Micronutrient status of populations and preventive nutrition interventions in South East Asia.

Objectives Since the 1990s, programs for the control of micronutrient deficiencies became a public health priority for many governments, including the countries partnering the project "Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia" (SMILING): Cambodia, Indonesia, Laos-PDR, Thailand and Vietnam. The aim of this study was to map which micronutrient deficiencies have been addressed and which interventions were in place in the SMILING countries. Methods The mapping covered the period up to 2012. Updated information from relevant surveys after 2012 is included in this paper after the completion of the SMILING project. The mapping of micronutrient status was limited to either national or at least large-scale surveys. Information on nutrition interventions obtained through a systematic mapping of national programs combined with a snowball collection from various sources. Results Among the five SMILING countries, Thailand differed historically by an early implementation of a nationwide community-based nutrition program, contributing to reductions in undernutrition and micronutrient deficiencies. For Cambodia, Indonesia, Laos PDR, and Vietnam, some national programs addressing micronutrients have been implemented following adjusted international recommendations. National surveys on micronutrient status were scattered and inconsistent across the countries in design and frequency. Conclusion for practice In conclusion, some micronutrient deficiencies were addressed in national interventions but the evidence of effects was generally lacking because of limited nationally representative data collected. Improvement of intervention programs to efficiently reduce or eliminate micronutrient deficiencies requires more systematic monitoring and evaluation of effects of interventions in order to identify best practices.

Maternal micronutrient supplementation with zinc and ß-carotene affects morbidity and immune function of infants during the first 6 months of life.

BACKGROUND/OBJECTIVES: Micronutrient deficiencies are prevalent worldwide, and a major cause of infant death. Supplementation with multiple micronutrients during pregnancy might improve micronutrient status of the newborn, thereby reducing morbidity and death. Moreover, maternal supplementation might affect the newborn's immune development. Therefore, this study investigated the effects of maternal zinc and ß-carotene supplementation on the infant's morbidity and immune function during the first 6 months of life. SUBJECTS/METHODS: Mothers were supplemented during pregnancy with ß-carotene and/or zinc, in addition to iron and folic acid, in a randomized, double-blind controlled trial. Newborn infants (n=136) were followed up for 6 months. RESULTS: Infants born from mothers receiving zinc during pregnancy had significantly fewer episodes of diarrhoea than infants born from mothers not receiving zinc (0.2 and 0.4, respectively), but more episodes of cough (1.3 and 0.9 respectively) during the first 6 months. Maternal ß-carotene supplementation had no effect on infants' morbidity. Cytokine production in the newborns was affected by maternal zinc and ß-carotene supplementation, with zinc supplementation giving higher interleukin-6 production (16% higher), and ß-carotene supplementation leading to lower interferon-γ production (36% lower). CONCLUSIONS: This study shows that maternal supplementation with zinc and ß-carotene affected the newborn's immune development in specific ways, but only maternal zinc supplementation significantly affected morbidity in the infants. Addition of zinc to routine iron and folic acid supplements for pregnant women could be an effective way to reduce diarrhoeal disease during the first 6 months of life, albeit at the expense of more episodes of cough.

Reduced production of immunoregulatory cytokines in vitamin A- and zinc-deficient Indonesian infants.

OBJECTIVE: To determine effects of vitamin A, zinc and iron deficiency in Indonesian infants on the ability to produce immunoregulatory cytokines. DESIGN, SETTING AND SUBJECTS: Immunological assessment was done in 59 infants participating in a cross-sectional nutritional survey in rural West Java, Indonesia. Production of T-helper cell type-1 (Th1, cell-mediated) cytokines interferon-gamma (IFN-gamma), interleukin-12 (IL-12), interleukin-18 (IL-18) and T-helper cell type-2 (Th2, humoral) cytokine interleukin-6 (IL-6) were measured after stimulation with lipopolysaccharide and phytohemagglutinin in an ex vivo whole blood culture system. Circulating neopterin concentrations were determined as an indicator of in vivo macrophage activity. RESULTS: Of the infants, 48% were vitamin A deficient, 44% were anemic (with 17% having iron deficiency anemia), and 17% were zinc deficient. Vitamin-A deficient infants had significantly reduced ex vivo production of IFN-gamma, but also significantly higher circulating neopterin concentrations. Production of IFN-gamma and IL-12 were strongly correlated, IFN-gamma and IL-18 production were not. Zinc deficiency was accompanied by significantly reduced white blood cell counts and reduced ex vivo production of IL-6. Iron status was not related to cytokine production. CONCLUSIONS: This study shows that in vitamin A deficiency there is Th1 dominance in a steady state, combined however with impairment of the Th1 response after stimulation, whereas in zinc deficiency, there is a decreased Th2 response. Overall, vitamin A deficiency and zinc deficiency have marked albeit different effects on the immunocompetence of infants, affecting both cell-mediated and humoral components of the immune system.

Effects of iron and zinc supplementation in Indonesian infants on micronutrient status and growth.

