Assessing Accuracy and Precision of Hemoglobin Determination in Venous, Capillary Pool, and Single-Drop Capillary Blood Specimens Using three Different HemoCue® Hb Models: The Multicountry Hemoglobin Measurement (HEME) Study.

BACKGROUND: Anemia prevalence estimates reported in population surveys can vary based on the blood specimen source (capillary or venous) and analytic device (hematology autoanalyzers or portable hemoglobinometers) used for hemoglobin (Hb) determination. OBJECTIVES: This study aimed to compare accuracy and precision of Hb measurement in three blood specimen types on three models of hemoglobinometers against the results from venous blood from the same individuals measured on automated analyzers (AAs). METHODS: This multisite (Cambodia, Ethiopia, Guatemala, Lebanon, Nigeria, and Tanzania) study assessed Hb measurements in paired venous and capillary blood specimens from apparently healthy women (aged 15-49 y) and children (aged 12-59 mo) using three HemoCue® Hb models (201+, 301, and 801). Measurements were compared against reference values: venous blood in hematology AA and adjusted via regression calibration or mean difference in HemoCue® Hb. Venous, capillary pool, and single-drop capillary blood specimens were assessed for accuracy and precision. RESULTS: Venous blood measured using HemoCue® Hb 301 exhibited a positive mean error, whereas responses in HemoCue® Hb 201+ and 801 were nondirectional compared with the reference. Adjustment with the reference harmonized mean errors for all devices across study sites to <1.0 g/L using venous blood. Precision was highest for venous blood (±5-16 g/L) in all sites, lowest for single-drop capillary (±9-37 g/L), and intermediate (±9-28 g/L) for capillary pool blood specimen. Imprecision differed across sites, especially with both capillary blood specimens, suggesting different levels of personnel skills. CONCLUSIONS: Findings suggest that venous blood is needed for accurate and precise Hb determination. Single-drop capillary blood use should be discouraged owing to high measurement variability. Further research should evaluate the viability and reliability of capillary pool blood for this purpose. Accuracy of HemoCue® Hb devices can be improved via standardization against results from venous blood assessed using AA.

Trends in Micronutrient Interventions, Anemia, and Iron Deficiency among Women and Children in Guatemala, 2009-2019.

Background: Food fortification and micronutrient supplementation are public health strategies to improve micronutrient status in Guatemala; their population effectiveness has not been evaluated in recent years. Objective: We evaluated trends in food fortification, micronutrient supplementation, anemia, and iron deficiency among nonpregnant women aged 15-49 y [women of reproductive age (WRA)] and children 6-59 aged mo [preschool age children (PSC)]. Method: Nationally representative serial cross-sectional surveys were used to assess changes in hemoglobin, anemia, ferritin, iron deficiency, iron deficiency anemia, and self-reported consumption of fortifiable foods and micronutrient supplements during 2008/2009, 2013, 2015, 2016, 2017/2018, and 2018/2019. Predictors of hemoglobin and ferritin were assessed using generalized linear mixed models adjusted for survey year as random effects, and the consumption of fortifiable foods, supplements, and other potential confounders were fixed effects. Results: Multiple micronutrient powder consumption among PSC during the previous 3 mo was 53.3% (95% CI: 49.4, 57.2) in 2013 and 33.6% (28.8, 38.4) in 2018/2019. Anemia among PSC was 11.3% (8.0, 14.5) in 2008/2009 and 6.1% (3.6, 8.6) in 2018/2019. Anemia among WRA was 10.7% (7.2, 14.2) in 2008/2009 and 3.9% (2.7, 5.2) in 2018/2019. Iron deficiency among PSC was 15.5% (12.1, 19.0) in 2008/2009 and 10.9% (7.4, 14.5) in 2016 (lowest), but 17.1 (13.3, 21.0) in 2017/2018 (highest). Iron deficiency among WRA was 14.9% (11.6, 18.2) in 2008/2009, 13.8% (11.8, 15.8) in 2013 (lowest), and 18.9% (16.3, 21.6) in 2017/2018 (highest). Wheat flour/bread consumption was positively associated with hemoglobin among PSC, and sugar consumption was positively associated with hemoglobin among WRA. The reported consumption of fortifiable foods was not associated with ferritin among PSC or WRA. Conclusions: Guatemala has implemented multiple food fortification strategies, and anemia has declined. Increases in iron deficiency in 2017-2019 warrant further attention. Secular trends toward poverty alleviation, education, and development might be responsible for changes not explained by the micronutrient interventions evaluated.

