performance was compared with that of metrics scored using 24HR and FFQ data: GDQS, Minimum Dietary Diversity-Women, Alternative Healthy Eating Index-2010, and Global Dietary Recommendations score. RESULTS: In covariate-adjusted models, application scores were significantly (P < 0.05) associated with higher energy-adjusted mean micronutrient adequacy computed using 24HR (range in estimated mean adequacy between score quintiles 1 and 5: 36.3%-44.5%) and FFQ (Q1-Q5: 40.6%-44.2%), and probability of protein adequacy from 24HR (Q1-Q5: 63%-72.5%). Application scores were inversely associated with BMI kg/m2 (Q1-Q5: 26.3-24.9), body fat percentage (Q1-Q5: 31.7%-29.1%), diastolic blood pressure (Q1-Q5: 84-81 mm Hg), and a locally-developed sodium intake score (Q1-Q5: 27.5-24.0 points out of 100); positively associated with high-density lipoprotein cholesterol (Q1-Q5: 49-53 mg/dL) and 24-h urinary potassium (Q1-Q5: 1385-1646 mg); and inversely associated with high midupper arm circumference (Q5/Q1 odds ratio: 0.52) and abdominal obesity (Q5/Q1 odds ratio: 0.51). Significant associations for the application outnumbered those for metrics computed using 24HR or FFQ. CONCLUSIONS: The GDQS app effectively assesses nutrient adequacy and metabolic risk in population surveys.

Breastfeeding duration is associated with higher adiposity at 6-8 months of age.

Breastfeeding (BF) has been identified as a protective factor against childhood obesity. However, evidence of the association between BF duration and adiposity remains inconclusive. Few studies have been conducted among Southeast Asian infants that have measured body composition during infancy using the gold standard stable isotope method. This study aimed to evaluate the association between BF duration and body composition during infancy. Healthy full-term Thai infants aged 6-8 months (n = 60) receiving exclusive or predominant BF for at least 3 months were recruited. Skinfold thickness (SFT) was measured by well-trained investigators. Body composition was assessed by the deuterium dilution technique. Infants with longer BF duration (>6 months; mean 7.5 ± 0.5 months, n = 29) had a higher subscapular SFT z-score than those with shorter BF duration (≤6 months; mean 5.3± 0.9 months, n = 31) by 0.48 (95% confidence interval [CI]: 0.01-0.94). After adjustment for age and sex, BF duration and age at introduction of complementary feeding (CF) were positively associated with fat mass and fat mass index at 6-8 months. One month increase in BF duration and CF age was associated with a 0.37 (95% CI: 0.05, 0.69) kg/m2 and 0.76 (95% CI: 0.18, 1.34) kg/m2 increase in the fat mass index, respectively. After adjusting for infant body mass index (BMI) during the earlier infancy period, the strength of the association was attenuated. This finding may reflect reverse causality where infants with lower BMI received formula or CF earlier. A longitudinal study with follow-up into childhood is warranted to confirm the effects of BF on adiposity in infancy and childhood.

Development and validity of semi-quantitative food frequency questionnaire as a new research tool for sugar intake assessment among Indonesian adolescents.

Robust evidence has shown that sugar is a major contributor to obesity and Non-Communicable Diseases (NCDs). However, there have not been sufficient tools to estimate sugar intakes. Therefore, developing a new and valid tool to assess sugar intake, based on cultural eating habits, is crucial. The study was done in two phases; the first focused on the development of Semi-quantitative Food Frequency Questionnaire (SFFQ), and the second focused on researching the validity of the questionnaire. Food items in the SFFQ were selected from the latest national survey review, exploratory survey, and food market observation. Forty-nine food items were included in the final SFFQ with five open-ended questions for fruit groups. One hundred and six adolescents aged 15-17 years participated in the study. The total sugar intake among the adolescents was 58.80 g/day (52.7 g sucrose; 1.47 g fructose; 1.49 glucose) which contributed to 11.6% of the total energy intake per day. The reliability analysis showed a good agreement between the two administered SFFQs in a one-month interval. The relative validity results, using 6-days food diaries as a reference method, demonstrated a superior ability to rank individuals into the same and adjacent classification and only <10% gross misclassification in all sugar intakes. The developed SFFQ in turn has been proven to have moderate to good validity and be applicable for a larger epidemiological study.