In this study the effects of supplementation of iron and zinc, alone or combined, on iron status, zinc status and growth in Indonesian infants is investigated. Micronutrient deficiencies are prevalent in infants in developing countries, and deficiencies often coexist; thus, combined supplementation is an attractive strategy. However, little is known about interactions between micronutrients. In a randomized, double-blind, placebo-controlled supplementation trial, 478 infants, 4 mo of age, were supplemented for 6 mo with iron (10 mg/d), zinc (10 mg/d), iron + zinc (10 mg of each/d) or placebo. Anthropometry was assessed monthly, and micronutrient status was assessed at the end of supplementation. Supplementation significantly reduced the prevalence of anemia, iron deficiency anemia and zinc deficiency. Iron supplementation did not negatively affect plasma zinc concentrations, and zinc supplementation did not increase the prevalence of anemia or iron deficiency anemia. However, iron supplementation combined with zinc was less effective than iron supplementation alone in reducing the prevalence of anemia (20% vs. 38% reduction) and in increasing hemoglobin and plasma ferritin concentrations. There were no differences among the groups in growth. The growth of all groups was insufficient to maintain the same Z-scores for height for age and weight for height. There is a high prevalence of deficiencies of iron and zinc in these infants, which can be overcome safely and effectively by supplementation of iron and zinc combined. However, overcoming these deficiencies is not sufficient to improve growth performance in these infants.

Concurrent micronutrient deficiencies in lactating mothers and their infants in Indonesia.

BACKGROUND: Deficiencies of vitamin A, iron, and zinc are prevalent worldwide, affecting vulnerable groups such as lactating women and infants. However, the existence of concurrent deficiencies has received little attention. OBJECTIVE: The aim was to investigate the extent to which deficiencies of vitamin A, iron, and zinc coexist and the nutritional relation between lactating mothers and their infants. DESIGN: In a cross-sectional survey in rural West Java, Indonesia, 155 lactating mothers and their healthy infants were assessed anthropometrically and blood, urine, and breast-milk samples were obtained. RESULTS: Marginal vitamin A deficiency was found in 54% of the infants and 18% of the mothers. More than 50% of the mothers and infants were anemic and 17% of the infants and 25% of the mothers were zinc deficient. There was a strong interrelation between the micronutrient status of the mothers and infants and the concentrations of retinol and beta-carotene in breast milk. Vitamin A deficiency in infants led to an increased risk of anemia and zinc deficiency (odds ratios: 2.5 and 2.9, respectively), whereas in mothers the risk of anemia and iron deficiency (odds ratios: 3.8 and 4.8, respectively) increased. In infants, concentrations of insulin-like growth factor I were related to concentrations of plasma retinol and beta-carotene but not to zinc. CONCLUSIONS: Micronutrient deficiencies were prevalent in West Java. The micronutrient status of lactating mothers and that of their infants were closely related; breast milk was a key connecting factor for vitamin A status. Furthermore, concurrent micronutrient deficiencies appeared to be the norm.

The safety and utilization of patient-controlled analgesia.

Between December 1989 and March 1996, more than 6000 patients were treated with patient-controlled analgesia (PCA) at Auckland Hospital. The overall incidence of potentially life-threatening complications was low (0.28%). A small number (276) received PCA with a background opioid infusion. This technique was associated with a higher incidence of such complications (1.08%, P < 0.05). To further characterize the safety and utilization of PCA, a subgroup of 300 patients was analyzed. The average duration of PCA was 76.4 +/- 39.2 hr. The peak morphine consumption was highest on the day of operation (45.4 +/- 37.0 mg) and rapidly declined over the next 3 postoperative days (40.6 +/- 39.0, 33.3 +/- 26.2, and 27.8 +/- 36.6 mg, respectively). The ratio of drug demands to deliveries decreased from 1.76 on the morning of the first postoperative day to 1.17 on the evening of the third. The percentage of patients with inadequate analgesia (pain score > or = 3/10) and an inability to comply with physiotherapy (Bruggemann comfort score < or = 2/10) was high on the first postoperative day (42% and 18%, respectively). Men used significantly more morphine than women (141.7 +/- 123.6 versus 102.7 +/- 111.2 mg, P < 0.0001) and general surgical patients used more morphine than urology and orthopedic patients (152.6 +/- 136.9 versus 96.0 +/- 84.2 and 83.7 +/- 97.9 mg, P < 0.0001). There was no association between morphine consumption and age (r = -0.216). Of the 6% of patients who experienced hypoxemia and 2% who experienced respiratory depression, virtually all had one of three risk factors: bolus dose greater than 1 mg morphine, age greater than 65 years, or intra-abdominal surgery. The most common side effects were nausea and sedation. The incidence of nausea was highest on day 1 (28%) and decreased over the next 2 days (14.3% and 4.7%, respectively). A similar pattern was observed with sedation (incidence over the first 3 days: 28%, 9.3%, and 3.3%, respectively). Overall patient satisfaction scores were high (8.3/10 +/- 1.9). We conclude that the risk of serious complications with PCA is very low, but worrying degrees of hypoxemia and bradypnea do occur. We suggest prescribing regimens that may reduce complications and identify patients at high risk.

A versatile vector for controlled expression of genes in Escherichia coli and Salmonella typhimurium.

We have constructed two expression vectors based on the pJF118HE vector developed for Escherichia coli by Fürste et al. [Gene 48 (1986) 119-131]. The tac promoter (ptac) was exchanged for the trc promoter (ptrc) and an NdeI site was created at the appropriate distance from the ribosome-binding site. The NdeI site permits cloning of a gene at its translation start point without altering the amino-acid sequence of the synthesized protein, while ptrc and the lacIQ gene confer inducible and controlable expression. We have tested these plasmids in E. coli and Salmonella typhimurium.