Experiences and Lessons Learned in Developing and Implementing a Population-Based Nutrition and Health Surveillance System in Guatemala 2011-2021.

Background: Practice-based experiences documenting development and implementation of nutrition and health surveillance systems are needed. Objectives: To describe processes, methods, and lessons learned from developing and implementing a population-based household nutrition and health surveillance system in Guatemala. Methods: The phases and methods for the design and implementation of the surveillance system are described. Efforts to institutionalize the system in government institutions are described, and illustrative examples describing different data uses, and lessons learned are provided. Results: After initial assessments of data needs and consultations with officials in government institutions and partners in the country, a population-based nutrition surveillance system prototype with complex sampling was designed and tested in 5 Guatemalan Highland departments in 2011. After dissemination of the prototype, government and partners expanded the content, and multitopic nutrition and health surveillance cycles were collected in 2013, 2015, 2016, 2017/18, and 2018/19 providing nationally representative data for households, women of reproductive age (15-49 y), and children aged 0-59 mo. For each cycle, data were to be collected from 100 clusters, 30 households in each, and 1 woman and 1 child per household. Content covered ∼25 health and nutrition topics, including coverage of all large-scale nutrition-specific interventions; the micronutrient content of fortifiable sugar, salt, and bread samples; anthropometry; and biomarkers to assess annually, or at least once, ∼25 indicators of micronutrient status and chronic disease. Data were collected by 3-5 highly trained field teams. The design was flexible and revised each cycle allowing potential changes to questionnaires, population groups, biomarkers, survey design, or other changes. Data were used to change national guidelines for vitamin A and B-12 interventions, among others, and evaluate interventions. Barriers included frequent changes of high-level government officials and heavy dependence on US funding. Conclusions: This system provides high-quality data, fills critical data gaps, and can serve as a useful model for others.

Perspective: Integration to Implementation (I-to-I) and the Micronutrient Forum-Addressing the Safety and Effectiveness of Vitamin A Supplementation.

An ongoing challenge to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance that are safe, efficacious, and avoid unintended consequences. The integration to effective implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the generation, translation, and implementation of evidence to public health guidance/programs. The I-to-I approach was developed under the auspices of the Micronutrient Forum and has been previously applied to the question of safety and effectiveness of interventions to prevent and treat nutritional iron deficiency. The present article applies the I-to-I approach to questions regarding the safety and utility of large-dose vitamin A supplementation programs, and presents the authors' perspective on key aspects of the topic, including coverage of the basic and applied biology of vitamin A nutrition and assessment, clinical implications, and an overview of the extant data with regard to both the justification for and utility of available intervention strategies. The article includes some practical considerations based on specific country experiences regarding the challenges of implementing vitamin A-related programs. This is followed by an overview of some challenges associated with engagement of the enabling communities that play a critical role in the implementation of these types of public health interventions. The article concludes with suggestions for potential approaches to move this important agenda forward.

Characterization of mitochondrial iron uptake in HepG2 cells.

There is increasing evidence that accumulation of redox-active iron in mitochondria leads to oxidative damage and contributes to various neurodegenerative diseases, such as Friedreich's ataxia and Parkinsons disease. In this work, we examined the existence of regulatory mechanisms for mitochondrial iron uptake and storage. To that end, we used rhodamine B-[(1,10-phenanthrolin-5-yl)amino carbonyl] benzyl ester, a new fluorescent iron-sensitive probe that is targeted specifically to the mitochondrion. We found that extracellular iron was incorporated readily into mitochondria in an apparently saturable process. Moreover, the rate of iron incorporation responded to the Fe status of the cell, an indication that the mitochondrion actively regulates its iron content.