Human Milk Intake of Thai Breastfed Infants During the First 6 Months Using the Dose-to-Mother Deuterium Dilution Method.

BACKGROUND: Data on infant human milk intakes in low- and middle-income countries are limited, although the deuterium oxide dose-to-mother method (DTM) is an accurate tool for its estimation. OBJECTIVE: We assessed human milk intakes of Thai infants during the first 6 months comparing exclusive breastfeeding (EBF), predominant breastfeeding (PBF), and partial breastfeeding (PartBF). METHODS: One hundred and ten healthy Thai lactating mother-infant pairs were followed from birth. Human milk intakes were determined at 6 weeks, 3 months, and 6 months using the DTM method. Daily energy and protein intakes were assessed using 3-day nonconsecutive 24-hour recalls. Sociodemographic characteristics were collected using a questionnaire. To compare breastfeeding practices, one-way analysis of variance with Tukey post hoc test assessed normally distributed data, while the Kruskal-Wallis test with Mann-Whitney U test was used for not normally distributed data. RESULTS: No difference existed in human milk intakes during the first 6 months between EBF (743-776 g/d) and PBF (748-862 g/d). Human milk intakes of PartBF infants were significantly lower compared to other infants. Human milk intake was sufficient to meet infant energy and protein requirements during the first 3 months for EBF and PBF groups. Infant formula largely replaced human milk during the first 3 months; other solid foods were also introduced among the PartBF infants. CONCLUSIONS: Human milk intakes were comparable between EBF and PBF infants during the first 6 months and provided adequate energy and protein to meet requirements. Infant formula largely replaced breast milk among PartBF infants, although other foods were also given early. This study was registered at clinicaltrials.gov as NCT04020640.

Alleviation of dry mouth by saliva substitutes improved swallowing ability and clinical nutritional status of post-radiotherapy head and neck cancer patients: a randomized controlled trial.

PURPOSE: The aim of this study is to investigate the effect of an edible saliva substitute, oral moisturizing jelly (OMJ), and a topical saliva gel (GC) on dry mouth, swallowing ability, and nutritional status in post-radiotherapy head and neck cancer patients. METHODS: Sixty-two post-radiation head and neck cancer patients with xerostomia completed a blinded randomized controlled trial. They were advised to swallow OMJ (n = 31) or apply GC orally (n = 31) for 2 months. Outcome measures were assessed at baseline, 1, and 2 months, including subjective and objective dry mouth (Challcombe) scores, subjective swallowing problem scores (EAT-10), water swallowing time, clinical nutritional status (PG-SGA), body weight, and dietary intake. RESULTS: After 1 and 2 months of interventions, subjective and objective dry mouth scores, subjective swallowing problem scores, swallowing times, and clinical nutritional status in both groups were significantly improved (p < 0.0001). Compared to GC, OMJ group had higher percent improvement in all outcome measures (p < 0.001) except swallowing time and clinical nutritional status. Interestingly, subjective dry mouth scores were significantly correlated with subjective swallowing problem scores (r = 0.5321, p < 0.0001). CONCLUSIONS: Continuous uses of saliva substitutes (OMJ or GC) for at least a month improved signs and symptoms of dry mouth and enhanced swallowing ability. An edible saliva substitute was superior to a topical saliva gel for alleviating dry mouth and swallow problems. These lead to improved clinical nutritional status. Thus, palliation of dry mouth may be critical to support nutrition of post-radiotherapy head and neck cancer patients. CLINICAL TRIAL REGISTRY: Clinicaltrials.gov NCT03035825.

Body mass index is associated with fat mass in normal, overweight/obese, and stunted preschool children in central Thailand.

BACKGROUND AND OBJECTIVES: Body mass index (BMI) is widely used as a surrogate measure of adiposity. The relationship between BMI and body fatness varies by race, sex, and age and more variations have been found among children. This study investigated the relationship between BMI and fat mass among 3-5 year old children having different nutritional status. METHODS AND STUDY DESIGN: A cross-sectional study was conducted in 15 daycare centers in central Thailand. 137 healthy preschool children were recruited according to their nutritional status: thin [BMI for age Z scores, (BAZ) <-2 SD], normal BMI (-2 SD<= BAZ <=+2 SD), overweight/obese (BAZ >+2 SD), and stunted [height for age Z scores < -2 SD]. Fat-free mass was determined by deuterium dilution technique. Fat mass (FM) in kilograms (TFM) and in percentage (FM%), and fat mass index (FMI, FM/height2) were calculated. RESULTS: FM and FMI were the highest in the overweight/obese groups. In the thin group, girls had higher FMI compared to boys (3.2 vs 2.8 kg/m2, p<0.05). The relationship between BMI with FMI and FM differed by nutritional status. BMI was more strongly associated with FMI, TFM, and FM% in the overweight/ obese (r=0.97, 0.95, 0.80, p<0.05) and the normal (r=0.88, 0.84, 0.68, p<0.05) groups but not in the stunted group, and inconsistent in the thin group. CONCLUSIONS: The inconsistency in the relationship between BMI and body fatness suggests that BMI is appropriate for reflecting adiposity in normal and overweight/obese children, but not undernourished preschool children.

Pre-pregnancy body mass index and gestational weight gain in Thai pregnant women as risks for low birth weight and macrosomia.

BACKGROUND AND OBJECTIVES: Maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) have been reported to be associated with pregnancy outcomes. Due to the nutrition transition in Thailand, the double burden of malnutrition is increasing and this may have negative consequences on birth outcomes. This study aimed to investigate the relationship between pre-pregnancy BMI and GWG with the risks of low birth weight and macrosomia. METHODS AND STUDY DESIGN: We performed a secondary analysis of data obtained from an iodine supplementation trial in mildly iodine-deficient Thai pregnant women. Pre-pregnancy BMI was classified using the WHO classification. GWG was categorized using the IOM recommendation. Binary and multinomial logistic regressions were performed. RESULTS: Among 378 pregnant women, the prevalence of pre-pregnancy underweight (BMI<18.5 kg/m2) and overweight (BMI>=25 kg/m2) were 17.2% and 14.3%, respectively. Normal weight women had the highest median GWG [15.0 (12.0, 19.0) kg] when compared to overweight women [13.2 (9.0, 16.3) kg]. Forty-one percent of women had excessive GWG, while 23% of women gained weight inadequately. Women with a high pre-pregnancy BMI had a 7-fold higher risk of having a macrosomic infant. Women who had excessive GWG were 8 times more likely to deliver a newborn with macrosomia. CONCLUSIONS: Both high pre-pregnancy maternal weight and excessive weight gain during pregnancy increase risk of infant macrosomia. Therefore, maintaining normal body weight before and throughout pregnancy should be recommended in order to reduce the risk of excessive infant birth weight and its associated complications.

Estimation of the Prevalence of Inadequate and Excessive Iodine Intakes in School-Age Children from the Adjusted Distribution of Urinary Iodine Concentrations from Population Surveys.

BACKGROUND: The urinary iodine concentration (UIC), a biomarker of iodine intake, is used to assess population iodine status by deriving the median UIC, but this does not quantify the percentage of individuals with habitually deficient or excess iodine intakes. Individuals with a UIC <100 µg/L or ≥300 µg/L are often incorrectly classified as having deficient or excess intakes, but this likely overestimates the true prevalence. OBJECTIVE: Our aim was to estimate the prevalence of inadequate and excess iodine intake in children (aged 4-14 y) with the distribution of spot UIC from iodine surveys. METHODS: With the use of data from national iodine studies (Kuwait, Oman, Thailand, and Qatar) and a regional study (China) in children (n = 6117) in which a repeat UIC was obtained in a subsample (n = 1060), we calculated daily iodine intake from spot UICs from the relation between body weight and 24-h urine volume and within-person variation by using the repeat UIC. We also estimated pooled external within-person proportion of total variances by region. We used within-person variance proportions to obtain the prevalence of inadequate or excess usual iodine intake by using the Estimated Average Requirement (EAR)/Tolerable Upper Intake Level (UL) cutoff method. RESULTS: Median UICs in Kuwait, Oman, China, Thailand, and Qatar were 132, 192, 199, 262, and 333 µg/L, respectively. Internal within-person variance proportions ranged from 25.0% to 80.0%, and pooled regional external estimates ranged from 40.4% to 77.5%. The prevalence of inadequate and excess intakes as defined by the adjusted EAR/UL cutoff method was ∼45-99% lower than those defined by a spot UIC <100 µg/L or ≥300 µg/L (P < 0.01). CONCLUSIONS: Applying the EAR/UL cutoff method to iodine intakes from adjusted UIC distributions is a promising approach to estimate the number of individuals with deficient or excess iodine intakes.