The mechanisms for regulating absorption of Fe bis-glycine chelate and Fe-ascorbate in caco-2 cells are similar.

Inorganic iron (Fe) absorption from the diet is controlled mainly in the intestinal tract where apical Fe uptake is inversely related to the Fe content in the enterocyte. Iron bis-glycine chelate is an iron compound that may be absorbed by a mechanism different from the regulated nonheme Fe pathway. Because Fe bis-glycine chelate is used increasingly as an Fe fortificant in foods, the critical question is whether this compound is a safe Fe supplement. We compared apical Fe uptake and transepithelial transport offered either as (59)Fe bis-glycine chelate or a (59)Fe-ascorbate (Fe-AA) complex in Caco-2 cells, as a model of human intestinal epithelia, grown in different Fe concentrations in the media (0.5, 5 and 20 micro mol/L Fe). Apical Fe uptake from (59)Fe-AA and (59)Fe bis-glycine chelate did not differ nor did transepithelial transport rates. The rate of (59)Fe uptake decreased with increasing intracellular Fe concentration (P < 0.001), an indication of a common absorption regulatory mechanism. We also evaluated the effect of an excess of Fe (100 micro mol/L) provided as Fe bis-glycine chelate or Fe-AA on the incorporation of 1 micro mol/L (55)Fe-AA into Fe-replete Caco-2 cells. The inhibition of Fe bis-glycine chelate on the absorption of the extrinsic tag of (55)Fe-AA (87.5%) did not differ from that of Fe added as Fe-AA (86.8%). These results suggest that Fe derived from Fe bis-glycine chelate and Fe-AA have similar regulatory absorption mechanisms.

Heme-iron absorption is saturable by heme-iron dose in women.

In developed countries where meat is an important constituent of the diet, much of the dietary iron is in the heme-iron form as hemoglobin and myoglobin. Heme-iron is absorbed more efficiently than inorganic iron by the human intestine. Thus, it is important to know how the dose of heme-iron affects iron absorption. The purpose of this study was to establish the dose-effect of heme-iron on the percentage and absolute amount of iron absorbed. Twenty-seven healthy women (28- to 50-y-old) were selected to participate in two iron absorption studies. Through the use of iron isotopes ((59)Fe and (55)Fe), the studies were performed to characterize the dose-response curve of non-heme-iron absorption (ferrous sulfate), and to establish the dose-response curve of heme-iron absorption (hemoglobin). The labeled hemoglobin was prepared by use of red blood cells from rabbits. The geometric means (+/-1 SEM range) of non-heme iron absorbed were 0.2 (0.2-0.3), 1.2 (1.0-1.5), 6.7 (5.7-8.0) and 13.0 (11.5-14.6) mg of iron for doses of 0.5, 5, 50 and 100 mg of iron as ferrous sulfate, respectively; and 0.1 (0.1-0.2), 0.4 (0.3-0.4), 2.2 (2.0-2.4) and 2.2 (1.7-3.0) mg of iron for doses of 0.5, 3, 15 and 30 mg of heme-iron as hemoglobin, respectively. The fitted curves for heme and non-heme iron differed (P < 0.04). These results strongly suggest that the heme-iron absorption pathway is saturable.

Characterization of mitochondrial iron uptake in HepG2 cells

There is increasing evidence that accumulation of redox-active iron in mitochondria leads to oxidative damage and contributes to various neurodegenerative diseases, such as Friedreich's ataxia and Parkinson's disease. In this work, we examined the existence of regulatory mechanisms for mitochondrial iron uptake and storage. To that end, we used rhodamine B- [(1,10-phenanthrolin-5-yl)amino carbonyl ] benzyl ester, a new fluorescent iron-sensitive probe that is targeted specifically to the mitochondrion. We found that extracellular iron was incorporated readily into mitochondria in an apparently saturable process. Moreover, the rate of iron incorporation responded to the Fe status of the cell, an indication that the mitochondrion actively regulates its iron content.