Vitamin D status among Thai school children and the association with 1,25-Dihydroxyvitamin D and parathyroid hormone levels.

In several low latitude countries, vitamin D deficiency is emerging as a public health issue. Adequate vitamin D is essential for bone health in rapidly growing children. In the Thai population, little is known about serum 25-hydroxyvitamin D [25(OH)D] status of infants and children. Moreover, the association between 25(OH)D and the biological active form of 1,25-dihydroxyvitamin D [1,25(OH)]2D is not clear. The specific aims of this study were to characterize circulating serum 25(OH)D, 1,25(OH)2D and their determinants including parathyroid hormone (PTH), age, sex, height and body mass index (BMI) in 529 school-aged Thai children aged 6-14 y. Adjusted linear regression analysis was performed to examine the impact of age and BMI, and its interaction with sex, on serum 25(OH)D concentrations and 1,25(OH)2D concentrations. Serum 25(OH)D, 1,25(OH)2D and PTH concentrations (geometric mean ± geometric SD) were 72.7±1.2 nmol/L, 199.1±1.3 pmol/L and 35.0±1.5 ng/L, respectively. Only 4% (21 of 529) participants had a serum 25(OH)D level below 50 nmol/L. There was statistically significant evidence for an interaction between sex and age with regard to 25(OH)D concentrations. Specifically, 25(OH)D concentrations were 19% higher in males. Moreover, females experienced a statistically significant 4% decline in serum 25(OH)D levels for each increasing year of age (P = 0.001); no decline was seen in male participants with increasing age (P = 0.93). When BMI, age, sex, height and serum 25(OH)D were individually regressed on 1,25(OH)2D, height and sex were associated with 1,25(OH)2D with females exhibiting statistically significantly higher serum 1,25(OH)2D levels compared with males (P<0.001). Serum 1,25(OH)2D among our sample of children exhibiting fairly sufficient vitamin D status were higher than previous reports suggesting an adaptive mechanism to maximize calcium absorption.

Influence of prenatal and postnatal growth on intellectual functioning in school-aged children.

OBJECTIVE: To assess the relative influence of size at birth, infant growth, and late postnatal growth on intellectual functioning at 9 years of age. DESIGN: A follow-up, cross-sectional study. SETTING: Three districts in Khon Kaen province, northeast Thailand. PARTICIPANTS: A total of 560 children, or 92% of former participants of a trial of iron and/or zinc supplementation during infancy. MAIN EXPOSURES: Prenatal (size at birth), early infancy (birth to 4 months), late infancy (4 months to 1 year), and late postnatal (1 to 9 years) growth. Multiple-stage least squares analyses were used to generate uncorrelated residuals of postnatal growth. MAIN OUTCOME MEASURES: Intellectual functioning was measured at 9 years using the Wechsler Intelligence Scale for Children and the Raven's Colored Progressive Matrices (Pearson). Analyses included adjustment for maternal, household, and school characteristics. RESULTS: Significant relationships were found between growth and IQ (Wechsler Intelligence Scale for children, third edition, Thai version), but only up to 1 year of age; overall, growth was not related to the Raven's Colored Progressive Matrices. The strongest and most consistent relationships were with length (birth, early infancy, and late infancy); for weight, only early infancy gain was consistently related to IQ. Head circumference at birth was not collected routinely; head circumference at 4 months (but not head circumference growth thereafter) was related to IQ. Late postnatal growth was not associated with any outcome. CONCLUSION: Physical growth in early infancy (and, to a lesser extent, physical growth in late infancy and at birth) is associated with IQ at 9 years of age. Early infancy may be a critical window for human development.

Long-term effects of iron and zinc supplementation during infancy on cognitive function at 9 y of age in northeast Thai children: a follow-up study.

BACKGROUND: Iron and zinc are important micronutrients for child growth and development. One would expect that iron and zinc supplementation in infancy would affect long-term cognitive development and school achievement, but this has not been evaluated. OBJECTIVE: We investigated the effect of iron or zinc supplementation or both during infancy on cognitive performance 8 y later. DESIGN: A follow-up study was performed in 560 children aged 9 y or 92% of those who had participated in a randomized controlled trial involving 4 groups who received daily iron, zinc, iron plus zinc, or a placebo at 4-6 mo of age for 6 mo. Cognitive performance was assessed by using the Wechsler Intelligence Scale for Children-Third Edition (Thai version), the Raven's Colored Progressive Matrices (CPM), and school performance tests. General linear mixed models were used to assess long-term effects. RESULTS: No significant differences in any of the outcomes at 9 y of age were observed at follow-up between the 4 groups. Mean intelligence quotients ranged across groups from 92.9 to 93.7 for full scale, 93.9-95.4 for verbal, and 93.1-94.0 for performance. The Raven's CPM score ranged from 21.4 to 22.4. CONCLUSION: Supplementation with iron or zinc or both during infancy does not lead to long-term cognitive improvement in 9-y-old children. This trial was registered at clinicaltrials.gov as NCT00824304.

A micronutrient-fortified seasoning powder reduces morbidity and improves short-term cognitive function, but has no effect on anthropometric measures in primary school children in northeast Thailand: a randomized controlled trial.

BACKGROUND: Reductions in iodine and zinc deficiencies and improvements in hemoglobin were achieved from a micronutrient-fortified seasoning powder consumed in school lunches by children in northeast Thailand. OBJECTIVE: The objective was to determine whether fortification with 4 micronutrients in a school lunch results in changes in children's growth, morbidity, and cognitive function compared with no fortification. DESIGN: In a randomized controlled trial of 569 children aged 5.5-13.4 y from 10 schools, we compared the efficacy of a seasoning powder fortified with or without 5 mg Fe, 5 mg Zn, 50 mug I, and 270 mug vitamin A per serving consumed with a school lunch 5 d/wk. Here we report on results of the secondary functional outcomes. RESULTS: The groups were comparable concerning compliance and loss to follow-up. The intervention had no statistically significant effect on anthropometric measures over 31 wk, but reduced the incidence of respiratory-related illnesses [rate ratio (RR): 0.83; 95% CI: 0.73, 0.94], symptoms of runny nose (RR: 0.80; 95% CI: 0.70, 0.92), cough (RR: 0.80; 95% CI: 0.66, 0.96), and diarrhea (RR: 0.38; 95% CI: 0.16, 0.90). For the visual recall test, those in the fortified group recalled 0.5 more items (95% CI: 0.1, 0.9) than did the controls. There were no statistically significant differences between groups in the results of the digits forward and backward tests or in school grades at the conclusion of the 2 semesters. CONCLUSION: The beneficial effects on morbidity and visual recall over a short period, in addition to some biochemical improvements, highlight the potential of this micronutrient-fortified seasoning powder supplied in a school lunch. This trial was registered at clinical trials.gov as ACTRN12605000341628.

Does zinc deficiency play a role in stunting among primary school children in NE Thailand?

Stunting in school-age years may result in a decrease in adult size, and thus reduced work capacity and adverse reproductive outcomes. We have compared the mean intakes of energy, protein and selected growth-limiting nutrients in fifty-eight stunted children and 172 non-stunted controls drawn from 567 children aged 6-13 years attending ten rural schools in NE Thailand. Control children were selected randomly after stratifying children by age in each school. Dietary data were calculated from 24-h recalls using nutrient values from Thai food composition data and chemical analysis. Inter-relationships between stunting and sociodemographic, anthropometric and biochemical variables were also examined. Biochemical variables investigated were serum albumin, zinc, ferritin, transferrin receptor and retinol, and iodine in casual urine samples. Significantly more males than females were stunted (males, n 38, 65.5% v. females, n 20. 34.5%: P=0.025). Stunted males had lower mean intakes of energy, protein, calcium, phosphorus and zinc, and a lower mean (95% CI) serum zinc (9.19 (8.53, 9.84) v. 9.70 (8.53, 9.29) micromol/1) than non-stunted males; no other biochemical differences were noted. Stunted males also had a lower mean arm muscle area (P= 0.015), after adjusting for age, than non-stunted males. In conclusion, the lower dietary intakes of the stunted males compared to their non-stunted counterparts may be associated with anorexia and hypogeusia induced by zinc deficiency. Hence, zinc deficiency may be a factor limiting linear growth, especially among boys in NE Thailand, but more research is needed to establish whether other factors also play a role.

Low zinc, iron, and calcium intakes of Northeast Thai school children consuming glutinous rice-based diets are not exacerbated by high phytate.

Phytate, a salt of phytic acid (myo-inositol 1,2,3,4,5,6-hexakisphosphate), is found in certain plant-based foods. It strongly chelates minerals, forming insoluble complexes in the small intestine that cannot be digested or absorbed. Information on the phytate content of rice-based diets of children in Northeast Thailand is limited. In this study 1-day weighed duplicate diet composites were collected from 40 Northeast Thai children (age 6-13 years) randomly selected from participants (n=567) of an efficacy trial in Ubon Ratchathani province. Diet composites were analyzed for zinc, iron, and calcium by atomic absorption spectrophotometry, and for phytate (as inositol penta-phosphate and hexa-phosphate) by high-performance liquid chromatography; the accuracy and precision were established using a certified reference material for the minerals and an inter-laboratory comparison for phytate. The median (1st, 3rd quartiles) zinc, iron, and calcium contents of the diet composites were 4.3 (3.7, 6.1), 4.3 (3.2, 6.5) and 130 (82, 216) mg/day, respectively. The inositol penta-phosphate and hexa-phosphate levels were so low they were below the detection limit, attributed in part to leaching of water-soluble potassium and magnesium phytate from glutinous rice after soaking overnight before cooking. Clearly, phytate will not compromise mineral absorption from these diets. Instead, low zinc intakes are probably primarily responsible for the low zinc status of these children. In contrast, although intakes of dietary iron appear low, the prevalence of biochemical iron deficiency was also low, suggesting that iron absorption may have been higher than previously assumed. Whether the low calcium intakes compromise optimal bone health in these growing Northeast Thai school children is unknown.

Primary school children from northeast Thailand are not at risk of selenium deficiency.

Selenium has important roles as an antioxidant, in thyroid hormone metabolism, redox reactions, reproduction and immune function, but information on the selenium status of Thai children is limited. We have assessed the selenium status of 515 northeast Thai children (259 males; 256 females) aged 6 to 13 years from 10 rural schools in Ubon Ratchthani province. Serum selenium (n=515) was analyzed by Graphite Furnace Atomic Absorption Spectrophotometry and dietary selenium intake by Hydride Generation Absorption Spectrophotometry from one-day duplicate diet composites, from 80 (40 females; 40 males) randomly selected children. Inter-relationships between serum selenium and selenium intakes, and other biochemical micronutrient indices were also examined. Mean (SD) serum selenium was 1.46 (0.24) micro mol/L. Concentrations were not affected by infection or haemoglobinopathies, but were dependent on school (P< 0.001), sex (P=0.038), and age group (P=0.003), with serum zinc as a significant covariate. None of the children had serum selenium concentrations indicative of clinical selenium deficiency (i.e. <0.1 micro mol/L). Significant correlations existed between serum selenium and serum zinc (r= 0.216; P < 0.001), serum retinol (r = 0.273; P < 0.001), urinary iodine (r = -0.110; P = 0.014), haemoglobin (r = 0.298; P <0.001), and haematocrit (r = 0.303; P< 0.001). Mean (SD) dietary selenium intake was 46 (22) micro g/d. Children with low serum selenium concentrations had a lower mean selenium intake than those with high serum selenium concentrations (38 +/- 17 vs.51 +/- 24 micro g/d; P< 0.010). In conclusion, there appears to be no risk of selenium deficiency among these northeast Thai children.

Iron and zinc supplementation improved iron and zinc status, but not physical growth, of apparently healthy, breast-fed infants in rural communities of northeast Thailand.

Iron deficiency is prevalent in children and infants worldwide. Zinc deficiency may be prevalent, but data are lacking. Both iron and zinc deficiency negatively affect growth and psychomotor development. Combined iron and zinc supplementation might be beneficial, but the potential interactions need to be verified. In a randomized, placebo-controlled trial using 2 x 2 factorial design, 609 Thai infants aged 4-6 mo were supplemented daily with 10 mg of iron and/or 10 mg of zinc for 6 mo to investigate effects and interactions on micronutrient status and growth. Iron supplementation alone increased hemoglobin and ferritin concentrations more than iron and zinc combined. Anemia prevalence was significantly lower in infants receiving only iron than in infants receiving iron and zinc combined. Baseline iron deficiency was very low, and iron deficiency anemia was almost nil. After supplementation, prevalence of iron deficiency and iron deficiency anemia were significantly higher in infants receiving placebo and zinc than in those receiving iron or iron and zinc. Serum zinc was higher in infants receiving zinc (16.7 +/- 5.2 micromol/L), iron and zinc (12.1 +/- 3.8 micromol/L) or iron alone (11.5 +/- 2.5 micromol/L) than in the placebo group (9.8 +/- 1.9 micromol/L). Iron and zinc interacted to affect iron and zinc status, but not hemoglobin. Iron supplementation had a small but significant effect on ponderal growth, whereas zinc supplementation did not. To conclude, in Thai infants, iron supplementation improved hemoglobin, iron status, and ponderal growth, whereas zinc supplementation improved zinc status. Overall, for infants, combined iron and zinc supplementation is preferable to iron or zinc supplementation alone.

A multimicronutrient-fortified seasoning powder enhances the hemoglobin, zinc, and iodine status of primary school children in North East Thailand: a randomized controlled trial of efficacy.

Anemia and co-existing deficiencies of zinc, iron, iodine, and vitamin A occur among children in many developing countries including NE Thailand, probably contributing to impairments in growth, immune competence, and cognition. Sustainable strategies are urgently required to combat these deficiencies. We assessed the efficacy of a micronutrient-fortified seasoning powder served with a school lunch on reducing anemia and improving the micronutrient status of rural NE Thai children. Children (n = 569) aged 5.5-13.4y from 10 schools were randomly assigned to receive a seasoning powder either unfortified or fortified with zinc (5 mg), iron (5 mg), vitamin A (270 microg), and iodine (50 microg) (per serving) and incorporated into a school lunch prepared centrally and delivered 5 d/wk for 31 wk. Teachers monitored school lunch consumption. Baseline and final micronutrient status, hemoglobinopathies, and infection or inflammation were assessed from blood and urine samples. For the primary outcome, anemia (based on hemoglobin), no intervention effect was apparent (odds ratio: 1.02 95% CI: 0.69, 1.51) after adjustment for design strata. The odds of zinc (based on serum zinc) and urinary iodine deficiency in the fortified group were 0.63 (0.42, 0.94) and 0.52 (0.38, 0.71) times those in the unfortified group, respectively. Fortification had no effect on serum retinol (0.61: 0.25,1.51), ferritin (1.12: 0.43, 2.96), or mean red cell volume (1.16: 0.82, 1.64). Therefore, a micronutrient-fortified seasoning powder is a promising vehicle for improving zinc, iodine, and hemoglobin status, and its potential for incorporation into lunch programs in day care centers and schools in NE Thailand warrants investigation.